Optimal Renal Replacement Therapy Research Articles

Characteristics of Inherited Metabolic Disorders Following Kidney Transplantation: A 13-Year Observational Study

Background and Objectives: Inherited metabolic disorders (IMDs), primarily cystinosis, Fabry disease, and methylmalonic acidemia (MMA), are genetic conditions that typically result in multi-organ disease manifestations. Kidney function progressively deteriorates in many cases, with patients eventually reaching end-stage kidney disease (ESKD) and requiring renal replacement therapy. Kidney transplantation has been deemed the optimal renal replacement therapy option to achieve long-term survival in patients with IMD. Whilst improved long-term survival is expected, the patterns of clinical evolution for IMD after transplantation remain largely unknown. Methods: Our group conducted a retrospective observational study that included 37 adult patients with IMD (11 with cystinosis, 20 with Fabry disease, and 6 with MMA). The study evaluated the clinical status and progression of these patients following kidney transplantation between January 2010 and December 2023. Results: This generally resulted in good graft outcomes for patients with IMD. Standard immunosuppression regimes included tacrolimus, mycophenolate mofetil, and prednisolone. The mean graft survival duration was noted to be 12 years in patients with cystinosis, 11 years in patients with Fabry disease, and 7 years in patients with MMA. Suboptimal outcomes were noted with grafts of cadaveric origin and poor adherence to the prescribed post-transplant immunosuppression regime. A greater extra-renal morbidity burden was associated with a reduced duration of graft function and increased mortality in patients with IMD. Conclusions: Our findings emphasise the need for a multi-disciplinary approach in the care of IMD patients following kidney transplantation.

An integrated machine learning model enhances delayed graft function prediction in pediatric renal transplantation from deceased donors

BackgroundKidney transplantation is the optimal renal replacement therapy for children with end-stage renal disease; however, delayed graft function (DGF), a common post-operative complication, may negatively impact the long-term outcomes of both the graft and the pediatric recipient. However, there is limited research on DGF in pediatric kidney transplant recipients. This study aims to develop a predictive model for the risk of DGF occurrence after pediatric kidney transplantation by integrating donor and recipient characteristics and utilizing machine learning algorithms, ultimately providing guidance for clinical decision-making.MethodsThis single-center retrospective cohort study includes all recipients under 18 years of age who underwent single-donor kidney transplantation at our hospital between 2016 and 2023, along with their corresponding donors. Demographic, clinical, and laboratory examination data were collected from both donors and recipients. Univariate logistic regression models and differential analysis were employed to identify features associated with DGF. Subsequently, a risk score for predicting DGF occurrence (DGF-RS) was constructed based on machine learning combinations. Model performance was evaluated using the receiver operating characteristic curves, decision curve analysis (DCA), and other methods.ResultsThe study included a total of 140 pediatric kidney transplant recipients, among whom 37 (26.4%) developed DGF. Univariate analysis revealed that high-density lipoprotein cholesterol (HDLC), donor after circulatory death (DCD), warm ischemia time (WIT), cold ischemia time (CIT), gender match, and donor creatinine were significantly associated with DGF (P < 0.05). Based on these six features, the random forest model (mtry = 5, 75%p) exhibited the best predictive performance among 97 machine learning models, with the area under the curve values reaching 0.983, 1, and 0.905 for the entire cohort, training set, and validation set, respectively. This model significantly outperformed single indicators. The DCA curve confirmed the clinical utility of this model.ConclusionsIn this study, we developed a machine learning-based predictive model for DGF following pediatric kidney transplantation, termed DGF-RS, which integrates both donor and recipient characteristics. The model demonstrated excellent predictive accuracy and provides essential guidance for clinical decision-making. These findings contribute to our understanding of the pathogenesis of DGF.

Initiation of continuous renal replacement therapy versus intermittent hemodialysis in critically ill patients with severe acute kidney injury: a secondary analysis of STARRT-AKI trial.

There is controversy regarding the optimal renal-replacement therapy (RRT) modality for critically ill patients with acute kidney injury (AKI). We conducted a secondary analysis of the STandard versus Accelerated Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial to compare outcomes among patients who initiated RRT with either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD). We generated a propensity score for the likelihood of receiving CRRT and used inverse probability of treatment with overlap-weighting to address baseline inter-group differences. The primary outcome was a composite of death or RRT dependence at 90-days after randomization. We identified 1590 trial participants who initially received CRRT and 606 who initially received IHD. The composite outcome of death or RRT dependence at 90-days occurred in 823 (51.8%) patients who commenced CRRT and 329 (54.3%) patients who commenced IHD (unadjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.75-1.09). After balancing baseline characteristics with overlap weighting, initial receipt of CRRT was associated with a lower risk of death or RRT dependence at 90-days compared with initial receipt of IHD (OR 0.81; 95% CI 0.66-0.99). This association was predominantly driven by a lower risk of RRT dependence at 90-days (OR 0.61; 95% CI 0.39-0.94). In critically ill patients with severe AKI, initiation of CRRT, as compared to IHD, was associated with a significant reduction in the composite outcome of death or RRT dependence at 90-days.

Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury.

Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.

Kidney Transplantation 1: An Overview--Recipient Evaluation and Immunosuppression

Kidney transplantation remains the optimal renal replacement therapy for patients with end-stage renal disease (ESRD). A timely referral to kidney transplantation and a thorough pretransplantation evaluation ensure improvement in the morbidity and mortality of ESRD patients. Basic knowledge of immune biology and an in-depth understanding of the different induction and maintenance therapies used post kidney transplantation are imperative for optimal patient management. In this review, we discuss the multidisciplinary process of pretransplantation evaluation of kidney transplant recipients. We also discuss state-of–the-art early management post kidney transplantation with the different immunosuppressive therapies currently available. This review contains 3 figures, 11 tables, and 106 references. Key words: crossmatch, donor-specific antibody, immunosuppression, human leukocyte antigen, immunosuppression, induction, maintenance, medical evaluation, transplantation

Metabolic Syndrome, a Real Barrier for Living Kidney Donor Transplant

IntroductionRenal transplantation is the optimal renal replacement therapy. In Mexico, most of the kidney transplants are from living donors. It is essential to identify conditions that increase the risk of developing chronic kidney disease (CKD) in donors, such as metabolic syndrome (MS). Materials and methodsIn retrospect from January 2008 to December 2018, the donation protocols for renal transplantation of the Hospital Central Sur Alta Especialidad “Picacho” were reviewed, classifying all the cases of donors by nephrectomy or no nephrectomy and describing the demographic characteristics, prevalence of metabolic diseases, and cause of rejection of the protocol. ResultsA total of 178 donors were studied: 82 women (46%), 96 men (54%), mean age of 42 years, average body mass index (BMI) 27.9 kg/m2, glomerular filtration rate (GFR) by Chronic Kidney Disease Epidemiology Collaboration 99 mL/min, 59 patients with grade I and II obesity (BMI ≥ 30 kg/m2), and 1 patient with morbid obesity (BMI ≥ 40 kg/m2). A total of 39 patients (22%) underwent nephrectomy and 139 (78%) did not. The following characteristics and alterations were found: Of the 139 patients who did not undergo nephrectomy, 91 had metabolic disorders, 20 had low GFR, 21 had albuminuria, and 4 recipients received cadaveric transplants, 3 due to critical conditions of the recipient. The metabolic alterations in the rejected donors were as follows: MS 54 (59%), prediabetes 55 (39%), newly diagnosed hypertension 70 (76%), diabetes mellitus 20 (14%), obesity 47 (51.6%), dyslipidemia 76 (83%), hyperuricemia 17 (12%). DiscussionThe prevalence of MS in apparently healthy donors is similar to that of other studies in Mexico. Both MS and its components are independently associated with an increased risk of cardiovascular disease and CKD. It has been shown that these donors have a greater degree of glomerular and interstitial fibrosis; therefore, diagnosis, prevention, and timely treatment in this group are important.

MP59-18 THE ROLE OF CXCL11 AND CXCL13 GENE EXPRESSIONS ON ALLOGRAFT FUNCTION IN KIDNEY TRANSPLANT RECIPIENTS

INTRODUCTION AND OBJECTIVE:Kidney transplantation (KTx) has been established as the optimal renal replacement therapy for end-stage renal disease, with a longer life expectancy, better quality of l...

Arterial Hypertension as a Risk Factor for Reduced Glomerular Filtration Rate after Living Kidney Donation.

Living kidney donation represents the optimal renal replacement therapy, but recent data suggest an increased long-term renal risk for the donor. Here, we evaluated the risk for reduced estimated glomerular filtration rate (eGFR), death, and major cardiovascular events such as nonfatal myocardial infarction or cerebrovascular event including TIA (transient ischemic attack) and stroke in 225 donors, who underwent pre-donation examinations and live donor nephrectomy between 1985 and 2014 at our center. The median follow-up time was 8.7 years (1.0–29.1). In multivariate analysis, age and arterial hypertension at baseline were significantly associated with a higher risk of adverse renal outcomes, such as (1) eGFR <60 mL/min/1.73 m2 (age per year: HR (hazard ratio) 1.05, 95% confidence interval (CI) 1.03–1.08, hypertension: HR 2.25, 95% CI 1.22–3.98), (2) eGFR <60 mL/min/1.73 m2 and a decrease of ≥40% from baseline (age: HR 1.08, 95% CI 1.03–1.13, hypertension: HR 4.22, 95% CI 1.72–10.36), and (3) eGFR <45 mL/min/1.73 m2 (age: HR 1.12, 95% CI 1.05–1.20, hypertension: HR 5.06, 95% CI 1.49–17.22). In addition, eGFR at time of donation (per mL/min/1.73 m2) was associated with a lower risk of (1) eGFR <60 mL/min/1.73 m2 (HR 0.98, 95% CI 0.97–1.00) and (2) eGFR <45 mL/min/1.73 m2 (HR 0.95, 95% CI 0.90–1.00). Age was the only significant predictor for death or major cardiovascular event (HR 1.08, 95% CI 1.01–1.16). In conclusion, arterial hypertension, lower eGFR, and age at the time of donation are strong predictors for adverse renal outcomes in living kidney donors.

Renal Replacement Therapy in Pediatric Acute Kidney Injury.

Acute kidney injury (AKI) is common in critically ill children and affects nearly 30-40% of patients admitted to the pediatric intensive care unit (ICU). Even with technological advances in critical care and dialysis, there is a high mortality rate of 66.8% to 90% in ICU patients. Renal replacement therapy (RRT) is often performed to treat patients with AKI. However, for optimal RRT treatment, it is crucial to consider the indications, modes of access, and prescription of each RRT method. Therefore, this review aims to discuss the various modalities of RRT in pediatric patients, which include peritoneal dialysis (PD), hemodialysis (HD), continuous RRT (CRRT), and sustained low-efficiency dialysis (SLED).

Proteomic profiling of peritoneal dialysis effluent-derived extracellular vesicles: a longitudinal study.

Peritoneal dialysis (PD) is an optimal renal replacement therapy for patients while waiting for kidney transplantation, but functional failure of the peritoneal membrane (PM), mainly induced by exposure to PD solutions, force many patients to early abandon PD therapy. PM function is evaluated by the peritoneal equilibration test (PET), a tedious technique only detecting alterations in extensively damaged PM. In a previous study, we showed that peritoneal dialysis effluent contained extracellular vesicles (PDE-EV), and that their proteome was significantly different between newly enrolled and long-term PD patients. Here, we report the results of a longitudinal study and compare PDE-EV proteome changes with PET results. PDE was collected from 11 patients every 6months (coincident with PET controls) from 0months up to 24months on PD. PDE-EV were isolated by size-exclusion chromatography and the proteome was analyzed by mass spectrometry (LC-MS/MS). Bioinformatic analyses were conducted to evaluate differences between groups. At follow-up endpoint, patients were classified as Stable (n = 7) or Unstable (n = 4) according to PET evolution. Strikingly, PDE-EV from the Stable group showed a significantly higher protein expression compared to Unstable patients already at 6months on PD, when PET alterations had not been detected yet. PDE-EV proteome show alterations much earlier than PET monitoring, thus unveiling the potential of PDE-EV proteins as feasible biomarkers of PM alteration in PD patients.

Home run-results of a chronic kidney disease Telemedicine Patient Education Study.

BackgroundChronic kidney disease (CKD) incidence is increasing and associated mortality and morbidity are high. Educating patients is effective in delaying progression and establishing optimal renal replacement therapy (RRT). Tele-education/telemedicine (TM) can be an effective tool to provide such education, but there are no available data quantifying its effectiveness. We attempted to establish such evidence correlating the effect of education in patient choices and with the start of actual RRT. We present results from a 3-year pilot study evaluating the effectiveness of comprehensive predialysis education (CPE) through TM for CKD patients compared with a standard care group [face to face (FTF)]. The patient’s ability to choose RRT was the primary endpoint. MethodsThis was a randomized controlled study providing CPE over three classes at nine sites (one FTF and eight TM). Three assessment tools were utilized to compare groups: CKD knowledge, literacy and quality of life.ResultsA total of 47.1% of FTF and 52.2% of TM patients reported not having enough information to choose a modality. This decreased by the third visit (FTF 7.4%, TM 13.2%). Home modality choices more than doubled in both groups (FTF 25.8–67.7%, TM 22.2–50.1%). In patients that completed one visit and needed to start RRT, 47% started on a home modality or received a pre-emptive transplant (home hemodialysis 6%, peritoneal dialysis 38%, transplant 3%). ConclusionsResults show almost 90% (TM 87%, FTF 95%) of the attendees could choose a modality after education. Home modality choices doubled. Patients were able to make an informed choice regardless of the modality of education.

MON-185 MALIGNANCY PREVALENCE IS LOWER IN WAITLISTED POTENTIAL KIDNEY TRANSPLANT RECIPIENTS COMPARED TO KIDNEY TRANSPLANT RECIPIENTS

The optimal renal replacement therapy is kidney transplantation because it improves quality of life, prolongs survival, and is cost-effective. Malignancy became the second leading cause of death in kidney allograft recipients. The aim of this study was to the prevalence of malignancy in patients with end-stage renal disease on the kidney transplantation waiting list and in kidney allograft recipients. The cross-sectional study was conducted in 50 prevalent patients on the waiting list and 315 kidney allograft recipients in one single evaluation center and ambulatory transplantation unit covering population of about 1 mln people (9 HD units and PD unit refer potential kidney transplant recipients). Patients who had been registered in the cadaver kidney waiting list and kidney allograft recipients did not differ in regard to age, sex, dialysis vintage and causes of end-stage renal failure. In waitlisted patients only 3 had a history of malignancy (renal cell carcinoma, tongue carcinoma, gastric cancer) which account for the 3% of the population. In kidney allograft recipients, in 58 patients malignancy developed which accounts for 18% of the population studied. The leading malignancy was skin cancer- 10 cases, followed by PTLD (post-transplant lymphoproliferative disorder) in 5 cases, Kaposi sarcoma- cases, brain cancer- 2 cases, Merkel carcinoma in 2 cases, lung cancer (small cell and non-small cell), unknown origin – 2 cases and other 27 malignancies were in single patient (including one leukemia and one multiple myeloma). 18 deaths were recorded in kidney allograft recipients with malignancy mainly in PTLD, Kaposi sarcoma, Merkel carcinoma, sarcoma and brain cancer. Skin cancer has the best outcome. Concluding, waitlisted patients represent a very selected and healthier dialyzed population. As dialyzed population is getting older, we might consider to expand the possibility for older and sicker population to benefit from kidney transplantation, however, the shortage of organs makes it very difficult to implement.As prevalence of malignancy is increasing in kidney allograft recipients, screening in this population is of utmost importance. Guidelines for cancer screening in both potential transplant recipients and kidney allograft recipient should be developed as nowadays there are scarcity of data in this matter. Minimization of immunosuppressive regimen should be considered, in particular, in high risk patients.

Factores predictores para la pesquisa precoz en la disfunción de catéteres venosos tunelizados en hemodiálisis

A functional vascular access ensures a quality of life for all patients with ESRD who require optimal renal replacement therapy. Among the most frequent problems in dialysis centers regarding the management of vascular accesses is the lack of monitoring methods to detect early the dysfunction of a vascular access and thus preserve the optimal functioning of it. Purpose: in order to establish a non-invasive, specific, low-cost and reproducible method of monitoring that would achieve early detection of the dysfunction of a CVCT and be used in clinical practice by medical and nursing staff. Methodology: Aware of this problem, we performed a prospective analytical observational study in order to detect predictive factors in the dysfunction of a CVCT (tunneled central venous catheter) in hemodialysis. We analyzed 32 patients with CVCT from the dialysis center of the Pontificia Universidad Catolica de Chile, during the months of November 2016 to September 2017 (130 sessions of dialysis). We programmed all the CVCT with an effective QB (real flow registered in dialysis machine) of 300ml / min, monitoring PA (blood pressure of vascular access registered in dialysis machine) not at 150mmHg, evaluating the patient's depuration by measuring KT on line (depuration of the patient per unit of real time) in each dialysis session, taking a chest x-ray post catheter installation to evaluate the location of This and recirculation test. Results: The dysfunction of a CVCT would not be related to the type of catheter (DP-P) but to its location. The parameters of dysfunctional alert in a CVCT are decrease in BP 150mm / Hg when programming an effective QB of 300ml / min, accompanied by a deficient depuration of the patient, measured through KT on line ( men <50 liters, Women <45 liters).

Optimizing continuous renal replacement therapy in the ICU: a team strategy.

The consideration of acute kidney injury, its incidence and its impact on the outcome of patients has grown continuously in recent years, leading to an increase in the use of renal replacement therapy (RRT) techniques. However, the successful conduct of RRT depends on the effectiveness of the entire team, doctors and nurses. It is therefore important to know the essential elements to be implemented in the ICU to ensure optimal RRT. Recent studies show that the successful conduct of a RRT session requires a good knowledge of the principles of the technique, regular basic training, identification of experts, drafting clear and well followed protocols and good communication between the various stakeholders. In addition, the use of the latest advances, such as regional citrate anticoagulation, allows further optimization of therapy, only if, again, both physicians and nurses are properly trained and highly involved. We now have a better understanding of the measures to be deployed to optimize RRT. Organization, training, evaluation and protocols are the key points of the team's efficiency for a safe and effective implementation of RRT.

Malignancy in a Potential Kidney Allograft Recipients-How Important is the Problem?

The optimal renal replacement therapy is kidney transplantation because it improves quality of life, prolongs survival, and is cost-effective. However, it also bears a risk of malignancy due to immunosuppressive therapy. The aim of this study was to examine demographic and comorbidity, including history of malignancy in patients with end-stage renal disease on the kidney transplantation waiting list in regard to their status (active vs temporarily disqualified, active vs inactive). The cross-sectional study was conducted in 281 prevalent patients (over 1/3 population the waitlisted in the country). Data analysis was based on the clinical and laboratory parameters enclosed in the registration form for kidney transplantation. Patients who had been registered in the cadaver kidney waiting list were aged 50±12 in the average, with a balanced sex ratio, median dialysis duration was 39 months, mean BMI was 27±5 kg/m2, median residual renal function was 500 ml, prevalence of hepatitis B and C was below 3%, with hepatitis C being more prevalent than B (p<0.001). The leading cause of ESRD was chronic glomerulonephritis, followed by diabetic nephropathy and ADPKD. When patients were analyzed in regard to their status on the waiting list (active or temporarily non-active) total cholesterol, LDL cholesterol, aspartate aminotransferase were lower and weakly dialysis dose was higher in patients on the active list vs non-active. Clinical status, including cardiovascular status (echocardiography parameters, coronary angiography results) were similar in both groups. In the screening period history of malignancy or active malignancy was present in 50% of patients and they were temporarily disqualified. After careful evaluation, oncology consult and assessment of waiting time before enlistment 31% of the patients were outlisted (inactive status). Concluding, malignancy became a serious problem in potential kidney allograft recipients. As detailed guidelines are not available, therefore, personalized approach (oncology consult or other specialists consult) in patients with history of malignancy and active malignancy is prerequisite. After careful evaluation patients could be waitlisted taking into consideration prior history, treatment and time elapsed from the diagnosis in order to yield the best possible outcomes.

Malignancy Prevalence in Waitlisted Potential Kidney Transplant Recipients is very low Relative to Patients after Kidney Transplantation

The optimal renal replacement therapy is kidney transplantation because it improves quality of life, prolongs survival, and is cost-effective. Malignancy became the second leading cause of death in kidney allograft recipients. The aim of this study was to the prevalence of malignancy in patients with end-stage renal disease on the kidney transplantation waiting list and in kidney allograft recipients. The cross-sectional study was conducted in 50 prevalent patients on the waiting list and 300 kidney allograft recipients. Patients who had been registered in the cadaver kidney waiting list and kidney allograft recipients did not differ in regard to age, sex, dialysis vintage and causes of end-stage renal failure. In waitlisted patients only 3 had a history of malignancy (renal cell carcinoma, tongue carcinoma, gastric cancer) which account for the 3% of the population. In kidney allograft recipients, in 52 patients malignancy developed which accounts for 17% of the population studied. The leading malignancy was skin cancer- 9 cases, followed by PTLD (post-transplant lymphoproliferative disorder) in 5 cases, Kaposi sarcoma- cases, brain cancer- 2 cases, Merkel carcinoma in 2 cases, lung cancer (small cell and non-small cell), unknown origin – 2 cases and other 22 malignancies were in single patient (including one leukemia and one multiple myeloma). 17 deaths were recorded in kidney allograft recipients with malignancy mainly in PTLD, Kaposi sarcoma, Merkel carcinoma, sarcoma and brain cancer. Skin cancer has the best prognosis. Concluding, as prevalence of malignancy is increasing in kidney allograft recipients, screening in this population is of utmost importance. Guidelines for cancer screening in both potential transplant recipients and kidney allograft recipient should be developed as nowadays there are scarcity of data in this matter. Minimization of immunosuppressive regimen should be considered, in particular, in high risk patients.

Nephrologist Personality Traits and Optimal Renal Replacement Therapy Modality Initiation - "Teamwork Makes the Dream Work"

Nephrologist Personality Traits and Optimal Renal Replacement Therapy Modality Initiation - "Teamwork Makes the Dream Work"

Analysis of 4000 kidney transplantations in a single center: Across immunological barriers.

Kidney transplant (KT) is the optimal renal replacement therapy for patients with end-stage renal disease (ESRD). The demand for kidneys, however, continues to exceed the supply. To overcome this problem, efforts to extend the donor pool by including human leukocyte antigen (HLA)- and ABO-incompatible (ABOi) KTs are increasing. The aim of this article was to retrospectively review data on recipients, donor profiles, and clinical outcomes in 4000 cases of KT. In addition, we analyzed clinical outcomes in ABOi and flow-cytometric crossmatch (FCXM) positive KT in a subgroup analysis.This was a retrospective, observational study using data extracted from medical records. A total of 4000 consecutive patients who underwent KT at our institution from January 1990 to February 2015 were included in this study. KTs across immunological barriers such as ABO incompatible (276 cases, 6.9%), FCXM positive (97 cases, 2.4%), and positive complement-dependent cytotoxicity (CDC) XM KT (16 cases, 0.4%) were included.From a Kaplan–Meier analysis, overall patient survival (PS) rates after KT at 1, 5, 10, and 20 years were 96.9%, 95.1%, 92.0%, and 88.9%, respectively. The overall graft survival (GS) rates after KT at 1, 5, 10, and 20 years were 96.3%, 88.9%, 81.2%, and 67.4%, respectively. Our subgroup analysis suggested that overall PS, GS, death-censored GS, and rejection-free GS in ABOi KT showed no significant differences in comparison with ABO-compatible KT if adequate immunosuppressive treatment was performed. The overall PS rate in patients who underwent FCXM positive KT did not differ significantly from that of the control group during the 3-year follow-up (P = 0.34). The overall GS, death-censored GS, and rejection-free GS also did not differ significantly between the FCXM KT and control groups (P = 0.99, 0.42, and 88).The outcomes of KTs continually improved during the study period, while the annual number of KTs increased. ABO or FCXM positive KTs can be performed safely with successful graft outcomes.

Findings from two large randomized controlled trials on renal replacement therapy in acute kidney injury

Many issues regarding the management of renal replacement therapy (RRT) in acute kidney injury (AKI) including timing of initiation, selection of RRT modality, and optimal dosing remain to be resolved. Two major randomized controlled trials, the Veterans Affairs/National Institutes of Health (VA/NIH) Acute Renal Failure Trial Network (ATN) and the Randomized Evaluation of Normal versus Augmented Level (RENAL) studies, which were elaborately designed to evaluate the benefit for delivering RRT of higher intensity in critically ill patients, were characterized by their sophisticated design, large sample sizes, and comprehensive data collection. Although no beneficial effect of higher intensity RRT was demonstrated by these studies, many ancillary studies conducted subanalyses which provided additional findings on other important clinical questions that remained unsolved. This review aims to overview the useful information obtained by the VA/NIH ATN and the RENAL studies to gain useful insights for optimal RRT in AKI.

Outcome of hemodialysis in elderly diabetic patients: a single-center experience

The optimal renal replacement therapy for elderly patients is unclear, and literature is evolving in this regard. For elderly individuals who progress to CKD5, hemodialysis is often a valuable treatment option. Although hemodialysis is a life-sustaining therapy and extends life, it may also create, increase, or prolong suffering in selected subgroups of geriatric patients. In our current study we focused on elderly diabetic patients above 65 years, as they constitute the more vulnerable subgroup, having multiple comorbid conditions. The primary objective was to study the patient’s survival and the association with different comorbidities. We conducted a retrospective analysis of 48 type 2 diabetic patients aged above 65 years. We reviewed their survival data and comorbid conditions – namely, vascular, cognitive, and autonomy. The mortality rate was 7.5% per year with significant association with prior cerebrovascular accident, cognitive impairment, and lost autonomy.