Practice Of Dialysis Research Articles

New Technologies in Peritoneal Dialysis

In recent years, there have been some interesting advances in the science and practice of peritoneal dialysis (PD). This review focuses on selected technological advances and the impact that these changes may have on this modality. New, so-called "biocompatible" fluids have more physiologic pH and reduced glucose degradation products. These new fluids may reduce the deleterious effects of chronic exposure to the peritoneal membrane. However, enthusiasm for these new fluids is outstripping rigorous evidence that they change patient outcome. Continuous-flow PD offers a way to increase dramatically small solute clearance. However, there are significant technological barriers to the implementation of this kind of dialysis. Furthermore, there is little evidence that augmented small solute clearance will improve survival in PD patients. Finally, new catheter insertion techniques provide perhaps the most practical advances in allowing successful commencement of this excellent home dialysis modality.

Tidal PD: Its role in the current practice of peritoneal dialysis

The role of tidal peritoneal dialysis (TPD) has been the subject of several studies over the past 30 years. The use of the newest generation of cyclers combined with the increasing number of chronic peritoneal dialysis (CPD) patients being maintained on cycler therapy has stimulated a reexamination of the role of TPD in the care of CPD patients. Several studies over the past decade have examined solute clearances with TPD in patients. These studies suggest that TPD does not result in an increase in clearances when compared to conventional intermittent peritoneal dialysis (IPD). TPD is now primarily used for comfort in patients who experience pain at the start of inflow and/or at the end of outflow. In TPD, the presence of at least some fluid in the abdomen during the exchanges generally eliminates these episodes of pain. It has recently been suggested that accurate assessment of drain and fill phases during automated PD may be helpful in redefining a role for TPD in CPD patients. If the 'slow' drainage time can be kept to a minimum, then it is possible that the efficiency of PD could be enhanced. Defining the critical volume and then optimizing the TPD regimen could perhaps increase the clearances noted with TPD.

Consensus development in acute renal failure: the Acute Dialysis Quality Initiative

Although acute renal failure is both common and highly lethal in the intensive care unit, our understanding of the epidemiology and pathophysiology of acute renal failure is limited, and treatment for acute renal failure is extremely variable around the world. The general lack of consensus with regard to definitions, prevention, and treatment of acute renal failure has limited progress in this field. Consensus in acute renal failure requires establishing a framework in which intensivists, nephrologists, pharmacologists, and others who care for critically ill patients with or at risk for acute renal failure can reach consensus and develop evidence-based practice guidelines. The Acute Dialysis Quality Initiative seeks to provide an objective, dispassionate distillation of the literature and description of the current state of practice of dialysis and related therapies as they are applied to acutely ill patients. The purposes of Acute Dialysis Quality Initiative are first, to develop a consensus of opinion, with evidence where possible, on best practice; and second, to articulate a research agenda to focus on important unanswered questions. Broad consensus in the diagnosis and management of acute renal failure and in the use of blood purification in nonrenal critical illness is achievable. Standardization of definitions, practice, and research methodology is urgently needed, and specific proposals have been made by an international, interdisciplinary group.

Chronic Hemodialysis in a Nigerian Teaching Hospital

The Jos University Teaching Hospital (JUTH) has dialyzed >320 patients with ESRD since 1993.Objective: To identify differences, and their causes, in the practice of dialysis between Nigerian state‐owned dialysis units and U.S.A.Methods: We analyzed the characteristics of chronic dialysis at JUTH.Results: At JUTH, chronic dialysis is started at development of frank uremia (K/DOQI standard: creatinine clearance >10 mL/min, no overt uremia). Frequency of hemodialysis was 3 times weekly in 2 patients, twice weekly in 1 and once weekly or longer in 7 patients. Breakdowns in the dialysis machinery, which is outdated, forced additional decreases in the frequency of dialysis. Duration of a dialysis session was 4 h by prescription, but much longer in several sessions because of dialysis machine breakdown during the session (US standard: 4 h). 2 patients were dialyzed through arterio‐venous fistulas and 8 patients were dialyzed though temporary femoral vein dialysis catheters removed after each dialysis session. A vascular surgeon was unavailable. The urea reduction ratio was 45.38.6% (U.S.A target: 65%). The cost of the first dialysis session at JUTH is $160. With reuse of dialysis supplies, including dialyzers, dialysis tubing, femoral catheters, and guide wires, the cost of each subsequent dialysis session is $33. The minimal cost of dialysis with 3 dialysis sessions weekly and a new dialyzer every week is $501 per month. The cost of dialysis is borne exclusively by the patient. For comparison, average monthly income is $74 for unskilled laborers, $222 for dialysis technicians, $296 for dialysis nurses, and $889 for academic nephrologists. The low dose of dialysis has adverse effects on patient quality of life (frequent admissions with uremia). Despite notable exceptions (2 patients on dialysis for 12 and 9 years, respectively), survival of dialysis patients at JUTH appears to be poor.Conclusions: Underdialysis is frequent in Nigeria and is the consequence of socioeconomic conditions and technologic deficits. Removal of the economic burden of dialysis from the patients with ESRD is the first logical step toward correction of underdialysis.

The Practice of Dialysis in the Developing Countries

There are few organized data on the practice of dialysis in developing countries, mostly because of a lack of renal registries. The economic, human, and technical resources required for long-term dialysis make it a major economical and political challenge. Most countries do not have not well-formed policies for treatment of end-stage renal disease. The dialysis facilities are grossly inadequate, and there are no reimbursement schemes to fund long-term dialysis. Hemodialysis units are mostly in the private sector and consist of small numbers of refurbished machines. Water treatment is frequently suboptimal, and this problem has led to a number of complications. Hepatitis B and C infections are widespread in dialysis units. Continuous ambulatory peritoneal dialysis (CAPD) seems to be the ideal dialysis option for patients living in remote areas, but high costs preclude its widespread usage. The Mexican experience suggests that even after it becomes affordable, CAPD needs to be used judiciously. Inadequate dialysis, infections, and malnutrition account for the high mortality among the dialysis population in developing countries. Acute peritoneal dialysis using rigid stylet-based catheters is the main form of dialysis in remote areas. Pediatric dialysis units are almost nonexistent. A significant lack of resources exists in developing countries, making the provision of highly technical and expensive care like dialysis a challenge.

Differences in Dialysis Practice Are the Main Reasons for the High Mortality Rate in the United States Compared to Japan

The cumulative survival of Japanese hemodialysis patients is more than 2.5 times better than that of dialysis patients in the United States (U.S.). The difference is particularly pronounced in older patients, being 4 times better in patients over the age of 50 years. The mortality in U.S. patients has increased from 10 to 25% over the last three decades, but has remained stable at around 10% in Japan. There is no obvious difference in patient selection. The Japanese accept almost as high a proportion of diabetic patients as does the United States, and the mean age of incident patients is higher in Japan. Renal transplantation, virtually absent in Japan, should increase mortality in U.S. dialysis patients by removing patients with the highest probability of survival, but even if one adds surviving transplant patients and studies prevalent populations, the survival rate is much better in Japan. Genetic factors are unlikely to explain differences in mortality, as older Americans live much longer than older Japanese. We speculate that the difference lies in the practice of dialysis. Patients in the United States are generally treated by much faster and shorter dialysis than in Japan. This puts a severe burden on the cardiovascular system of older patients, leading to the poorer survival rate. Japanese physicians also appear to be better trained in dialysis and to spend more time with their patients. The nursing shortage in the United States may also contribute to the increased mortality. Whatever the explanations, the U.S. dialysis community must work to equal and, hopefully, surpass the now superior survival of Japanese dialysis patients.

Peritoneal Dialysis in the 21st Century

ABSTRACT. One of the greatest biotechnologic advances of the last 25 yr is genetic engineering—the ability to identify and isolate individual genes and transfer genetic elements between cells. Genetic engineering forms the basis of a unique biotechnology platform called gene therapy: an approach to treating disease through genetic manipulation. It is becoming clear that during peritoneal dialysis, the peritoneal membrane undergoes various structural and functional changes that compromise the dialyzing efficiency of the membrane and eventually lead to membrane failure. A gene therapy strategy based on genetic modification of the peritoneal membrane could improve the practice of peritoneal dialysis through the production of proteins that would be of therapeutic value in preventing membrane damage and preserving its dialyzing capacity. The peritoneal membrane can be genetically modified by either ex vivo or in vivo gene transfer strategies with a variety of potentially therapeutic genes, including those for anti-inflammatory cytokines, fibrinolytic factors, and antifibrotic molecules. These genes could be administered either on an acute basis, such as in response to peritonitis, or on an intermittent basis to maintain physiologic homeostasis and perhaps to prevent the adverse changes in the membrane that occur over time. The anticipated effect of a gene therapy strategy could be measured in maintenance of desired transport characteristics and in patients being able to remain on the therapy for longer periods of time without the negative outcomes. In summary, the use of a gene therapy strategy to enhance peritoneal dialysis is an innovative and exciting concept with the potential to provide new treatment platforms for patients with end-stage renal disease.

The Potential of Gene Therapy in the Peritoneal Cavity

Gene therapy is a promising new treatment modality based on molecular genetic modification to achieve a therapeutic benefit. We believe that gene therapy in the peritoneal cavity holds considerable promise, and we describe strategies by which genetic modification can be used to treat a variety of disease states or conditions. First, we can envision a strategy, based on genetic modification of the peritoneal membrane, to improve the practice of peritoneal dialysis through the production of proteins that would be of therapeutic value in preventing membrane damage and in preserving or enhancing its function as a dialyzing membrane. Second, the membrane could be genetically modified for either local or systemic delivery of therapeutic proteins. This approach could be applied to a variety of pathologies or conditions that require either sustained or transient delivery of therapeutic proteins, such as enzymes or growth factors. Third, gene transfer has already been incorporated into several strategies for the treatment of intra-abdominal carcinomas, and it has been effective in animal models of ovarian and bladder cancer and of peritoneal mesothelioma. Finally, gene transfer can be a valuable tool in increasing our understanding of the biology of the peritoneal membrane. By being able to manipulate the expression of specific genes through gene transfer, their role in various (patho)physiological processes can be identified. In summary, gene therapy in the peritoneal cavity has significant potential to address a variety of diseases or pathophysiological conditions, and to further our knowledge of peritoneal cavity biology.

Trends in treatment and survival for hemodialysis patients in the United States

Details regarding dialysis therapy have been studied by the US Renal Data System (USRDS) in four random samples of US hemodialysis patients during the years 1986 to 1997. During this decade, the delivered dose of hemodialysis therapy has increased by at least 0.2 Kt/V. The frequency of twice weekly dialysis prescription decreased, whereas the duration of each treatment showed only minor changes. A large shift to more biocompatible membranes, particularly to synthetic membranes, was observed. The use of acetate dialysate almost disappeared. Outcomes research by the USRDS showed significantly lower mortality risk associated independently with higher delivered Kt/V, substituted cellulose or synthetic membranes, and bicarbonate dialysate. The projected reduction in mortality risk from these changes in hemodialysis therapy was of a similar magnitude to the observed 14% to 17% reduction in mortality rate during the years 1990 to 1996. National observational studies of dialysis patients may influence the practice of dialysis and lead to improved survival. (Am J Kidney Dis 1998 Dec;32(6 Suppl 4):S34-8)

Prescription and Practice of Dialysis in Australia, 1988

Facilities for provision of treatment of end-stage renal failure with hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD) are available in many centers, most of which are government-funded. Medicare provides free treatment for all patients. There are no specific criteria for determining a patient's acceptance for dialysis treatment: age, quality of life, and capacity for independent living are important factors. The usual HD prescription is three dialysis periods weekly, hollow-fiber dialyzer, 1.0-1.2 m2 surface area, for 4 to 5 hours, with blood flow rate 250 mL/min and acetate-based dialysate flow rate 500 mL/min. Reuse of the dialyzer is common, but many units practice single use to reduce the expense and time necessary for processing the dialyzer and the risks of formalin exposure. There is only limited use of hemofiltration, or highly efficient dialyzers for shortened hours at higher blood flow rates. The choice of dialysis prescription is influenced by the physician's preference for the patient to be treated at home or in a self-care center with limited assistance. CAPD is preferred for home dialysis, especially for elderly or diabetic patients. There is no personal financial incentive to the physician to favor any particular form of dialysis. The costs of dialysis do influence the provision and prescription of treatment, causing the reuse of dialyzers and the limited use of bicarbonate-based HD and highly permeable dialyzers. Nevertheless, adequate dialysis should be available to all patients, and noncompliance with prescribed dialysis is infrequent. Quality-assurance programs have been developed both for nursing and medical care.(ABSTRACT TRUNCATED AT 250 WORDS)

Should patients with renal failure associated with myeloma be dialysed?

In a study of renal function in multiple myeloma seven patients presented with renal failure and three developed it 16-106 months after diagnosis. All were dialysed. Infection with dehydration was a precipitating factor in all seven cases of acute or acute on chronic renal failure. Of these, two patients recovered normal renal function and one other was left with permanent renal impairment but no longer required dialysis. Results from the seven patients with acute renal failure and for the three with more chronic features support the practice of dialysis for all patients who present with renal failure. Dialysis is not indicated for those patients with progressive myelomatous disease. The study showed no evidence that chemotherapy permitted recovery from established renal failure. The prognosis in this elderly group is heavily dependent on the presence of cardiovascular or other degenerative disease.

Renal failure and practice of peritoneal dialysis in Obstetrics and Gynecology

Renal failure and practice of peritoneal dialysis in Obstetrics and Gynecology