Preservation Of Residual Kidney Function Research Articles

PREVALENCE OF APPARENT-TREATMENT RESISTANT HYPERTENSION IN PERITONEAL DIALYSIS PATIENTS ASSESSED WITH THE USE OF 24-HOUR AMBULATORY BLOOD PRESSURE MONITORING

Objective: The prevalence of apparent-treatment resistant hypertension (aTRH) among patients with predialysis chronic kidney disease is 2–3 times higher than in the general population. The aim of the present study was to investigate the prevalence of aTRH in end-stage kidney disease (ESKD) patients undergoing peritoneal dialysis (PD). Design and method: A total of 140 ESKD patients treated with PD in 4 centers of Northern Greece underwent 24-hour ambulatory blood pressure monitoring with the oscillometric device Mobil-O-Graph (IEM, Stolberg, Germany). aTRH was defined as 24-hour ambulatory blood pressure (BP) equal or higher than 130/80 mmHg, despite the use of at least 3 antihypertensive medications of different categories or controlled hypertension in patients treated with at least 4 antihypertensives. Loop diuretics that are commonly prescribed in PD patients for long-term preservation of residual kidney function are generally ineffective in lowering BP and were not considered as a separate antihypertensive drug category in our analysis. To explore the association of volume overload with the severity of hypertension, the body composition of study participants was analyzed via bioimpendence spectroscopy (BCM, Fresenius Medical Care, Germany). Results: Of the 140 PD patients enrolled in the study, 42 (30%) had aTRH, 45 (32.1%) had uncontrolled hypertension under treatment with < 3 BP-lowering medications and the remaining 53 patients (37.9%) were either normotensives or had controlled hypertension with < 3 antihypertensives. The prevalence of aTRH among drug-treated hypertensives was 32.5%. Overhydration > 2.5L with the use of bioimpendence spectroscopy was detected in 38.1% of patients with aTRH, in 15.6% of patients with uncontrolled hypertension and in 18.9% of normotensives or patients with controlled hypertension (P< 0.05). Conclusions: The present study showed that aTRH affects approximately 30% of ESKD patients undergoing PD. However, the prevalence of true-resistant hypertension in this high-risk population is probably lower, since 38.1% of patients with aTRH had subclinical volume overload detected with the method of bioimpendence spectroscopy.

Proteomics and Extracellular Vesicles as Novel Biomarker Sources in Peritoneal Dialysis in Children.

Peritoneal dialysis (PD) represents the dialysis modality of choice for pediatric patients with end-stage kidney disease. Indeed, compared with hemodialysis (HD), it offers many advantages, including more flexibility, reduction of the risk of hospital-acquired infections, preservation of residual kidney function, and a better quality of life. However, despite these positive aspects, PD may be associated with several long-term complications that may impair both patient’s general health and PD adequacy. In this view, chronic inflammation, caused by different factors, has a detrimental impact on the structure and function of the peritoneal membrane, leading to sclerosis and consequent PD failure both in adults and children. Although several studies investigated the complex pathogenic pathways underlying peritoneal membrane alterations, these processes remain still to explore. Understanding these mechanisms may provide novel approaches to improve the clinical outcome of pediatric PD patients through the identification of subjects at high risk of complications and the implementation of personalized interventions. In this review, we discuss the main experimental and clinical experiences exploring the potentiality of the proteomic analysis of peritoneal fluids and extracellular vesicles as a source of novel biomarkers in pediatric peritoneal dialysis.

MO705: Factors Associated with Uncontrolled Ambulatory Hypertension in Peritoneal Dialysis Patients

Abstract BACKGROUND AND AIMS Hypertension among patients on long-term peritoneal dialysis (PD) is common and remains often inadequately control (Cocchi et al. Prevalence of hypertension in patients on peritoneal dialysis: results of an Italian multicentre study. Nephrol Dial Transplant. 1999; 14(6): 1536–40; Vaios et al.. Assessment and management of hypertension among patients on peritoneal dialysis. Clin J Am Soc Nephrol. 2019; 14(2): 297–305). The aim of the present study was to describe the epidemiology of hypertension using the ‘gold-standard’ method of ambulatory blood pressure monitoring (ABPM) and to identify determinants of inadequate ambulatory blood pressure (BP) control in this high-risk population. METHOD In 140 stable patients receiving PD in four centers of Northern Greece, we performed 24-h ABPM using the oscillometric Mobil-O-Graph device (IEM, Stolberg Germany) (Franssen and Imholz. Evaluation of the Mobil-O-Graph new generation ABPM device using the ESH criteria. Blood Press Monit. 2010; 15(4): 229–31). Hypertension was defined as 24-h ambulatory BP ≥ 130/80 mmHg or current use of at least 1 BP-lowering medication (Williams et al. 2018 ESC/ESH guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018; 36(10): 1953–2041). The volume status of study participants was assessed with the method of bioimpedance spectroscopy (Fresenius Medical Care, Bad Homburg, Germany). Univariate and multivariate binary logistic regression analysis was performed to identify factors that were independently associated with uncontrolled ambulatory hypertension. RESULTS Ambulatory hypertension was diagnosed in 95% of the patients enrolled in the study. Despite the fact that 96.9% of hypertensives were being treated with an average of 2.4 BP-lowering medications daily, adequate control of 24-h ambulatory BP was achieved in only 38.3% of them. In univariate regression analysis, there was a significant interaction of uncontrolled ambulatory hypertension with the mode of PD, history of cardiovascular disease and smoking status. In multivariate analysis, among variables inserted in the model, the higher overhydration index in bioimpedance spectroscopy [odds ratio (OR): 1.308; 95% confidence interval (CI): 1.023–1.673/L higher overhydration] and the history of cardiovascular disease (OR: 3.069; 95% CI: 1.157–8.140) were the two factors that were associated with higher odds of uncontrolled ambulatory hypertension. In contrast, the presence of residual diuresis ≥ 0.5 L/24 h (OR: 0.304; 95% CI: 0.105–0.881) was the only parameter associated with lower odds of inadequate ambulatory BP control. CONCLUSION Among patients on PD, ambulatory hypertension is highly prevalent and remains often poorly controlled, despite the extensive use of antihypertensive drug therapy. Achievement of adequate volume control and long-term preservation of residual kidney function appear to be two attractive non-pharmacological strategies for optimization of the management of hypertension in this high-risk population.

Future Directions for Dialysis

Dialysis is life-saving for an exponentially growing number of kidney failure patients. Yet, the current concept also has several drawbacks, such as high societal cost, incomplete kidney function replacement, dismal outcomes, low quality of life and a considerable ecologic footprint. In spite of many changes over the last fifty years, the original concept remained largely unmodified and the drawbacks did not disappear. In this article, we present a number of alternative solutions that are currently considered or tested which might have a potential impact on uremic toxin concentration, quality of life or environmental footprint that goes beyond what is currently achieved with traditional dialysis. These comprise applications of regenerative medicine; bioartificial kidney; conceptual changes in extracorporeal removal; energy-neutral, water-limiting dialysis; material recycling; keto-analogues; xenobiotics; and preservation of residual kidney function. As metabolism generating uremic toxins also generates beneficial compounds, some of these options may also maintain or restore this balance in contrast to dialysis that likely removes without distinction. All proposed options are also exemplary of how out-of-the-box thinking is needed to disrupt the status quo in treatment of kidney diseases that has now persisted for too long.

Benefits of Incremental Hemodialysis Seen in a Historical Cohort Study.

PurposePrevious research on incremental hemodialysis transition has mainly focused on one or two benefits or prognoses. We aimed to conduct a comprehensive analysis by investigating whether incremental hemodialysis was simultaneously associated with adequate dialysis therapy, stable complication indicators, long-lasting arteriovenous vascular access, and long-lasting preservation of residual kidney function (RKF) without increasing mortality or hospitalization.Patients and MethodsIncident hemodialysis patients from Huashan Hospital in Shanghai, China, over the period of 2012 to 2019, were enrolled and followed every three months until death or the time of censoring. Changes in complication indicators from baseline to all post-baseline visits were analyzed by mixed-effects models. The outcomes of RKF loss, arteriovenous vascular access complications, and the composite of all-cause mortality and cardiovascular events were compared between incremental and conventional hemodialysis by Cox proportional hazards model.ResultsOf the 113 patients enrolled in the study, 45 underwent incremental and 68 conventional hemodialysis. There were no significant differences in the changes from baseline to post-baseline visits in complication indicators between the two groups. Incremental hemodialysis reduced the risks of RKF loss (HR, 0.33; 95% CI, 0.14–0.82), de novo arteriovenous access complication (HR, 0.26; 95% CI, 0.08–0.82), and recurrent arteriovenous access complications under the Andersen–Gill (AG) model (HR, 0.27; 95% CI, 0.10–0.74) and the Prentice, Williams and Peterson Total Time (PWP-TT) model (HR, 0.31; 95% CI, 0.12–0.80). There were no significant differences in all-cause hospitalization or the composite outcome between groups.ConclusionIncremental hemodialysis is an effective dialysis transition strategy that preserves RKF and arteriovenous access without affecting dialysis adequacy, patient stability, hospitalization risk and mortality risk. Randomized controlled trials are warranted.

A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function

Twice-weekly hemodialysis, as part of incremental initiation, has reported benefits including preservation of residual kidney function (RKF). To explore this, we initiated a randomized controlled feasibility trial examining 55 incident hemodialysis patients with urea clearance of 3 ml/min/1.73 m2 or more across four centers in the United Kingdom randomized to standard or incremental schedules for 12 months. Incremental hemodialysis involved twice-weekly sessions, upwardly adjusting hemodialysis dose as RKF was lost, maintaining total (Dialysis+Renal) Std Kt/V above 2. Standard hemodialysis was thrice weekly for 3.5-4 hours, minimum Dialysis Std Kt/V of 2. Primary outcomes were feasibility parameters and effect size of group differences in rate of loss of RKF at six months. Health care cost impact and patient-reported outcomes were explored. Around one-third of patients met eligibility criteria. Half agreed to randomization; 26 received standard hemodialysis and 29 incremental. At 12 months, 21 incremental patients remained in the study vs 12 in the standard arm with no group differences in the urea clearance slope. Ninety-two percent of incremental and 75% of standard arm patients had a urea clearance of 2 ml/min/1.73 m2 or more at six months. Serious adverse events were less frequent in incremental patients (Incidence Rate Ratio 0.47, confidence interval 0.27-0.81). Serum bicarbonate was significantly lower in incremental patients indicating supplementation may be required. There were three deaths in each arm. Blood pressure, extracellular fluid and patient-reported outcomes were similar. There was no signal of benefit of incremental hemodialysis in terms of protection of RKF or Quality of Life score. Median incremental hemodialysis costs were significantly lower compared to standard hemodialysis. Thus, incremental hemodialysis appears safe and cost-saving in incident patients with adequate RKF, justifying a definitive trial.

YouTube as a platform for knowledge and awareness of peritoneal dialysis: A content analysis.

One of the main barriers to choosing peritoneal dialysis (PD) is the lack of awareness and PD knowledge. There is an increasing trend in the use of the internet as a search tool for health-related information. This study aims to determine how useful YouTube videos are to get information about PD. YouTube videos were evaluated independently by two nephrologists. The videos' quality was assessed with DISCERN scoring system, global quality score (GQS) and the Journal of the American Medical Association (JAMA) scoring system. We determined the quartile (Q) of the videos as follows: most reliable top 25% videos Q1 and others Q2-4. A total of 295 videos were evaluated. University or society-sourced videos made up 15% (n = 43) of all videos, and healthcare providers were the primary target audience compared to patients (p < 0.001). JAMA, GQS and DISCERN scores were significantly higher for the videos that were targeted healthcare providers compared to the patients (p < 0.001, for all). A total of 34% of the videos in Q1 were obtained from the university or society. Nevertheless, only 17% of the videos prepared for the patients were among the Q1. A small number of videos mentioned that PD maintains the residual kidney function (RKF) longer compared to haemodialysis. Universities and societies should upload videos to provide easy-to-understand information on PD. Also, the important benefits of PD, like the preservation of RKF, should be further highlighted in these videos. It may increase the PD penetrance by increasing patients' awareness.

Incremental Versus Conventional Hemodialysis for Preservation of Residual Kidney Function in Patients on Regular Hemodialysis

Incremental hemodialysis has many potential benefits to patients clinicians and health systems.The aim of this work was to evaluate incremental hemodialysis twice/week compared with conventional dialysis thrice/week for preservation of the residual kidney function among patients initiating regular hemodialysis.Study design Prospective, comparative study.Setting Nephrology department Military Hospitals AL-maadi kobry AL-koba and air force military hospital.Subjects We assigned 40 patients with chronic kidney disease stage V D who early started hemodialysis into2 groups Group1:20 patients underwent incremental hemodialysis twice/week and Group2:20 patients underwent conventional hemodialysis thrice/week.Methods: All patients followed for laboratory findings of complete blood picture creatinine urea calcium albumin phosphorus parathyroid hormone alkaline phosphatase glomerular filtration rate. Also Kt/v at start and every month was done.Clinical outcome measures included mortality cardiovascular outcome hospital admission and dialysis complications.Results: In the studied population,the mean age was45.95±2.97 years.Regarding sex 60% were males and 40% were females. Regarding outcome data20%of patients had hypotension15%had hospital admission,while nobody suffered mortality.Comparative study betwee the 2 groups revealed; significant decrease in hypotension incidence in incremental group 40%compared to conventional group 10% p=0.03.Conclusion: To conclude, our study examines associations between HD treatment frequency and patient survival. In agreement with recent literature,30,31 our findings suggest that in an incident HD population, certain selected patients with adequate RKF, adequate control of interdialytic weight gain,and low or moderate comorbid disease burden CCI <5 an incremental HD approach

Impact of cooled hemodialysis for preservation of residual kidney function among Egyptian patients

Background/aim Emerging evidence on lowering dialysate temperature suggests a cardiorenal protective effect of dialysate cooling (CD) against dialysis-induced ischemia in hemodialysis (HD) patients prone to intradialytic hypotension (IDH). Whether this benefit of CD could be extended to incident HD populations without baseline IDH to preserve residual kidney function (RKF) is unknown. Patients and methods One hundred incident HD patients were randomly assigned to receive either incremental CD less than or equal to 36°C (intervention, N=50 patients) or standard-temperature (ST) dialysate (control, N=50 patients) for 12 months. The primary endpoint was to test the safety and efficacy of CD to preserve RKF. Results By the end of 12 months, CD patients showed less decline in estimated glomerular filtration rate compared with standard-temperature patients (6.2 vs. 4.6 ml/min/1.73 m2, P=0.025); in addition, Cox regression analysis showed that CD was an independent variable for the preservation of RKF (P=0.044, hazard ratio: 0.478, confidence interval: 0.23–0.89). CD was well tolerated, with less fatigue and IDH; however, coldness, shivering, and discomfort were significantly higher in the CD group. Conclusion In incident HD patients without baseline IDH, cooled dialysis might help preserve RKF with a reasonable safety profile. Further studies are warranted to explore these findings.

Aortic stenosis in patients with kidney failure: Is there an advantage for a PD-first policy?

Aortic stenosis (AS) is the most common valvular disease. It is twice as prevalent in patients with kidney failure as compared to the general population. In addition, AS progresses at a faster rate and is associated with a higher risk of death and poorer quality of life in patients on dialysis. Chronic kidney disease-mineral and bone disorder (CKD-MBD), inflammation, and hemodynamic disturbances contribute to the pathophysiology and progression of AS. Whether the type of dialysis modality, that is, hemodialysis (HD) versus peritoneal dialysis (PD), has a differential impact on the development and progression of AS in patients with kidney failure remains debated. Recent data indicate that the prevalence of valvular calcifications might be lower and the development of AS delayed in PD patients, as compared to those treated with HD. This could be accounted for by several mechanisms including reduced valvular shear stress, better preservation of residual kidney function (with better removal of protein-bound uremic toxins and CKD-MBD profile), and lower levels of systemic inflammation. Given the high morbidity and mortality rates related to interventional procedures in the population with kidney failure, surgical and transcatheter aortic valve replacement should be considered in selected patients with severe AS. Strategies slowing down the progression of aortic valve remodeling should remain the cornerstone in the management of individuals with kidney failure and mild to moderate AS. This review explores the potential benefits of PD in patients with kidney failure and AS and provides some clues to help clinicians in the decision-making process when options for kidney replacement therapy are considered in patients with AS.

P1531DIURETIC USE IN HEMODIALYSIS PATIENTS: BENEFIC ASSOCIATION WITH RESIDUAL RENAL FUNCTION AND ALL-CAUSE MORTALITY

Abstract Background and Aims In patients with end-stage renal disease (ESRD) on hemodialysis, the preservation of residual kidney function may result in a diversity of benefits in terms of survival and quality of life. The control of fluid and electrolyte homeostasis may play an important role in this setting. Elevated predialysis serum potassium is a common electrolyte disturbance that may worsen patient’s outcomes. Our aim was to study the impact of furosemide therapy in predialysis serum potassium levels, indicators of estimated residual renal function, and inflammatory markers, in ESRD patients under hemodialysis; moreover, we aimed to study the impact of furosemide-associated changes on mortality rate. Method A cross-sectional study was carried out on 289 adult patients on chronic dialysis therapy (hemodiafiltration and high flux hemodialysis). Patients were divided in 2 groups: the diuretic group (DG, n=116; 120.0 (IQR: 80-160) mg/daily median furosemide dose) and the non-diuretic group (NDG, n = 173), in which patients did not use furosemide. A large set of data was analyzed, encompassing hematological data, serum electrolyte parameters, inflammatory markers, dialysis adequacy, and biomarkers of residual kidney function. A 2-year follow up study was also performed by registering events of death (all-cause mortality). Results The DG patients, compared with NDG patients, presented: significantly lower predialysis serum potassium; more favorable blood biomarkers of kidney function - lower β-trace protein, cystatin C, creatinine and urea; greater residual glomerular filtration rate derived from equations with cystatin C, creatinine and creatinine–cystatin C; lower inflammation (significantly lower levels of high-sensitivity C-reactive protein); intradialytic ultrafiltration volume (L) was similar for the two groups. Mortality was significantly lower for DG patients, compared with NDG (13.6% versus 24.7%; P=0.029). Conclusion In ESRD patients under chronic dialysis, we found a significant association between current diuretic therapy and lower predialysis serum potassium levels, more favorable biomarkers of kidney function and a decreased inflammatory response that seem to contribute to a higher survival rate. Acknowledgments: The work was supported by UIDB/04378/2020 with funding from FCT/MCTES through national funds, by North Portugal Regional Coordination and Development Commission (CCDR-N)/NORTE2020/Portugal 2020 (Norte-01-0145-FEDER-000024) and by REQUIMTE-Rede de Química e Tecnologia-Associação in the form of a researcher (S. Rocha) – project Dial4Life co-financed by FCT/MCTES (PTDC/MEC-CAR/31322/2017) and FEDER/COMPETE 2020 (POCI-01-0145-FEDER-031322).

Residual kidney function in nocturnal vs conventional haemodialysis patients: a prospective observational study.

Residual kidney function (RKF) provides substantial volume and solute clearance even after dialysis initiation. Preservation of RKF is associated with improved outcomes including mortality in patients on both peritoneal and haemodialysis (HD). Factors predicting RKF loss are unclear, including HD modality. Nocturnal haemodialysis (NHD) may result in less aggressive fluid and solute shifts, however, retrospective data suggests frequent NHD may accelerate RKF decline. The aim of the study was to determine if decline in RKF differs between patients undergoing conventional haemodialysis (CHD) versus NHD. A prospective observational study of incident HD patients was undertaken comparing patients undertaking CHD (4-5h, 3days/week) and NHD (8h, 3-5 nights/week). Change in RKF was measured by urea and creatinine clearance (48-h interdialytic urine collection) and glomerular filtration rate (GFR) (Cr51-EDTA nuclear scan) at initiation of dialysis (baseline) and 12months. A total of 18 incident HD patients were recruited (8 CHD, 10 NHD). Three patients withdrew after baseline (n = 15). Baseline RKF was similar between groups with mean nuclear GFR of 13.3 ± 4.1mL/min in the CHD cohort vs 13.5 ± 4.6mL/min in the NHD group (p = 0.89). Baseline urine volume was 2399 ± 950mLs and 2794 ± 1662mLs in the CHD and NHD, respectively (p = 0.57). Nuclear GFR declined from time 0 to 12months to 9.3 ± 2.5mL/min and 10.4 ± 4.3mL/min in the CHD and NHD, respectively (p = 0.52). There was a significant decline in 48-h urine volume over 12months with a mean volume of 1943 ± 1087.0mLs in the CHD compared to 601.7 ± 315.3mLs in the NHD (p = 0.01). No significant difference was found in other measures of RKF between groups over 12months. This small prospective cohort study found that the loss of residual urine volume was greater in the NHD vs the CHD cohort but there was no difference in other measures of RKF.

Prescribing high-quality peritoneal dialysis: The role of preserving residual kidney function

Maintenance of residual kidney function (RKF) is independently associated with increased survival in patients with end-stage renal disease. Presence of RKF is also associated with improved volume status, better nutritional status, reduced erythropoietin requirement, and decreased rate of peritonitis in patients on peritoneal dialysis (PD). Thus, the preservation of RKF is an important therapeutic end point in the management of patients on PD. Measurement of RKF in PD patients should be based on the mean of 24-h urinary creatinine and urea clearances, and ideally, this should be done quarterly. Compared to those started on hemodialysis, patients initiated on PD appear to have slower decline in RKF. The choice of PD modality should be based on patient preference, as there is no clear evidence to date showing one modality is superior than the other in preserving RKF. Peritoneal dialysates with neutral pH and low glucose degradation products seem to have a favorable effect on RKF. An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker should be used whenever possible to preserve RKF and reduce cardiac mortality. Both loop diuretics and icodextrin can be utilized to maintain fluid balance in PD patients. However, caution should be taken to avoid volume depletion which could accelerate RKF decline. Short-term use of aminoglycosides does not have a detrimental impact on RKF, but prolonged use (>3 weeks) should be avoided to minimize the risk of ototoxicity. Lastly, potential nephrotoxic agents such as intravenous contrast should be used judiciously.

Advancing American Kidney Health: Perspective from DaVita, Inc.

Advancing American Kidney Health (AAKH) ([1][1]) has the potential to transform kidney care in America and outlines what the kidney care community has been striving to achieve for decades, as described in the recently released Kidney Care Partners Kidney Care First initiative ([2][2]). This includes

IHDIP: a controlled randomized trial to assess the security and effectiveness of the incremental hemodialysis in incident patients

BackgroundMost people who make the transition to renal replacement therapy (RRT) are treated with a fixed dose thrice-weekly hemodialysis réegimen, without considering their residual kidney function (RKF). Recent papers inform us that incremental hemodialysis is associated with preservation of RKF, whenever compared with conventional hemodialysis. The objective of the present controlled randomized trial (RCT) is to determine if start HD with one sessions per week (1-Wk/HD), it is associated with better patient survival and other safety parameters.Methods/designIHDIP is a multicenter RCT experimental open trial. It is randomized in a 1:1 ratio and controlled through usual clinical practice, with a low intervention level and non-commercial. It includes 152 incident patients older than 18 years, with a RRF of ≥4 ml/min/1.73 m2, measured by renal clearance of urea (KrU). The intervention group includes 76 patients who will start with incremental HD (1-Wk/HD). The control group includes 76 patients who will start with thrice-weekly hemodialysis régimen. The primary outcome is assessing the survival rate, while the secondary outcomes are the morbidity rate, the clinical parameters, the quality of life and the efficiency.DiscussionThis study will enable to know the number of sessions a patient should receive when starting HD, depending on his RRF. The potentially important clinical and financial implications of incremental hemodialysis warrant this RCT.Trial registrationU.S. National Institutes of Health, ClinicalTrials.gov. Number: NCT03239808, completed 13/04/2017. Sponsor: Foundation for Training and Research of Health Professionals of Extremadura.

Incremental dialysis in ESRD: systematic review and meta-analysis.

Incremental dialysis may preserve residual renal function and improve survival in comparison with full-dose dialysis; however, available evidence is limited. We therefore compared all-cause mortality and residual kidney function (RKF) loss in incremental and full-dose dialysis and time to full-dose dialysis in incremental hemodialysis (IHD) and incremental peritoneal dialysis (IPD). We performed a systematic review and meta-analysis of cohort studies of adults with ESRD starting IHD and IPD. We identified in PubMed and Web of Science database all cohort studies evaluating incremental dialysis evaluating three outcomes: all-cause mortality, RKF loss, time to full dialysis. IPD was defined as < 3 daily dwells in Continuous Ambulatory Peritoneal Dialysis and < 5 sessions per week in Automated Peritoneal Dialysis, while IHD was defined as < 3 HD sessions per week. 22 studies (75,292 participants), 15 in HD and 7 in PD, were analyzed. Mean age at dialysis start was 62 and 57years in IHD and IPD subjects, respectively. When compared to full dose, incremental dialysis (IHD or IPD) had an overall mortality risk of 1.14 [95% CI 0.85-1.52] with high heterogeneity among studies (I2 86%, P < 0.001), and lower mean RKF loss (- 0.58ml/min/months, 95% CI 0.16-1.01, P = 0.007). Overall, time to full-dose dialysis was 12.1months (95% CI 9.8-14.3) with no difference between IHD and IPD (P = 0.217). Incremental dialysis allows longer preservation of RKF thus deferring full-dose dialysis, by about 1 year in HD and PD, with no increase in mortality risk. Large and adequate studies are needed to confirm these findings.

The evaluation of residual kidney function in patients with ckd vd and approaches of its preservation

The work is a literature review. Residual kidney function (RKF) is one of the crucial indicators of mortality and quality of life in patients with chronic kidney disease. Residual renal function provides better control of hydration, blood pressure, clearance of substances with low and middleweight, anemia, Ca/P metabolism, chronic inflammation. However, approaches to preservation of RKF in dialysis patients have been studied not enough, the importance of RKF preservation is underlined. The wide range of predictors of RKF loss are presented in the article, approaches to measurement of RKF, the relationship between level and presence of RKF with survival and mortality of patients with CKD 5D were analyzed. The possibility of RKF preservation and extension using different approaches by correction of dialysis prescription were estimated. There is no standardized method for applying incremental hemodialysis in practice. Onceto twice-weekly hemodialysis regimens are often used randomly, without knowing the benefit for current patient or how to escalate the dialysis dose if RKF declines over time. It is important to change the HD/HDF prescription according to the range of RRF using objective data.

Incremental dialysis for preserving residual kidney function-Does one size fit all when initiating dialysis?

While many patients have substantial residual kidney function (RKF) when initiating hemodialysis (HD), most patients with end stage renal disease in the United States are initiated on 3-times per week conventional HD regimen, with little regard to RKF or patient preference. RKF is associated with many benefits including survival, volume control, solute clearance, and reduced inflammation. Several strategies have been recommended to preserve RKF after HD initiation, including an incremental approach to HD initiation. Incremental HD prescriptions are personalized to achieve adequate volume control and solute clearance with consideration to a patient's endogenous renal function. This allows the initial use of less frequent and/or shorter HD treatment sessions. Regular measurement of RKF is important because HD frequency needs to be increased as RKF inevitably declines. We narratively review the results of 12 observational cohort studies of twice-weekly compared to thrice-weekly HD. Incremental HD is associated with several benefits including preservation of RKF as well as extending the event-free life of arteriovenous fistulas and grafts. Patient survival and quality of life, however, has been variably associated with incremental HD. Serious risks must also be considered, including increased hospitalization and mortality perhaps related to fluid and electrolyte shifts after a long interdialytic interval. On the basis of the above literature review, and our clinical experience, we suggest patient characteristics which may predict favorable outcomes with an incremental approach to HD. These include substantial RKF, adequate volume control, lack of significant anemia/electrolyte imbalance, satisfactory health-related quality of life, low comorbid disease burden, and good nutritional status without evidence of hypercatabolism. Clinicians should engage patients in on-going conversations to prepare for incremental HD initiation and to ensure a smooth transition to thrice-weekly HD when needed.

Hémodialyse incrémentale

The majority of incidental haemodialysis patients are systematically treated at the rate of three sessions per week, regardless of their level of residual kidney function. Incremental haemodialysis is a therapeutic strategy adapted to the residual kidney function level of each patient, to offer patients only the “dialysis dose” needed to supplement their residual kidney function, while ensuring that they achieve the objective of total clearance (renal+per-HD) recommended (weekly Standard Kt/V urea>2.3 volumes. Incremental haemodialysis therefore allows a lower dose and lower dialysis frequency in patients with residual kidney function. Incremental haemodialysis through better residual kidney function preservation could improve patient survival and also have other benefits in terms of quality of life, preservation of vascular access and in terms of decreased expenditure health. Some logistical hurdles make its safely prescription still difficult but software should soon be made available to practitioners for a simpler and more accurate daily management of this prescription.

Assessment of dialysis adequacy: beyond urea kinetic measurements

Adequacy of dialysis is a term that has been used for many years based on measurement of small solute clearance using urea and creatinine. This has been shown in some but not all studies in adults to correlate with survival. However, small solute clearance is just one minor part of the effectiveness of dialysis and in fact ‘optimum’ dialysis, rather than ‘adequate’ dialysis is what most paediatric nephrologists would want for their patients. Additional ways to assess the success of dialysis in children would include dialysis access complications and longevity, preservation of residual kidney function, body composition, biochemical and haematological control, nutrition and growth, discomfort during the dialysis process and psychosocial adjustment including hospitalisation and school attendance. These criteria need to be balanced against a dialysis programme that has the least possible adverse effects on quality of life.