Preservation Of Residual Renal Function Research Articles

Pharmacologic therapeutics in sarcopenia with chronic kidney disease.

Inflammation, metabolic acidosis, renin-angiotensin system activation, insulin resistance, and impaired perfusion to skeletal muscles, among others, are possible causes of uremic sarcopenia. These conditions induce the activation of the nuclear factor-kappa B and mitogen-activated protein kinase pathways, adenosine triphosphate ubiquitin-proteasome system, and reactive oxygen species system, resulting in protein catabolism. Strategies for the prevention and treatment of sarcopenia in chronic kidney disease (CKD) are aerobic and resistance exercises along with nutritional interventions. Anabolic hormones have shown beneficial effects. Megestrol acetate increased weight, protein catabolic rate, and albumin concentration, and it increased intracellular water component and muscle mass. Vitamin D supplementation showed improvement in physical function, muscle strength, and muscle mass. Correction of metabolic acidosis showed an increase in protein intake, serum albumin levels, body weight, and mid-arm circumference. The kidney-gut-muscle axis indicates that dysbiosis and changes in gut-derived uremic toxins and short-chain fatty acids affect muscle mass, composition, strength, and functional capacity. Biotic supplements, AST-120 administration, hemodiafiltration, and preservation of residual renal function are alleged to reduce uremic toxins, including indoxyl sulfate (IS) and p-cresyl sulfate (PCS). Synbiotics reversed the microbiota change in CKD patients and decreased uremic toxins. AST-120 administration changed the overall gut microbiota composition in CKD. AST-120 prevented IS and PCA tissue accumulation, ameliorated muscle atrophy, improved exercise capacity and mitochondrial biogenesis, restored epithelial tight junction proteins, and reduced plasma endotoxin levels and markers of oxidative stress and inflammation. In a human study, the addition of AST-120 to standard treatment had modest beneficial effects on gait speed change and quality of life.

Peritoneal Dialysis in High-Risk Occupations.

Renal Replacement Therapy (RRT), involving two modalities of dialysis, namely haemodialysis (HD) and/or peritoneal dialysis (PD) remain the mainstay of therapy for patients with End Stage Renal Disease (ESRD) worldwide. The goals of renal replacement therapy are multi-pronged. They are not only limited to ensuring patient survival, but also improving patient overall well-being and quality of life. The relationship between employment and quality of life are often closely linked.  Peritoneal dialysis provides patients with greater flexibility, independence and control over their treatment. This is particularly advantageous to the working ESKD patients. On the other hand, HD sessions can often interfere with work schedules due to HD facility attendance and the duration of each session. This case report highlights PD and its impact on improved quality of life by specifically supporting the case patient ‘s ability to maintain employment as a commercial truck driver. In addition, it edifies both ESRD patients and clinicians, particularly in developing countries, on the advantages of PD. These advantages extend beyond the physiological preservation of residual renal function and patient survival, but also embody the improvement of the overall well-being and quality of patients’ lives by broadening the employment horizon of patients in even high-risk occupations such as commercial truck driving.

#2674 ASSOCIATION BETWEEN SARCOPENIA, BODY COMPOSITION AND FRAILTY IN PERITONEAL DIALYSIS PATIENTS: A MULTI-CENTRIC STUDY

Abstract Background and Aims Patients with chronic kidney disease (CKD) have an increased risk of mortality due to many causes. One of them is sarcopenia, a progressive skeletal muscle disorder that increases adverse outcomes such as fractures, falls, and physical disability, and has been considered an independent risk factor for mortality. Sarcopenia could be defined as a muscle failure in which muscle strength is the most solid measure of muscle function and a better predictor of adverse events rather than muscle mass. Grip strength is considered a reliable surrogate for measures of arm and leg strength. The aim of this study was to evaluate the prevalence of probable sarcopenia in peritoneal dialysis (PD) patients and its association with body composition and several clinical variables. Method This retrospective multi-centric descriptive study was conducted at the Hospital de Santa Cruz (Lisboa) and Hospital Universitario de Badajoz (Badajoz). We performed a single evaluation of 62 patients on peritoneal dialysis from at least 3 months, aged >18 years in whom we measured muscle strength by handgrip strength using a dynamometer. We divided patients into two groups, using cut-off points to consider probable sarcopenia for men and women less than 27 kg and 16 kg, respectively. Patients with acute infection, amputated limbs, and implantable cardiac devices were excluded. The following data were analyzed: age, anthropometric variables, gender, duration, modality of PD, presence of hypertension, diabetes, and cardiovascular disease, obtained from electronic medical records. We also analyze data from body composition using a bioelectrical impedance device (overhydration, extracellular intracellular water ratio (E/I), lean and fat tissue index and phase angle), PD parameters (weekly urea Kt/v, nGFR, D/P Cr, nPCR, residual urine output) and measured serum concentrations of hemoglobin, PCR, NT-ProBNP, PTH, Ca-125, calcium, and phosphorus. We assessed patients for the Clinical Fragility Scale (CFS) and measured performance in activities of daily living using the Barthel Scale. Results Records of 62 patients, 61% male, mean age 57 ± 22 years, and body mass index 27.5 ± 5.1 kg/m2 were reviewed, with 15 (18.8%) classified as probable sarcopenic. Old age (p = 0.005), high CFS score (p = 0.005), E/I ratio (p < 0,001), and low values of lean tissue index (p < 0.031), mean phase angle (p < 0.001) and residual urine output (p < 0,018) were correlated with the presence of probable sarcopenia. In the multivariable analysis, age (HR 1.135; CI 95% 1.015 - 1.269), CFS score (HR 2.637; CI 1,008 - 6,900), and urine output (HR 0,996; CI 95% 0.993 - 0.999) were also related to probable sarcopenia. There was no association between the presence of anemia, cardiovascular disease, type of peritoneal transport, and clearance of small solutes. Conclusion This study reported a low prevalence of probable sarcopenia in PD patients. We corroborate the association between age and frailty in the sarcopenic group. The percentage of extracellular water, muscle mass, and phase angle measured by bioimpedance could be useful variables to identify sarcopenic or at-risk patients. In multivariate analysis, age, higher CFS score, and urine output have been associated with sarcopenia. Preservation of residual renal function seems to be associated with less sarcopenia, which reinforces the importance of preserving residual renal function in PD patients. It's also important to identify sarcopenic or at-risk patients in order to promote early detection and treatment.

The role of residual renal function on potassium intake and excretion in patients on peritoneal dialysis.

Patients on chronic dialysis are at increased risk of developing disorders in potassium balance. The preservation of residual renal function (RRF), frequently observed in patients on peritoneal dialysis (PD), may contribute to better control of serum potassium. This study aimed to investigate the role residual renal function on potassium intake and excretion in PD patients. In this cross-sectional study, dietary potassium was evaluated by the 3-day food record. Potassium concentration was determined in serum, 24h dialysate, stool ample, and 24h urine of patients with diuresis > 200mL/day, who were considered non-anuric. Fifty-two patients, 50% men, 52.6 ± 14.0years, and PD vintage 19.5 [7.0-44.2] months, were enrolled. Compared to the anuric group (n = 17, 33%), the non-anuric group (n = 35, 67%) had lower dialysate potassium excretion (24.8 ± 5.3 vs 30.9 ± 5.9mEq/d; p = 0.001), higher total potassium intake (44.5 ± 16.7 vs 35.1 ± 8.1mEq/d; p = 0.009) and potassium intake from fruit (6.2 [2.4-14.7] vs 2.9 [0.0-6.0]mEq/d; p = 0.018), and no difference in serum potassium (4.8 ± 0.6 vs 4.8 ± 0.9mEq/L; p = 0.799) and fecal potassium (2.2 ± 0.5 vs 2.1 ± 0.7mEq/L; p = 0.712). In non-anuric patients, potassium intake correlated directly with urinary potassium (r = 0.40; p = 0.017), but not with serum, dialysate, or fecal potassium. In the anuric group, potassium intake tended to correlate positively with serum potassium (r = 0.48; p = 0.051) and there was no correlation with dialysate or fecal potassium. The presence of residual renal function constitutes an important factor in the excretion of potassium, which may allow the adoption of a less-restrictive diet.

Inkapsulirajuća peritoneumska skleroza - retka i ozbiljna komplikacija peritoneumske dijalize - prikaz slučaja

Introduction: End-stage renal disease is a terminal illness with a glomerular filtration rate of less than 15 mL/min. when must start one of the methods of renal replacement therapy: hemodialysis, peritoneal dialysis or kidney transplantation. Peritoneal dialysis is based on the processes of diffusion and osmosis, while the transport of substances takes place through the peritoneal membrane. The advantages of peritoneal dialysis compared to hemodialysis include longer-term preservation of residual renal function, preservation of blood vessels and a better quality of life for the patient. Complications of peritoneal dialysis can be infectious, metabolic and mechanical. Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis (PD) treatment. The incidence of EPS is variable between 0.7 and 3.7%, while it increases with the length of PD treatment (0.7-6.4% after 5 years to as much as 17.2% after 15 years). The diagnosis of EPS is based on clinical symptoms. and signs as well as specific, but not pathognomonic, radiological and pathohistological findings. Features of IPS on computed tomography (CT) images are thickening and calcification of the peritoneal membrane, thickening of the intestinal wall, narrowing and dilatation of the in-testine, as well as "trapped" fluid collections. Case report: A 60-year-old patient, who has been treated with peritoneal dialysis for 4 years, was hospitalized due to severe gastrointestinal complaints. Due to clinical findings a peritoneal equilibration test was performed, which determined that it was a moderately fast transporter. Based on the findings of the computed tomography, the diagnosis was confirmed. Treatment is started tamoxifen and prednisone was started, the response to therapy was positive. Despite the control of sclerosing peritonitis, death occurred because of cardiac decompensation. Conclusion: Early diagnosis is necessary to start specific treatment in a timely manner and, if possible, preserve peritoneal dialysis as a treatment method and patient survival.

Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units

Summary Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysisTransitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.

Incremental peritoneal dialysis after unplanned start initiation.

Incremental peritoneal dialysis (PD) is characterized as less than a "standard dose" PD prescription. Compared to standard treatment, it has many potential advantages, including better preservation of residual renal function, a lower risk of peritonitis, and a decreased care delivery burden while reducing the environmental impact and economic cost. Unplanned PD can be defined when treatment starts up to 14 days after catheter insertion and is recognized as a safe and feasible clinical approach. In this perspective paper, we briefly discuss both strategies and share our experience and clinical routine in managing incremental PD after unplanned initiation.

On the importance of the interplay of residual renal function with clinical outcomes in end-stage kidney disease.

Chronic kidney disease (CKD) is one of the most important public health concerns of the century, and is associated with high rates of morbidity, mortality and social costs. CKD evolving towards end-stage kidney disease (ESKD) is on the rise resulting in a greater number of patients requiring peritoneal dialysis (PD) and hemodialysis (HD). The aim of this manuscript is to review the current literature on the interplay of residual renal function (RRF) with clinical outcomes in ESKD. The persistence of RRF is one of the most important predictors of decreased morbidity, mortality, and better quality of life in both PD and HD patients. RRF contributes to the well-being of ESKD patients through various mechanisms including higher clearance of solutes, maintenance of fluid balance, removal of uremic toxins and control of electrolytes. Furthermore, RRF has beneficial effects on inflammation, anemia, malnutrition, diabetes mellitus, obesity, changes in the microbiota, and cardiac diseases. Several strategies have been proposed to preserve RRF, such as blockade of the renin-angiotensin-aldosterone system, better blood pressure control, incremental PD and HD. Several clinical trials investigating the issue of preservation of RRF are ongoing. They are needed to broaden our understanding of the interplay of RRF with clinical outcomes in ESKD.

Views and practices of renal nurses in monitoring residual renal function for haemodialysis patients

BackgroundHaemodialysis is a treatment option offered to patients with end-stage kidney disease. Patients who commence haemodialysis will often have some degree of residual renal function (RRF) with a continued urine output between treatment schedules. Efforts to preserve the remaining RRF can offer several health benefits for haemodialysis patients. AimTo explore the views and practices of Australian and New Zealand renal nurses in monitoring RRF of haemodialysis patients between treatment schedules. MethodsThis study used a cross-sectional research design. Participants were recruited through distribution of an electronic survey. Quantitative descriptive data were analysed and presented as frequencies, percentages, medians, and interquartile ranges. Reporting of this study adhered to the STROBE checklist. FindingsFifty-five renal nurses completed the survey. Of these, 10 (18.2%) always, 41 (74.5%) sometimes, and 3 (5.5%) never discussed urine output with patients before commencing haemodialysis. Eight (14.5%) participants indicated ultrafiltration goals did not include calculations based on urine output between treatment schedules. DiscussionThe monitoring of RRF provides several health benefits for patients requiring maintenance haemodialysis. Practice differences in fluid assessment policies did not always account for self-reported urine output. The inclusion of an estimated daily urine output between treatment schedules has the potential to lower ultrafiltration goals minimising the risk of intradialytic hypotension. ConclusionThe survival and quality of life for patients requiring maintenance haemodialysis can be improved by the preservation of RRF. Findings from this study suggest practice differences occur among renal nurses in the monitoring of urine output.

Kidney replacement therapy and global issues: world experience and our challenges

The problem of renal replacement therapy (RRT) is relevant in today’s world due to a large number of people with chronic kidney disease (CKD). According to current data, about 10–11 % of people suffer from CKD, of which up to 5 % need RRT. Unfortunately, the number of people with CKD in the world is increasing, which determines the growing need for RRT. There are three types of RRT, namely: hemodialysis, peritoneal dialysis, and kidney transplantation. Kidney transplantation is the most effective method of RRT, but its possibilities in the world are limited. Therefore, most people receive hemo- or peritoneal dialysis. But the long-term effects of choosing a dialysis method are not always predictable. The peritoneal dialysis and hemodialysis show similar effectiveness during the first two years. Subsequent studies comparing the efficacy of the two methods do not provide a clear picture due to differences in patient initial parameters and differences in treatment initiation time. It is clear that peritoneal dialysis can have significant advantages in low-income countries due to the resource costs of the latter. The known benefits of peritoneal dialysis, such as flexibility of use, high quality of life, and preservation of residual renal function, increase its attractiveness, especially for young people with stage 5 CKD. The main strategies today are timely detection and prevention of CKD, control of comorbidities, as well as the development of documents and recommendations for standardization and improving the quality of renal replacement therapy.

The Role of Peritoneal Dialysis in Different Phases of Kidney Transplantation.

The utilization of peritoneal dialysis (PD) has been increasing in the past decade owing to various government initiatives and recognition of benefits such as better preservation of residual renal function, quality of life, and lower cost. The Advancing American Kidney Health initiative aims to increase the utilization of home therapies such as PD and kidney transplantation to treat end stage kidney disease (ESKD). A natural consequence of this development is that more patients will receive PD, and many will eventually undergo kidney transplantation. Therefore, it is important to understand the effect of pretransplant PD on posttransplant outcomes such as delayed graft function (DGF), rejection, thrombosis, graft, and patient survival. Furthermore, some of these patients may develop DGF, which raises the question of the utility of PD during DGF and its risks. Although transplant is the best renal replacement therapy option, it is not everlasting, and many transplant recipients must go on dialysis after allograft failure. Can PD be a good option for these patients? This is another critical question. Furthermore, a significant proportion of nonrenal solid organ transplant recipients develop ESKD. Is PD feasible in this group? In this review, we try to address all of these questions in the light of available evidence.

Peritoneal Dialysis in Advanced Heart Failure Patients with Chronic Severe Congestion Resistant to Optimal Pharmacological Treatment.

Resistant congestion is a difficult clinical picture in advanced heart failure with poor quality of life, worse functional capacity, and frequent hospitalizations. Optimal medical treatment is the first-line therapy. However, diuretic resistance, comorbid conditions such as chronic kidney disease, and obstacles in drug up-titration make it difficult to control congestion. In some of these cases, hemodialysis or peritoneal dialysis is required for short or long-term ultrafiltration therapy. Peritoneal dialysis is a more comfortable treatment option for this group of patients because of the slower and longer duration of ultrafiltration, better preservation of residual renal function, ability to be performed at home, and mobility of the patient during the procedure. In this review, home peritoneal dialysis/ultrafiltration methods have been addressed as an alternative treatment option in advanced heart failure patients with chronic severe congestion resistant to optimal pharmacological treatment.

Peritoneal Dialysis in Advanced Heart Failure Patients with Chronic Severe Congestion Resistant to Optimal Pharmacological Treatment.

Resistant congestion is a difficult clinical picture in advanced heart failure with poor quality of life, worse functional capacity, and frequent hospitalizations. Optimal medical treatment is the first-line therapy. However, diuretic resistance, comorbid conditions such as chronic kidney disease, and obstacles in drug up-titration make it difficult to control congestion. In some of these cases, hemodialysis or peritoneal dialysis is required for short or long-term ultrafiltration therapy. Peritoneal dialysis is a more comfortable treatment option for this group of patients because of the slower and longer duration of ultrafiltration, better preservation of residual renal function, ability to be performed at home, and mobility of the patient during the procedure. In this review, home peritoneal dialysis/ultrafiltration methods have been addressed as an alternative treatment option in advanced heart failure patients with chronic severe congestion resistant to optimal pharmacological treatment.

Association between lipid profile and residual renal function in incident peritoneal dialysis patients.

Residual renal function (RRF) is one of the most crucial factors in the management of peritoneal dialysis (PD). The aim of this study was to evaluate the association between lipid profile and preservation of RRF among incident PD patients. This retrospective cohort study investigated 113 patients (male, 72%; age, 59 ± 14 years) who initiated PD between 2006 and 2017. We investigated the relationships between high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) at PD initiation and change in renal Kt/V during the first year after PD initiation. Alterations in renal Kt/V during the first year after PD initiation correlated negatively with HDL-C at PD initiation but not with LDL-C. On multivariate analysis, HDL-C at PD initiation was independently associated with a change in renal Kt/V during the first year after PD initiation. These results suggest the importance of lipid management among incident PD patients for the preservation of RRF.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient’s needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

Perceived Barriers to Peritoneal Dialysis Among Kenyan Nephrologists: A Cross-Sectional Descriptive Study.

Background:Peritoneal dialysis (PD) is a well-recognized technique of renal replacement therapy (RRT), with similar efficacy as well as survival outcomes as hemodialysis (HD). Despite its advantages including prolonged preservation of residual renal function, potentially lower cost and advances with automated techniques, and commercialization of more biocompatible solutions, the overall prevalence of patients treated with PD is still very low in developed countries and even more so in Africa and low-middle income countries like Kenya. According to our knowledge, no local studies have been done on prevalence of peritoneal dialysis or on potential barriers to utilization of PD as an RRT modality.Objective:To explore perceptive barriers of nephrologists to PD utilization.Methodology:A computer-base, 22-question questionnaire was formulated using the Delphi technique and sent out to all the nephrologists via emails. There were 30 nephrologists, in clinical practice in Kenya, at the time when the study was conducted. This is according to the registry maintained by the Kenya Renal Association (KRA). Their contacts were obtained from the registry.Design:A cross-sectional descriptive studySetting:A computer based 22-question questionnaire was administered to 23 nephrologists in Kenya.Results:Among the total number of 23 nephrologists, 39% reported to be looking after patients maintained on PD despite 59% of them reporting that they think patients should be maintained on PD. Only 21% of respondents felt limited training in PD limited their use of PD and only 23% felt poor personal experience contributed to limited use. Other barriers that came up with a relative majority of the respondents included lack of nursing expertise, concerns with PD catheter placement, concerns about long-term viability of continuous peritoneal dialysis, concerns about technique failure and peritonitis, lack of facility support for PD, and lack of dialysis education programs.Conclusion:A significant proportion of nephrologists in this survey felt PD, as a modality of RRT, was underutilized and reported systemic and technical factors as being potential barriers.

MO696INCREMENTAL PERITONEAL DIALYSIS: BENEFICIAL EFFECTS

Abstract Background and Aims Incremental peritoneal dialysis (Incr_Dial) is a renal replacement therapy strategy based on lower dose prescription rather than the standard “full dose” (Full_Dial). Individualized clearance goals were achieved combining residual renal function (RRF) and peritoneal clearance. Maintaining RRF is a crucial issue to peritoneal dialysis (PD) patients and the best PD strategy to preserve it is subject to debate. The aim of this study is to compare Incr_Dial and Full_Dial in terms of RRF preservation and other clinical outcomes. Method This was a single-center, retrospective descriptive study. We included a cohort of incident and prevalent adult PD patients in the PD Unit between January – December of 2020. Patients without a follow-up < six months and who started PD at another center were excluded. Patients were assigned according to their first PD protocol in two groups – Group A: Incr_Dial protocol (continuous ambulatory PD: less than four dwells daily, less than 2 L dwell volumes, less than seven days a week treatment, or some combination of these; automated PD: without a long dwell, less than 10 L daily delivered by cycler and day dwells, treatment for less than 7 days a week or some combination of these); Group B: Full_Dial protocol. Statistical analysis was performed using SPSS 20.0. Statistical significance level p <0.05. Results Among 84 PD patients, 68% underwent incremental PD (Group A) and 31% underwent conventional full-dose PD (Group B). The mean age was 55.9±15.4 years, 60.7% were male and 32.5% diabetic. There were no statistically significant differences between the two groups regarding: demographic characteristics, comorbidities (diabetes, hypertension, cardiac insufficiency or ischemic heart disease) and drugs (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and/or loop diuretics). The median Incr_Dial duration to achieve PD full dose was 10.2 months (IQ 5.1-17). At the beginning of PD, there was no statistically significant difference in diuresis between both groups (A: 1.79L vs B: 1.2L, p=0.07), however after 6 months of PD there was a superior urinary output in Group A (A: 1.67L vs B: 1.1L, p=0.037). Group A (Incr_Dial) was also associated with a superior renal clearance of creatinine at the beginning (A: 81 L/sem/1.73m2 vs B: 56.8L/sem/1.73m2, p=0.021) and after 12 months (A: 70.7L/sem/1.73m2 vs B: 26.3 L/sem/1.73m2, p<0.01); and superior Kt/V renal/week at the beginning (A: 1.48 vs B: 1.02, p=0.02) and after 12 months (A: 1.28 vs B: 0.49, p<0.001). There are no differences between mortality (A: 1.9% vs B: 12%, p=0.094), peritonitis-free time (A: 158 days vs B: 236 days, p=0.133) and the numbers of peritonitis per year (A: 0.32 vs B: 0.5, p=0.940). However, the rate of hospital admissions per year was lower in Group A (A: 0.22 vs B: 0.70, p=0.001). Conclusion Incremental PD is a safe strategy of renal replacement therapy to start PD. In our PD population, it showed similar patient survival rates and a significantly less hospital admissions. Incremental PD was also beneficial for preserving RRF when compared to full-dose PD.

Effectiveness of fibroblast growth factor 23 lowering modalities in chronic kidney disease: a systematic review and meta-analysis.

The heightened fibroblast growth factor 23 (FGF23) level in patients with chronic kidney disease (CKD) is associated with increased cardiovascular disease and mortality. We performed a systematic review and meta-analysis to synthesize the available strategies to reduce FGF23 in CKD patients. We conducted a meta-analysis by searching the databases of MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) and single-arm studies that examined the effects of dietary phosphate restriction, phosphate binders, iron supplements, calcimimetics, parathyroidectomy, dialysis techniques, and the outcome of preservation of residual renal function (RRF) on FGF23 levels in CKD patients. Random-effects model meta-analyses were used to compute changes in the outcome of interests. A total of 41 articles (7590 patients), comprising 36 RCTs, 5 prospective studies were included in this meta-analysis. Dietary phosphate restriction less than 800mg per day yielded insignificant effect on FGF23 reduction. Interestingly sevelamer, lanthanum, iron-based phosphate binders, and iron supplement significantly lowered FGF23 levels. In CKD patients with secondary hyperparathyroidism, calcimimetics prescription could significantly reduce FGF23 levels, while surgical parathyroidectomy had no significant effect. In dialysis patients, preservation of RRF and hemoperfusion as well as hemodiafiltration provided a significant decrease in FGF23 levels. The present meta-analysis demonstrated that non-calcium-based phosphate binders including sevelamer, lanthanum, and iron-based phosphate binders, iron supplements, calcimimetics, hemoperfusion, and preservation of RRF could effectively reduce FGF23 in CKD patients.

Protein-bound uremic toxin lowering strategies in chronic kidney disease: asystematic review and meta-analysis.

Accumulation of protein-bound uremic toxins, including indoxyl sulfate and p-cresyl sulfate, are associated with increased cardiovascular disease and mortality in chronic kidney disease (CKD). We performed a systematic review and meta-analysis to synthesize the available strategies for lowering protein-bound uremic toxin levels in CKD patients. We conducted a meta-analysis by searching the databases of MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials for observational studies and randomized controlled trials (RCTs) that examined the effect of dietary protein restrictions, biotic supplements (including prebiotics, probiotics, and synbiotics), AST-120, dialysis techniques, and the outcome of preservation of residual renal function (RRF) on indoxyl sulfate and p-cresyl sulfate levels. Random-effect model meta-analyses were used to compute changes in the outcomes of interest. A total of 38 articles (2,492 patients), comprising 28 RCTs, 8 single-arm or prospective cohort studies, and 2 cross-sectional studies were included in this meta-analysis. When compared with placebo, prebiotics, synbiotics, and AST-120 provided significantly lower levels of both serum indoxyl sulfate and p-cresyl sulfate. There were no significant reductions in serum indoxyl sulfate and p-cresyl sulfate levels in patients receiving probiotics. Preservation of RRF in dialysis patients resulted in lower levels of both of the protein-bound uremic toxins. When compared with conventional hemodialysis, hemodiafiltration significantly decreased serum p-cresyl sulfate alone, whereas a significant change in serum indoxyl sulfate levels was observed only in studies with long-term observation periods. Very low protein diet (VLPD) and other oral medications yielded insignificant differences in protein-bound uremic toxins. The present meta-analysis demonstrated that prebiotics, synbiotics, and AST-120 can effectively reduce both serum indoxyl sulfate and p-cresyl sulfate in CKD patients when compared with placebo. Preservation of RRF was associated with lower serum indoxyl sulfate and p-cresyl sulfate levels. The effect of biotic supplements was detected only in dialysis patients. For non-dialysis CKD patients, the results were limited due to the small number of studies. Further studies are needed to determine the efficacy in these populations.

Is Twice-weekly Maintenance Hemodialysis Justified?

Background: The benefits of twice-weekly dialysis at initiation are significant with respect to access longevity, preservation of residual renal function, economic factors, and patient quality of life. It is widely practiced in developing countries due to resource and financial constraints. We present a 3-year follow-up of patients on twice-weekly dialysis and their outcomes.Material and Methods: This was a 3-year observational follow-up study of patients initiated on twice-weekly hemodialysis. Adequacy and basic cost-effective hematological and biochemical parameters were studied monthly. In case of complications, the patient was shifted to thrice-weekly hemodialysis.Results: 88 incident hemodialysis patients were followed up. Total sessions of hemodialysis (HD) studied were 16,406. The mean hemoglobin level was 9.53 g/dl with hyperphosphatemia in 74.88% patients. The mean residual renal function (RRF) at initiation was 5.71 +/- 3.70 ml/min. The mean interdialytic weight gain was 1.91 +/- 1.26 kg with a mean ultrafiltration of 2600 ± 410 ml. The spKt/V and eKt/V were adequate in 68.54% and 48.34% patients; however, the standard Kt/V of 2 was achieved in only 10.51% patients. Emergency HD was done in 41 sessions (0.24%). There were 24 deaths (27.27%) during this period with the mean time to mortality being 503.12 +/- 296.62 days.Conclusion: Initiation at twice-weekly schedules for patients on maintenance hemodialysis is a viable option with increments in case of requirement, more so in patients with good urine output and residual renal function. The biochemical and hematological parameters were stable and within KDOQI guidelines and do not worsen with time.