Provision Of Renal Replacement Therapy Research Articles

Technical Considerations for Renal Replacement Therapy in Children

Provision of renal replacement therapy to the critically ill child entails numerous technical and prescriptive considerations because pediatric nephrologists and intensive care physicians are faced with patients ranging in size from 2-kg neonates to 200-kg adolescents or young adults. The current article focuses on the common technical and prescriptive issues that inform the care of children with acute kidney injury.

Acute Kidney Injury and Dialysis in Children: Illustrative Cases

Pediatric nephrologists and critical care physicians are faced with a heterogeneous patient population with varied epidemiology caring for children with acute kidney injury or other diseases that may require renal replacement therapy provision. We have composed 4 detailed case scenarios to highlight the challenges and interdisciplinary approach required for optimal care provision to children, and that serve to direct the different articles contained in this special issue of Seminars of Nephrology devoted to acute kidney injury in children.

How can we achieve global equity in provision of renal replacement therapy?

There is a significant emerging burden of chronic and end-stage kidney disease in low- and middle-income countries, driven by population ageing and the global epidemic of type 2 diabetes. Sufferers of end-stage kidney disease require ongoing dialysis or kidney transplantation to survive; however, in many low- and middle-income countries, treatment options are strictly limited or unaffordable. Low numbers of maintenance dialysis patients and transplant recipients reflect profound economic and service provision challenges for health-care systems in low- and middle-income countries in sustaining renal replacement therapy programmes. Underdeveloped organ donor and transplant programmes, health system and financing issues, ethical regulation of transplantation and the cost of pharmaceuticals commonly pose additional barriers to the delivery of efficient and cost-effective renal replacement therapy. Development of locally appropriate transplant programmes, effective use of nongovernmental sources of funding, service planning and cost containment, use of generic drugs and local manufacture of dialysis consumables have the potential to make life-saving renal replacement therapy available to many more in need. Select low- and middle-income countries demonstrate more equitable provision of renal replacement therapy is possible outside high-income countries. For other low- and middle-income countries, education, the development of good public policy and a supportive international environment are critical. Prevention of end-stage kidney disease, ideally as part of an integrated approach to chronic vascular diseases, must also be a key objective.

Drug Dosing Considerations in Alternative Hemodialysis

The provision of renal replacement therapy for patients with chronic kidney disease has been reasonably standardized for decades, with thrice-weekly hemodialysis being the standard. Short-daily and nocturnal hemodialysis are 2 new hemodialysis techniques, each are administered 6 to 7 days a week but differ primarily in the duration of the treatment and blood-flow rate. The emergence of these hemodialysis regimens has shown promise in attenuating some of the complications associated with chronic kidney disease. The benefits of these daily regimens are postulated to be a result of enhanced solute clearance and improved extracellular volume management. The improved solute clearance associated with daily hemodialysis is likely to lead to altered dialytic clearance of drugs given to patients receiving these therapies. The purpose of this paper is to review the concepts pertinent to drug removal by hemodialysis and discuss the issues related to these new dialysis techniques and how they may have a impact on drug removal and the design of dosing regimens.

Chronic kidney disease in children: the global perspective.

In contrast to the increasing availability of information pertaining to the care of children with chronic kidney disease (CKD) from large-scale observational and interventional studies, epidemiological information on the incidence and prevalence of pediatric CKD is currently limited, imprecise, and flawed by methodological differences between the various data sources. There are distinct geographic differences in the reported causes of CKD in children, in part due to environmental, racial, genetic, and cultural (consanguinity) differences. However, a substantial percentage of children develop CKD early in life, with congenital renal disorders such as obstructive uropathy and aplasia/hypoplasia/dysplasia being responsible for almost one half of all cases. The most favored end-stage renal disease (ESRD) treatment modality in children is renal transplantation, but a lack of health care resources and high patient mortality in the developing world limits the global provision of renal replacement therapy (RRT) and influences patient prevalence. Additional efforts to define the epidemiology of pediatric CKD worldwide are necessary if a better understanding of the full extent of the problem, areas for study, and the potential impact of intervention is desired.

The effect of gender, age, and geographical location on the incidence and prevalence of renal replacement therapy in Wales

BackgroundThis study used a cross sectional survey to examine the effect of gender, age, and geographical location on the population prevalence of renal replacement therapy (RRT) provision in Wales.MethodsPhysicians in renal centres in Wales and in adjacent areas of England were asked to undertake a census of patients on renal replacement therapy on 30 June 2004 using an agreed protocol. Data were collated and analysed in anonymous form.Results2434 patients were on RRT in Wales at the census date. Median age of patients on RRT was 56 years, peritoneal dialysis 58 years, haemodialysis 66 years and transplantation 50 years. The three treatment modalities had significantly different age-specific peak prevalence rates and distributions. RRT age-specific prevalence rates peaked at around 70 years (1790 pmp), transplantation at around 60 years (924 pmp), haemodialysis at around 80 years (1080 pmp) and peritoneal dialysis did not have a clear peak prevalence rate. Age-specific incidence of RRT peaked at a rate of 488 pmp at 79 years, as did incidence rates for haemodialysis, which peaked at the same age. Age had less effect on the initiation of peritoneal dialysis, which had a broad plateau between the early fifties and late seventies. Kidney transplantation rates were highest in the early fifties but were markedly absent in old age.ConclusionDifferences in the provision of RRT are evident, particularly in the very elderly, where the gender difference for haemodialysis is particularly marked. The study illustrates that grouping patients over 75 years into a single age-band may mask significant diversity within this age group. Significant numbers of very elderly patients who are currently not receiving RRT may wish to receive RRT as the elderly population increases, and as technology improves survival and quality of life on RRT.The study suggests that if technologies that are more effective were developed, and which had a lower impact on quality of life, there might be up to a 17% increase in demand for RRT in those aged over 75 years; around 90% of this increased demand would be for haemodialysis.

The first international consensus conference on continuous renal replacement therapy

Management of acute renal failure (ARF) in the critically ill is extremely variable and there are no published standards for the provision of renal replacement therapy in this population. We sought to review the available evidence, make evidence-based practice recommendations, and delineate key questions for future study. We undertook an evidence-based review of the literature on continuous renal replacement therapy (CRRT) using MEDLINE searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated practice guidelines and/or directions for future research. Of the 46 questions considered, we found consensus for 20. We found inadequate evidence for 21 questions and for the remaining five we found data but no consensus. Full versions of workgroup findings are available on the Internet at http://www.ADQI.net. Despite limited data, broad areas of consensus exist for use of CRRT and guideline development appears feasible. Equally broad areas of disagreement also exist and additional basic and applied research in acute renal failure is needed.

Quantity versus quality: ethics and provision of renal replacement therapy.

50 years ago if one had renal failure the prognosis was certain death within a short timeframe. Now if one receives renal replacement therapy the prognosis has dramatically changed. But in this time of economic constraints and ever decreasing human resources are we now to be faced with the necessity to make choices about who receives replacement therapy? This paper looks at the ethics of providing treatment for large numbers but at the risk of 2nd class treatment, or selection of a few to receive the best treatment possible. The author asks what is the point of choice for the provision of therapy; before treatment has begun or having started who has the right to stop treatment and should there be criteria for discontinuing this treatment? The paper examines the ethical issues facing all the health care team especially those caring for the chronically ill. The financial benefits of one kind of therapy over the other are examined and again the author puts the question, is it economics that governs the treatment prescribed, or a real choice made with knowledge? The author has found that "hands on" health care teams are still aiming to treat the ever increasing workload but at what cost? How long can we continue to accept patients for treatment when we may be putting at risk other patients and the very people who are providing the care?

Racial inequity in America's ESRD program.

The end-stage renal disease (ESRD) program has a significant overrepresentation of racial and ethnic minority groups. The increased susceptibility of nonwhite populations to ESRD has not been fully explained and probably represents a complex interplay of genetic, cultural, and environmental influences. Because the program delivers care under a uniform health care payment system, it represents a unique environment in which to explore variation in health care delivery. A number of disparities in outcomes and delivery of ESRD care have been noted for racial minority participants. These include possible overdiagnosis of hypertensive nephrosclerosis, decreased provision of renal replacement therapy, limited referral for home dialysis modalities, underprescription of dialysis, increased use of synthetic grafts rather than fistulas as permanent angioaccess, and delayed wait-listing for renal transplantation. Transplantation inequities mean that black patients are likely to remain on dialysis relatively longer, so that their susceptibility to less than optimal processes of care increases disproportionately. Improved survival and quality of life (QOL) for blacks with ESRD may have encouraged provider complacency about racial disparities in the ESRD program and in particular about referral for transplantation. It is also apparent that minority ESRD patients may, similar to their non-ESRD counterparts, be referred less frequently for invasive cardiovascular (CV) procedures. Despite these observations of inequality in ESRD care, the adjusted mortality for minority participants in the ESRD program are better than for the majority population. This seeming paradox may define an opportunity to improve outcomes for minorities with ESRD even more.

The provision of renal replacement therapy for adults in England and Wales: recent trends and future directions.

We assessed the level of provision of renal replacement therapy for adults in England and Wales. All autonomous main renal units in England (n = 52) and Wales (n = 5) were surveyed in 1996. Data for England were compared to the 1993 National Renal Review. The acceptance rate in England 1995 was 82 (80-85) per million population (p.m.p.) compared with 67 (65-70) p.m.p. in 1991-2. The rate in 1995 in Wales was 109 (98-122) p.m.p. The prevalence rate in England was 476 p.m.p. at end-1995 compared to 393 p.m.p. in 1993, in Wales it was 487 p.m.p. The number of main renal units in England did not rise between 1993 and 1995; capacity was increased by use of more treatment shifts and temporary haemodialysis stations, and by opening more satellite units. The main growth was in hospital haemodialysis. There was an uneven geographical distribution of services. Patients accepted were older with more comorbidity. The use of better-quality processes of dialysis increased. The steady-state position for RRT will not be reached for over a decade. Health authorities will face continued pressure to fund increases in quantity and quality improvements. A stronger evidence base of the effectiveness of therapies, and a national registry to monitor the equity and cost-effectiveness of services are needed.

Hemodialysis and L-arginine, but not D-arginine, correct renal failure-associated endothelial dysfunction

In end-stage renal failure (ESRF) symptomatic hemodialysis-related hypotension may prevent effective provision of renal replacement therapy. Endogenous inhibitors of nitric oxide synthase accumulate in ESRF and are cleared by dialysis. We, therefore, hypothesised that removal of these inhibitors by hemodialysis would increase endothelial nitric oxide generation and promote venodilation. In vivo responses of norepinephrine preconstricted dorsal hand veins to locally active doses of acetylcholine (an activator of nitric oxide synthase) and glyceryl trinitrate (GTN; a nitric oxide donor) were examined in patients undergoing maintenance hemodialysis for ESRF and in healthy age- and sex-matched controls. Patient studies were undertaken before and after dialysis. Studies before dialysis were repeated with co-infusion of either L-arginine or its inactive enantiomer D-arginine. Venodilation in response to acetylcholine was impaired before, and corrected by, dialysis whereas venodilation to GTN was similar before and after dialysis. Venodilation in response to acetylcholine before dialysis was restored by co-infusion of L- but not D-arginine. Therefore, patients with ESRF undergoing hemodialysis have impaired acetylcholine-mediated venodilation consistent with the accumulation in ESRF of functionally important inhibitors of nitric oxide synthase that are cleared by dialysis.

High incidence of end-stage renal disease in Indo-Asians in the UK

In a retrospective survey, we show that the incidence of end-stage renal disease (ESRD) is significantly raised among immigrant Indo-Asians referred to two UK renal units (p < 0.001). In addition to the expected increase in diabetic nephropathy, glomerulonephritis and chronic pyelonephritis are also seen more frequently in Indo-Asians. The most striking finding was a five-fold increase in ESRD of uncertain cause (p < 0.001) presenting with small smooth kidneys, which was strongly associated with active, mostly non-renal tuberculosis. The causes of this generalized increased susceptibility to renal disease are unknown. These findings have important implications both for primary health care screening and for planning the provision of renal replacement therapy.

Provision of Renal Replacement Therapy for Diabetic Patients in the UK

Provision of Renal Replacement Therapy for Diabetic Patients in the UK