Rapid Decline In Residual Renal Function Research Articles

#2752 Decline of residual renal function in peritoneal patients: in search of the lost kidney?

Abstract Background and Aims The latest (2020) recommendations of the International Society of Peritoneal Dialysis have proposed a new paradigm of adequacy. In this context, preserving residual renal function (RRF) is considered one of the most important therapeutic targets to reduce cardiovascular risk and mortality. Incremental peritoneal dialysis can contribute to preserving RRF. The goal of this study is to evaluate factors which are associated with a decline in RRF in APD patients. Method We conducted a retrospective study of incidental peritoneal dialysis patients between 2020 and 2022. We started considering 62 patients who underwent APD. 23 were excluded due to lack of data, follow-up of less than 1 year, need for haemodialysis sessions before or during follow-up, interfering surgery (bariatric surgery and nephrectomy) and treatment using the CAPD technique. We analyzed data from 39 APD patients (see Table 1) and classified them into two groups based on their RRF decline using the cut-off of 1 ml/min/year (calculated as the mean of urea and creatinine clearance). They were distinguished into slow progressors and fast progressors and we identified any differences in clinical and dialysis parameters at baseline and 12-month follow-up. We calculated dialytic, renal and total Kt/V in both groups and looked for possible predictors of faster RRF loss. For statistical analysis, we used ANOVA for continuous variables, Kruskal-Wallis for non-continuous variables and Fisher for qualitative variables. Finally, predictive data were extracted using logistic regression. Results We found 22 slow progressors and 17 fast progressors. A significant difference was found in the prevalence of cardiovascular disease (18.2% vs 47.1%, p 0.028), residual renal function (5.71 ml/min vs 6.85 ml/min, p 0,03) and dialysing solution volumes (13.2 L vs 14.1 L, p 0.05) between the two groups, with higher values in the fast progressors. In this group, more male patients were also observed (p 0.11), treated with 2 or more antihypertensive drugs (p 0.30) and exposed to higher weekly dialysate glucose (p 0.23) and daily ultrafiltration rates (p 0.23). At the 12-month follow-up, the mean decline in renal function was -1, 56 ml/min in the entire sample, -3.03 ml/min in the fast progressors group and -0.43 ml/min in the slow progressors group; the change in daily Uf inversely correlated with the change in RRF (p 0.025; r -0.35, Fig. 1). There was a mean reduction in ultrafiltrate volume (-22.7 ml vs +123.5 ml, p 0.028) and in the amount of glucose in the dialysing solutions (-138.6 g vs +100.5 g, p 0.007) compared to baseline values in patients who preserved RRF. In contrast, the difference between the two groups in the number of patients who started PD with<5 sessions per week is borderline (p 0.099). Weekly dialysis Kt/V is higher in fast-progressor patients (1 vs 0.88; p 0.205) with a total weekly Kt/V in both cases above the recommended target of 1.7. On multivariate regression analysis, baseline renal function and the presence of heart disease correlate with a more rapid decline in RRF (p 0.047; p 0.021 respectively). Conclusion With the limitations of low sample size and short follow-up time, we observed that ultrafiltration and peritoneal exposure to dialysate glucose may play a role in RRF loss, but more research is needed to confirm this. We found that patients with heart disease and higher baseline RRF were more likely to experience a faster decline in RRF. Overall findings suggest that maintaining RRF is crucial in APD patients, and incremental dialysis can help preserve it. We recommend further studies with longer follow-up times to better understand the relationship between RRF and APD.

Intra-abdominal pressure and residual renal function decline in peritoneal dialysis: a threshold-based investigation

Background The potential impact of elevated intra-abdominal pressure (IAP) on residual renal function (RRF) has not been determined. The objective of this study was to investigate the relationship between IAP and the rate of RRF decline in newly initiated peritoneal dialysis (PD) patients, and to identify the optimal IAP threshold value for delaying the deterioration of RRF. Methods A cohort of 62 newly initiated PD patients who completed both 6- and 12-month follow-up evaluations was obtained using the Durand method. A logistic regression model was used to identify variables associated with a rapid decline in RRF. Receiver operating characteristic (ROC) curves were generated to determine the optimal threshold value. Another retrospective cohort analysis was performed to validate the identified critical value. Results For each 1 cmH2O increase in IAP, the risk of a rapid decline in the RRF increased by a factor of 1.679. Subsequent analysis revealed that patients in the high IAP group had more significant decreases in residual renal estimated glomerular filtration rate (eGFR) (Z = −3.694, p < 0.001) and urine volume (Z = −3.121, p < 0.001) than did those in the non-high IAP group. Furthermore, an IAP ≥15.65 cmH2O was a robust discriminator for the prediction of the rate of RRF decline. Conclusion Patients in the high IAP group experienced a more rapid decline in RRF. Additionally, an optimal critical pressure of 15.65 cmH2O was identified for predicting the rate of RRF decline. IAP, as one of the factors contributing to the rapid decline in RRF in the first year of PD, should be given due attention.

Are USPD patients suitable for incremental peritoneal dialysis: Yes or no?

Incremental peritoneal dialysis (IPD) is the practice of initiating PD exchange less than 4 times a day in consideration of residual renal function (RRF). This study determined whether IPD could be used for urgent-start peritoneal dialysis (USPD) patients when starting dialysis, and when compared to full-dose PD, could IPD affect the RRF in USPD patients. 169 USPD patients with eGFR between 4 and 6 mL/min/1.73m2 were retrospectively analyzed. The duration of follow-up was 1 year. Patients were divided into an incremental PD (i-PD) group (dialysis dose ≤ 6,000 mL) and a full-dose PD (f-PD) group (dialysis dose ≥ 8,000 mL). The demographics, clinical indices, peritoneal transport function, dialysis adequacy, and complications of peritoneal dialysis were compared between both groups. (1) 111 patients (average age 45.01 ± 12.84 years) were included in the i-PD group and 58 patients (average age 43.5 ± 15.62 years) in the f-PD group. The demographics and clinical indices of both groups before PD were similar (p < 0.05). (2) During the follow-up period, the dialysis dose in the f-PD group exceeded that of the i-PD group (p < 0.05). The dialysis adequacy of both groups was as expected. (3) During the follow-up period, peritoneal transport function, the RRF, the blood pressure control, correction of anemia, and correction of calcium and phosphorus abnormalities were similar in both groups. (4) The peritoneal dialysis-related infection, mechanical complications, and technical survival rate were similar between groups. Incremental PD did not cause a rapid decline of RRF in USPD patients. The dialysis effect and complications from it, were similar to full-dose peritoneal dialysis. Thus, USPD patients can be treated by IPD.

Rapid Change in Residual Renal Function Decline Is Associated with Lower Survival and Worse Residual Renal Function Preservation in Peritoneal Dialysis Patients.

The survival advantage observed among peritoneal dialysis patients early on after dialysis initiation has been largely attributed to residual renal function (RRF) preservation due to higher baseline residual function and fewer comorbidities. We hypothesize that a rapid decline in RRF is associated with higher risk of anuria and mortality. In a retrospective cohort study of 581 subjects on peritoneal dialysis with longitudinal prevalent data, we assessed whether RRF change over time, in addition to baseline RRF, increased risk of mortality and anuria using Kaplan-Meier analysis and Cox proportional hazard analysis to control for known risk factors. Rapid RRF decline (≥ 0.09 decline) over a 12-month period was associated with a 2.6-fold increase in the risk of death (hazard ratio [HR] 2.60, 95% confidence interval [CI] 1.66 - 4.07, compared with < 0.09 decline) and a 2-fold increase in anuria (HR 2.06, 95% CI 1.24 - 3.42). Each quartile of increasing severity of RRF decline over a 12-month period increased risk incrementally for death (2nd quartile: HR 3.04, CI 1.26 - 7.34; 3rd quartile: HR 4.01, CI 1.71 - 9.83; 4th quartile HR 5.78, CI 2.10 - 15.9) and generally for anuria (quartiles with HR 5.72 - 7.21). The escalating risk of mortality and anuria was greater for those with diabetes mellitus. In conclusion, rapid decline in RRF over a 12-month period increased the risk of mortality and likewise anuria, beyond previously established risk factors for mortality and anuria. The impact on mortality and RRF preservation was particularly severe for those with diabetes mellitus.

Excessive Weight Gain during the First Year of Peritoneal Dialysis Is Associated with Inflammation, Diabetes Mellitus, and a Rapid Decrease in Residual Renal Function.

ObjectivesSignificant weight gain is a potential problem in most patients starting peritoneal dialysis (PD); however, few studies have explored the clinical effects of increased body weight (BW) in these patients. We evaluated the effect of excess weight gain during the first year after PD on residual renal function (RRF).MethodsA total of 148 incident PD patients were analyzed in a longitudinal observational study. The mean duration of follow-up was 23.8 months. RRF was measured at baseline (within 1 month of starting PD) and thereafter at 6-month intervals for 2–3 years or until loss of RRF. BW was measured at the time of RRF measurement, and excess weight gain was defined as a BW increase over the median value (3.0%).ResultsThe median 1-year increase in BW was 2.3kg (IQR, 1.01–4.58) or 3.0% (IQR, 1.13–5.31). The mean slope of RRF decline was –0.068 ± 0.053 mL/min/month/1.73m2, and RRF loss developed in 48 patients at a mean follow-up time of 19.4 ± 6.8 months. Patients with BW increases > 3.0% showed significantly increased RRF decline rate compared to those without excess weight gain (p<0.001), and the BW increase (%/year) correlated significantly with higher hs-CRP levels and RRF decline rate. High systolic blood pressure, diabetes, large amount of proteinuria and excess BW gain significantly influenced the RRF decline rate. Also, it increased the risk of RRF loss by 4.17-fold (95% confidence intervals, 1.87–9.28; p<0.001).ConclusionsExcess weight gain during the first year of PD was closely linked to systemic inflammation, diabetes and rapid decline in RRF.

Utility of Urinary Biomarkers in Predicting Loss of Residual Renal Function: The BAL Anz Trial

The ability of urinary biomarkers to predict residual renal function (RRF) decline in peritoneal dialysis (PD) patients has not been defined. The present study aimed to explore the utility of established biomarkers from kidney injury models for predicting loss of RRF in incident PD patients, and to evaluate the impact on RRF of using neutral-pH PD solution low in glucose degradation products. The study included 50 randomly selected participants from the balANZ trial who had completed 24 months of follow-up. A change in glomerular filtration rate (GFR) was used as the primary clinical outcome measure. In a mixed-effects general linear model, baseline measurements of 18 novel urinary biomarkers and albumin were used to predict GFR change. The model was further used to evaluate the impact of biocompatible PD solution on RRF, adjusted for each biomarker. Baseline albuminuria was not a useful predictor of change in RRF in PD patients (p = 0.84). Only clusterin was a significant predictor of GFR decline in the whole population (p = 0.04, adjusted for baseline GFR and albuminuria). However, the relationship was no longer apparent when albuminuria was removed from the model (p = 0.31). When the effect of the administered PD solutions was examined using a model adjusted for PD solution type, baseline albuminuria, and GFR, higher baseline urinary concentrations of trefoil factor 3 (TFF3, p = 0.02), kidney injury molecule 1 (KIM-1, p = 0.04), and interferon γ-induced protein 10 (IP-10, p = 0.03) were associated with more rapid decline of RRF in patients receiving conventional PD solution compared with biocompatible PD solution. Higher urinary levels of kidney injury biomarkers (TFF3, KIM-1, IP-10) at baseline predicted significantly slower RRF decline in patients receiving biocompatible PD solutions. Findings from the present investigation should help to guide future studies to validate the utility of urinary biomarkers as tools to predict RRF decline in PD patients.

Effect of Peritoneal Dialysis Modality on the 1-Year Rate of Decline of Residual Renal Function

PurposeThe effect of different peritoneal dialysis (PD) modalities on the decline in residual renal function (RRF) is unclear due to inconsistencies among studies. In particular, the effect of automated peritoneal dialysis (APD) modalities [continuous cyclic peritoneal dialysis (CCPD) and nightly intermittent peritoneal dialysis (NIPD)] on RRF has not been examined in a large cohort.Materials and MethodsWe conducted a single-center retrospective study to investigate the association between PD modalities and decline in RRF in 142 incident PD patients [34 on CCPD, 36 on NIPD, and 72 on continuous ambulatory peritoneal dialysis (CAPD)]. RRF was measured within 2 months from PD start and at 1 year after PD initiation.ResultsThe RRF at 1 year after PD initiation was 1.98±2.20 mL/min/1.73 m2 in CCPD patients and 3.63±3.67 mL/min/1.73 m2 in NIPD patients, which were moderately lower than 4.23±3.51 mL/min/1.73 m2 in CAPD patients (p=0.064). Moreover, there was no significant difference in the 1-year rate of decline of RRF between CCPD and NIPD patients, although APD patients had a faster 1-year RRF decline rate than CAPD patients (CCPD and NIPD vs. CAPD: -45.68 and -36.69 vs. 1.17%/year, p=0.045). APD was associated with a more rapid decline in RRF in patients with end-stage renal disease undergoing PD, although multivariate analysis attenuated the significance of this finding (β=-31.50; 95% CI, -63.61 to 0.62; p=0.052).ConclusionOur results suggest that CAPD might be more helpful than APD for preserving RRF during the first year of dialysis therapy, although there was no significant difference in the 1-year rate of decline of RRF between the two APD modalities.

Proteinuria as a Risk Factor for Decline in Residual Renal Function in Non-Diabetic Peritoneal Dialysis Patients

Background: Preservation of residual renal function (RRF) is a major issue for patients on peritoneal dialysis (PD). Whether proteinuria is associated with a decline in RRF in patients on PD remains unclear. Patients and Methods: We reviewed the medical records at the Yeungnam University Hospital in Korea and identified patients who started PD between June 1995 and August 2011. A total of 147 non-diabetic patients were enrolled in the study. The patients were divided into 3 groups with respect to the tertile of initial proteinuria level: Low (n = 49; <320 mg/day), Middle (n = 49; 320-822 mg/day), and High groups (n = 49; >822 mg/day). Results: The mean patient age was 50.2 ± 15.0 years in the Low tertile, 50.2 ± 15.4 years in the Middle tertile, and 49.0 ± 15.1 years in the High tertile. Decline in RRF during follow-up period was greater in the High tertile than that in the other tertiles (P = 0.001). The proportion of patients with RRF >50% of baseline at 24 months after the initiation of PD was 83% in the Low tertile, 66% in the Middle tertile, and 40% in the High tertile (P < 0.001). The multivariate analysis after adjusting for initial RRF, age, gender, underlying disease of end-stage renal disease except diabetes mellitus, PD modality, use of icodextrin, PD-associated peritonitis, and tertile of the initial proteinuria level revealed that High tertile of the initial proteinuria level was associated with a decline in RRF (hazard ratios: 2.442 for the Middle tertile, P = 0.007 ; 3.713 for the Low tertile, P < 0.001). Conclusion: The present study demonstrates that proteinuria may be is associated with a rapid decline in RRF in non-diabetic patients on PD, although the potential role of additional factors should be further investigated in prospective studies.

Left Atrial Enlargement Is Associated with a Rapid Decline in Residual Renal Function in ESRD Patients on Peritoneal Dialysis

Left atrial (LA) volume index (LAVI) has been considered a stable indicator of diastolic dysfunction and an independent predictor of mortality in patients with end-stage renal disease. To date, however, little is known about the relationship between LA enlargement and the changes in residual renal function (RRF). This study was undertaken to investigate the association between LA enlargement and the decline in RRF in 121 incident peritoneal dialysis patients. Within 2 months after the initiation of peritoneal dialysis, LA enlargement was determined by echocardiography and RRF by 24-hour urine collection. Subsequently, RRF was measured every 6 months. The rates of decline in RRF were significantly greater in patients with LA enlargement (LAVI > 32mL/m(2)) compared with those without LA enlargement (-0.17 ± 0.18 vs -0.07 ± 0.16 mL/min/month/1.73 m(2), P=.002). In a linear mixed model, there was a significant difference in the rates of RRF decline over time between patients with and without LA enlargement (P < .001). Pearson's correlation analysis revealed that there were significant inverse correlations between the rates of the decline in RRF and LAVI (r= -0.22, P= .018). In multiple linear regression analysis adjusted for other risk factors, LAVI was found to be an independent determinant of the rates of decline in RRF (β= -0.026, P= .018). This study shows that a higher LAVI is independently associated with a more rapid decline in RRF in patients with end-stage renal disease on peritoneal dialysis.

Left Ventricular Diastolic Dysfunction as a Predictor of Rapid Decline of Residual Renal Function in Patients with Peritoneal Dialysis

The aim of this study was to evaluate whether diastolic dysfunction at the start of dialysis could influence renal and cardiovascular survival rates in 82 patients undergoing peritoneal dialysis. Diastolic dysfunction was determined using left ventricular hypertrophy, the ratio of early peak transmitral inflow velocity to peak diastolic mitral annular velocity (E/E'), and left atrial volume index (LAVI). Residual renal function (RRF) was measured with 24-hour urine collections at baseline (within 1 month of beginning peritoneal dialysis) and thereafter at 6-month intervals for 2 years. To evaluate the long-term prognostic significance of diastolic dysfunction, the 4-year cardiac event-free survival was also evaluated. The median slope of RRF decline was -0.07 mL/min/mo/1.73 m(2). Forty-five patients (54.9%) with rapid RRF declines (< -0.07 mL/min/mo/1.73 m(2)) had a higher prevalence of diabetes and eccentric left ventricular hypertrophy, as well as significantly elevated E/E' ratios and LAVIs. There was a close relationship between baseline E/E' ratio (r = -0.221, P = .048), LAVI (r = -0.276, P = .015), and RRF decline rate, and both E/E' > 15 (odds ratio, 3.61; 95% confidence interval, 1.07-12.12) and LAVI > 32 mL/m(2) (odds ratio, 3.54; 95% confidence interval, 1.08-11.58) were significant independent predictors of the loss of RRF. Furthermore, E/E' > 15 also provided additional prognostic value in predicting future cardiac events (hazard ratio, 6.74; 95% confidence interval, 1.07-12.12; P = .023). Left ventricular diastolic dysfunction may be a significant predictor of rapid decline in RRF and adverse cardiac outcomes in patients starting peritoneal dialysis.

Rate of decline of residual renal function is associated with all-cause mortality and technique failure in patients on long-term peritoneal dialysis

Residual renal function (RRF) at the initiation of peritoneal dialysis (PD) therapy can predict patient outcome. However, RRF declines with time at variable rates in different patients. This study was performed to compare the impact of baseline RRF and the rate of RRF decline on patient survival and on death-censored technique survival after initiation of long-term PD. We enrolled 270 patients with sufficient urine amount (daily urine volume >100 mL) from a medical centre in North Taiwan who began PD between January 1996 and December 2005 and followed them until December 2007. The study population was stratified by the decline rate of RRF into a fast, intermediate and slow decline group. The Kaplan-Meier survival analysis was used to determine patient survival and technique survival. The Cox regression model was used to identify factors associated with patient outcome. The proportional odds polychotomous logistic regression model was used to identify variables associated with rapid decline of RRF. During an average follow-up period of 45 months, 50 (18.5%) deaths, 67 (24.8%) death-censored technique failures (transfer to haemodialysis) and 43 (15.9%) renal transplantations occurred. The median rate of RRF decline was 0.885 mL/min/1.73 m(2) per year. Survival analysis showed that patients with fast RRF decline had worse survival and increased risk of technique failure. The multivariate Cox regression model confirmed that the rate of RRF decline was an independent factor associated with patient and technique survival and was a more powerful prognostic factor than basal RRF. Variables associated with a rapid decline of RRF were larger body mass index, presence of diabetes, prior history of congestive heart failure, use of diuretics, peritonitis episodes and hypotensive events. Our data indicate that the rate of decline of RRF is a more powerful prognostic factor than baseline RRF associated with all-cause mortality and technique failure in patients on long-term PD. To prevent accelerated loss of RRF, it is imperative that every effort be made to avoid overdiuresis, peritonitis and hypotensive episodes, especially in those with diabetes, obesity and congestive heart failure.

Biocompatible membranes preserve residual renal function in patients undergoing regular hemodialysis

Initiation of hemodialysis causes a further decrease of residual renal function (RRF). To assess the impact of the biocompatibility of the dialysis membrane, we performed a prospective randomized investigation in 20 normotensive patients with tubulointerstitial nephritis. The patients were randomly allocated to treatment with either a high-flux polysulfone or cellulose membrane over a period of 12 months. RRF, defined by creatinine clearance and daily urine volume, was found to decrease in both groups of patients after the initiation of hemodialysis. Of the two membranes used, however, the cellulose membrane caused an accelerated decrease of RRF (P < 0.05). The better maintenance of RRF in patients treated with polysulfone membranes was associated with higher Kt/V values and increased hematocrit values (P < 0.05). The pathophysiologic mechanism underlying the more rapid decline of RRF could not be explained by intradialytic hypotension, but may be related to the nephrotoxic effects of inflammatory mediators due to bioincompatibility. Therefore, the use of polysulfone membranes might be preferable in patients with relevant RRF.