End-stage Renal Disease Therapy Research Articles

Impact of the serum bone-specific alkaline phosphatase level at the initiation of hemodialysis therapy for end-stage renal disease on cardiovascular events

BackgroundPatients with end-stage renal disease (ESRD) have high rates of hospitalization for cardiovascular (CV) events and short-term mortality after the initiation of hemodialysis (HD) therapy. To improve outcomes, it is important to identify predictive laboratory markers. We investigated whether the serum bone-specific alkaline phosphatase (BAP) level at the initiation of HD therapy for ESRD was associated with adverse events. MethodsThis was a retrospective cohort study of 47 ESRD outpatients who were referred to our clinic for HD. The serum BAP level was measured within 1month after the initiation of HD. Patients were divided into high-BAP and low-BAP groups according to the median serum BAP level (24.6U/L). The impact of the serum BAP level on CV events (coronary artery disease, peripheral arterial disease, cerebrovascular disease, other CV events including aortic dissection, and mortality) was investigated. ResultsDuring a median follow-up period of 72months, CV events occurred in 14 patients (29.8%). Kaplan–Meier analysis showed that the disease-free and overall survival rates were lower in the high-BAP group than in the low-BAP group (p=0.003 and p=0.037, respectively, log-rank test). After adjustment for age, sex, and other confounding factors, Cox proportional hazards analysis found that the high-BAP group had a 5.9-fold higher rate of CV events than the low-BAP group (hazard ratio: 5.89; 95% confidence interval: 1.184–29.309; p=0.030). ConclusionsThe serum BAP level at the initiation of HD therapy for ESRD is a useful non-invasive biomarker for predicting CV events.

Low-protein diet for diabetic nephropathy.

Diabetic nephropathy is the leading cause of progressive kidney disease, leading to end-stage renal disease and renal replacement therapy. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers have been considered effective at slowing the progression of kidney function deterioration. However, these drugs cannot sufficiently halt the progression of nephropathy to the extent that is required. A low-protein diet (LPD) is believed to be a nutritional intervention that may slow kidney disease progression. In fact, preclinical animal experiments have demonstrated excellent renoprotective effects of an LPD. However, in human clinical trials, analyses of the effects of protein restriction on diabetic nephropathy have not yet revealed consistently positive outcomes of this nutritional intervention. In this review, we analyze the potential renoprotective effects of an LPD on diabetic nephropathy and summarize the outcomes of clinical trials that have systematically investigated the efficacy of an LPD in diabetic nephropathy. In addition, we discuss some potential approaches associated with nutritional interventions to combat progressive kidney disease.

Pilot Experience in Senegal with Peritoneal Dialysis for End-Stage Renal Disease

♦ Peritoneal dialysis (PD) is occasionally used in western sub-Saharan Africa to treat patients with end-stage renal disease (ESRD). The present study is a retrospective review of the initial six years' experience with PD for ESRD therapy in Senegal, a West African country with a population of over 12 million. ♦ Single-center retrospective cohort study of patients treated with PD between March 2004 and December 2010. Basic demographic data were collected on all patients. Peritonitis rates, causes of death and reasons for transfer to hemodialysis (HD) were determined in all patients. ♦ Sixty-two patients were included in the study. The median age was 47 ± 13 years with a male/female ratio of 1.21. Nephrosclerosis and diabetic nephropathy were the main causes of ESRD. The mean Charlson score was 3 ± 1 with a range of 2 to 7. Forty five peritonitis episodes were diagnosed in 36 patients (58%) for a peritonitis rate of 1 episode/20 patient-months (0.60 episodes per year). Staphylococcus aureus and Pseudomonas aeruginosa were the most commonly identified organisms. Touch contamination has been implicated in 26 cases (57.7%). In 23 episodes (51%), bacterial cultures were negative. Catheter removal was necessary in 12 cases (26.6%) due to mechanical dysfunction, fungal or refractory infection. Sixteen patients died during the study. ♦ Peritoneal dialysis is a suitable therapy which may be widely used for ESRD treatment in western sub-Saharan Africa. A good peritonitis rate can be achieved despite the difficult living conditions of patients. Challenges to the development of PD programs include training health care providers, developing an infrastructure to support the program, and developing a cost structure which permits expansion of the PD program.

Multidisciplinary clinical strategies for encapsulating peritoneal sclerosis in peritoneal dialysis: Update from Japan

Peritoneal dialysis is established as a first-line standard renal replacement therapy for end-stage renal disease. However, the development of encapsulating peritoneal sclerosis has been a critical complication among long-term peritoneal dialysis patients. During the past decade, multidisciplinary approaches have been used to suppress encapsulating peritoneal sclerosis. The present article reviews the historical and present status of encapsulating peritoneal sclerosis in Japan.

Renal replacement therapy in Europe: a summary of the 2011 ERA-EDTA Registry Annual Report.

BackgroundThis article provides a summary of the 2011 ERA–EDTA Registry Annual Report (available at www.era-edta-reg.org).MethodsData on renal replacement therapy (RRT) for end-stage renal disease (ESRD) from national and regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. From 27 registries, individual patient data were received, whereas 17 registries contributed data in aggregated form. We present the incidence and prevalence of RRT, and renal transplant rates in 2011. In addition, survival probabilities and expected remaining lifetimes were calculated for those registries providing individual patient data.ResultsThe overall unadjusted incidence rate of RRT in 2011 among all registries reporting to the ERA–EDTA Registry was 117 per million population (pmp) (n = 71.631). Incidence rates varied from 24 pmp in Ukraine to 238 pmp in Turkey. The overall unadjusted prevalence of RRT for ESRD on 31 December 2011 was 692 pmp (n = 425 824). The highest prevalence was reported by Portugal (1662 pmp) and the lowest by Ukraine (131 pmp). Among all registries, a total of 22 814 renal transplantations were performed (37 pmp). The highest overall transplant rate was reported from Spain, Cantabria (81 pmp), whereas the highest rate of living donor transplants was reported from Turkey (39 pmp). For patients who started RRT between 2002 and 2006, the unadjusted 5-year patient survival on RRT was 46.8% [95% confidence interval (CI) 46.6–47.0], and on dialysis 39.3% (95% CI 39.2–39.4). The unadjusted 5-year patient survival after the first renal transplantation performed between 2002 and 2006 was 86.7% (95% CI 86.2–87.2) for kidneys from deceased donors and 94.3% (95% CI 93.6–95.0) for kidneys from living donors.

MMP-1 and -3 haplotype is associated with congenital anomalies of the kidney and urinary tract

Congenital anomalies of the kidney and urinary tract (CAKUT) are a common cause of progressive chronic kidney disease that may lead to end-stage renal disease and renal replacement therapy in childhood. Altered expression or activity of matrix metalloproteinases (MMPs) have been found in CAKUT. The MMP-1, -3, and -8 polymorphisms studied here are located in the gene promoters and alter expression. Our aim was to investigate associations of MMP polymorphisms, solely and in haplotypes, with CAKUT in children. A case-control study with 101 pediatric patients and 281 controls was performed. The MMP-1 (-1607 1G/2G), -3 (5A/6A), and -8 (-799 C/T) genotypes were determined by PCR-restriction fragment length polymorphism. We found statistically significant associations of MMP-3 5A/6A polymorphism (p < 0.0001) and 1G-(1607)-6A haplotype, with no preferences for MMP-8 -799C or T alleles, with CAKUT (OR = 2.93, 95 % CI 1.43-5.98, adjusted for gender, p = 0.003) and with obstructive uropathies in a subgroup of patients (OR = 4.57, 95 % CI 2.74-7.61, adjusted for gender, p < 0.0001). MMP-3 genotypes and MMP-3 and -1 haplotypes encompassing either MMP-8 -799C or T alleles were associated with CAKUT and obstructive uropathies in pediatric patients. Still, functional and association studies are needed to elucidate evident roles of MMPs in CAKUT.

An update on sickle cell nephropathy

Sickle cell disease (SCD) is a major health problem in many countries. Sickle cell nephropathy (SCN) is now a well-characterized entity with specific manifestations, risk factors and prognosis. The presence of sickled erythrocytes in the renal medullary vessels is the hallmark of the disease with a variety of renal complications. Renal manifestations of SCD include renal ischemia, microinfarcts, renal papillary necrosis and renal tubular abnormalities with variable clinical presentations. Proximal tubule dysfunction generally impairs urinary concentration, while more distal tubule dysfunction may impair potassium excretion, leading to hyperkalemia. Glomerular disease with proteinuria may develop due to ischemia and results in a compensatory increase in the renal blood flow and glomerular filtration rate; such hyperfiltration, combined with glomerular hypertrophy, probably contributes to glomerulosclerosis. Acute and chronic kidney disease are the expected outcomes of the disease. Both dialysis and kidney transplantation are effective renal replacement therapies for end-stage renal disease due to SCN, with a higher advantage for transplantation. Whether bone marrow transplantation in the early stage of the disease can halt the progression of SCN is unknown and awaits clinical studies.

Epidemiology and Mortality of New-Onset Diabetes After Dialysis

OBJECTIVEWe examined the predictors and risks associated with pre-existing versus new-onset diabetes mellitus (DM) after initiation of chronic dialysis therapy in end-stage renal disease (ESRD) patients.RESEARCH DESIGN AND METHODSIn the Taiwan National Health Insurance Research Database, we examined records of ESRD patients who initiated dialysis between 1999 and 2005. Patients were followed until death, transplant, dialysis withdrawal, or 31 December 2008. Predictors of new-onset DM and mortality were calculated using Cox models.RESULTSA total of 51,487 incident dialysis patients were examined in this study, including 25,321 patients with pre-existing DM, 3,346 with new-onset DM, and 22,820 without DM at any time. Patients’ age (mean ± SD) was 61.8 ± 11.5, 61.6 ± 13.7, and 56.5 ± 16.6 years in pre-existing, new-onset DM, and without DM groups, respectively. The cumulative incidence rate of new-onset DM was 4% at 1 year and 21% at 9 years. Dialysis modality was not a risk factor for new-onset DM (peritoneal dialysis to hemodialysis hazard ratio [HR] of new-onset DM, 0.94 [95% CI 0.83–1.06]). Pre-existing DM was associated with 80% higher death risk (HR 1.81 [95% CI 1.75–1.87]), whereas the new-onset DM was associated with 10% increased death risk (HR 1.10 [95% CI 1.03–1.17]).CONCLUSIONSWhereas dialysis modality does not appear to associate with new-onset DM, both pre-existing and new-onset DM are related to higher long-term mortality in maintenance dialysis patients.

Should high-flux hemodialysis be replaced by online hemodiafiltration for treating end-stage renal disease patients?

End-stage renal failure is caused by several diseases (mainly diabetic nephropathy, vascular diseases, acute or chronic glomerulonephritis, tubule-interstitial nephritis, and various inherited diseases such as autosomal dominant polycystic kidney disease) that lead to loss of renal function and require the initiation of renal replacement therapies. In developed countries, the prevalence of end-stage renal disease (ESRD) ranges from 1–2 cases per 1000 inhabitants and is associated with high morbidity, mortality and cost. Since the beginning of maintenance therapy for ESRD through dialysis or transplantation, the number of patients treated for terminal kidney failure worldwide has continued to grow at a rate far exceeding the growth rate of the general population. By 2013, more than 1 million patients were estimated worldwide to receive dialysis treatment, with the numbers growing at an annual global average rate of 7% [1]. Nowadays, renal replacement therapies are based on renal transplantation, peritoneal dialysis and various hemodialysis (HD) techniques. Obviously, the most effective treatment option for ESRD patients is renal transplantation and, in fact, approximately 50% of patients with ESRD in developed countries have a functioning graft. Unfortunately, only 25–35% of patients with ESRD will receive a living or deceased kidney allograft during their lifetime. Thus, dialysis techniques will be needed for patients waiting for a kidney transplant and for those who are not candidates for transplantation. Despite continuous improvement in HD devices, membrane biocompatibility, dialysate purification and distinct pharmacological therapies (erythropoietinstimulating agents, phosphate binders or antiparathyroid agents), mortality among these patients remains too high, at approximately 15–20% per year [2]. The kidney participates in the regulation of acid–base balance, electrolyte concentrations, extracellular fluid volume and blood pressure. These functions are accomplished by mechanisms of filtration, reabsorption, and secretion, which are done in the nephron. Filtration (convection) is the process by which small and large molecules are filtered from the blood to make an ultrafiltrate that becomes urine. The kidney generates 180 l of filtrate a day and reabsorbs a large percentage leading to the generation of only approximately 2 l of urine daily. Conversely, conventional HD techniques are based on the diffusion capacity of molecules across a semi-permeable membrane, which allows adequate clearance of low-molecular-weight particles. However, clearance of middle and large molecules is considerably less adequate. To increase the clearance of middle–large molecules, synthetic membranes with high-flux (HF) permeability (ultrafiltration coefficient higher than 20 ml/h/mmHg/m 2 ) were introduced many years ago. Comparison of HF - HD and low-flux HD (LF - HD) has yielded contradictory results: the HEMO study conducted in the USA showed no survival differences [3] while the MPO study showed that HF - HD was associated with better long-term survival in patients with hypoalbuminemia and diabetes mellitus [4]. Clearance of middle–large molecules is maximized by combining diffusive and convective transport, a hemodiafiltration modality that attempts to mimic 1

Measuring health: related quality of life in hemodialysis patients. Psychometric properties of the Missoula-VITAS Quality of Life Index (MVQOLI-15) in Greece

Different measuring tools have been used to understand the outcomes of end-stage renal disease (ESRD) therapies. However, survival, cost-effectiveness and quality of life (QOL) are the main parameters to evaluate treatment of ESRD. The current study meant to assess the psychometric properties (reliability and validity) of the Missoula-VITAS Quality of Life Index (MVQOLI-15) translation to Greek in patients undergoing hemodialysis (HD). A total sample of 79 HD patients voluntarily participated in this pilot study. Domain analysis of MVQOLI-15-Greek was conducted based on the collected data at initial assessment. The reliability properties of the instrument were tested using the following measures; internal consistency, repeatability, test-retest reliability and convergent validity. Domain analysis demonstrated that all domains of the questionnaire had good variability. MVQOLI-15-Greek internal consistency was satisfactory with an overall Cronbach&amp;rsquo;s a at 0.74. Pearson&amp;rsquo;s r and intraclass correlation coefficient revealed strong correlations (ranging from 0.91 to 0.98) between initial assessment and reassessment. MVQOLI-15-Greek convergent validity analysis indicated that the domains were strongly related to the same construct. The findings of the study indicate that the Greek version of MVQOLI-15 provided satisfactory psychometric properties supporting its use within pathological populations and in the context of national QOL measurement.

Measuring Health: Related Quality of Life in Hemodialysis Patients. Psychometric Properties of the Missoula-VITAS Quality of Life Index (MVQOLI-15) in Greece.

Different measuring tools have been used to understand the outcomes of end-stage renal disease (ESRD) therapies. However, survival, cost-effectiveness and quality of life (QOL) are the main parameters to evaluate treatment of ESRD. The current study meant to assess the psychometric properties (reliability and validity) of the Missoula-VITAS Quality of Life Index (MVQOLI-15) translation to Greek in patients undergoing hemodialysis (HD). A total sample of 79 HD patients voluntarily participated in this pilot study. Domain analysis of MVQOLI-15-Greek was conducted based on the collected data at initial assessment. The reliability properties of the instrument were tested using the following measures; internal consistency, repeatability, test-retest reliability and convergent validity. Domain analysis demonstrated that all domains of the questionnaire had good variability. MVQOLI-15-Greek internal consistency was satisfactory with an overall Cronbach’s a at 0.74. Pearson’s r and intraclass correlation coefficient revealed strong correlations (ranging from 0.91 to 0.98) between initial assessment and re-assessment. MVQOLI-15-Greek convergent validity analysis indicated that the domains were strongly related to the same construct. The findings of the study indicate that the Greek version of MVQOLI-15 provided satisfactory psychometric properties supporting its use within pathological populations and in the context of national QOL measurement.

Anti-glomerular basement membrane antibody disease is an uncommon cause of end-stage renal disease

There are few reports regarding outcomes of anti-glomerular basement membrane (GBM) disease in patients who underwent renal replacement therapy. To help define this we studied all patients with anti-GBM disease who started renal replacement therapy for end-stage renal disease (ESRD) in Australia and New Zealand (ANZDATA Registry) between 1963 and 2010 encompassing 449 individuals (0.8 percent of all ESRD patients). The median survival on dialysis was 5.93 years with death predicted by older age and a history of pulmonary hemorrhage. Thirteen patients recovered renal function, although 10 subsequently experienced renal death after a median period of 1.05 years. Of the 224 patients who received their first renal allograft, the 10-year median patient and renal allograft survival rates were 86% and 63%, respectively. Six patients experienced anti-GBM disease recurrence in their allograft, which led to graft failure in two. Using multivariable Cox regression analysis, patients with anti-GBM disease had comparable survival on dialysis or following renal transplantation (hazard ratios of 0.86 and 1.03, respectively) compared to those with ESRD due to other causes. Also, renal allograft survival (hazard ratio of 1.03) was not altered compared to other diseases requiring a renal transplant. Thus, anti-GBM disease was an uncommon cause of ESRD, and not associated with altered risks of dialysis, transplant or first renal allograft survival. Death on dialysis was predicted by older age and a history of pulmonary hemorrhage.

Can sonographic peritoneal thickness be used to follow pediatric patients on peritoneal dialysis?

Peritoneal dialysis (PD) is an effective and successful therapy for end-stage renal disease (ESRD). However, PD does not have a life-long effectiveness, and peritoneal membrane failure is commonly observed in long-term PD patients. We hypothesized that ultrasonography could be used to follow these patients. We recruited two patient groups (age range 3-18 years), of whom 20 had ESRD with ongoing PD for ≥24months (study group) and 20 were pre-dialysis non-ESRD patients (control group). None of the patients had peritonitis during the preceding 3months, and none had a history of abdominal surgery or malignancy. We measured the sonographic thickness of the parietal peritoneum and obtained Doppler indices of the superior mesenteric artery (SMA) by trans-abdominal ultrasonography. Peritoneal thickness as determined by sonography was significantly greater in the PD group than in the controls. The correlation between duration of PD and thickness of the peritoneal membrane was linear and statistically significant. We categorized all 20 patients as either rapid transporters or slow transporters for both creatinine and glucose. The peritoneal membranes of patients who were rapid transporters for both creatinine and glucose were significantly thicker than those of the slow transporters. No statistical difference was found between the Doppler indices of the SMA between the groups. Thickness of the parietal peritoneum as determined by sonography is associated with PD duration and transport characteristics. We conclude that ultrasonography is a non-invasive and practical method which can be useful for following PD patients.

Peritoneal Dialysis—Moving from Current Status to the Future

Peritoneal dialysis (PD) has been widely used as one of the major renal replacement therapies (RRT) for end-stage renal disease (ESRD) patients. Although PD therapy has witnessed remarkable technical advances, and the patient's survival early after starting PD is comparable, or superior, to that of hemodialysis, it is currently faced with many challenges. Long-term PD is associated with progressive loss of UF capacity, resulting in increased cardiovascular morbidity or ultimate discontinuation of PD. This is related to inflammation, new vessel formation (angiogenesis), and fibrotic thickening of the peritoneal membrane (PM). Bioincompatible PD fluid, along with peritonitis, is the major contributor to the PM change. In order to establish PD as a more general and longstanding renal replacement therapy, clinicians and scientists need to investigate the pivotal issues such as adequate volume control and long-term preservation of the peritoneal membrane and the prevention from devastating conditions such as encapsulating peritoneal sclerosis. In this special issue, we have compiled elegant reviews and clinical studies with a special interest in the above-mentioned “Contemporary issues of PD therapy.” This special issue deals with many of the current issues such as PD catheter implantation by nephrologists, clinical benefits of the newer biocompatible PD fluid, peritonitis, and how to cope with low ultrafiltration volume with bimodal and twice-daily icodextrin use and several others. It is the hope of our editorial committee that this special issue will contribute to an improved patient care and serve as a stimulus to seek a new knowledge in renal replacement therapy. Kook-Hwan Oh Yong-Lim Kim Wai-Kei Lo Peter J. Margetts

How do genetic and environmental factors interact in diabetic kidney disease?

361 ISSN 1758-1907 10.2217/DMT.12.44 © 2012 Future Medicine Ltd Diabetes Manage. (2012) 2(5), 361–364 Diabetic kidney disease (DKD), also known as diabetic nephropathy, is one of the most serious complications of diabetes and results from a complex interplay of metabolic and hemodynamic disturbances in genetically predisposed individuals. Classically, DKD is characterized by persistent proteinuria, elevated arterial blood pressure, and progressive decline in renal function. In recent years, a subset of patients with diabetes and progressive loss of renal function without significant proteinuria either treated or untreated with renin–angiotensin–aldosterone system inhibitors have also been identified. Diabetes accounts for approximately 44% of patients on replacement therapy for endstage renal disease each year, including dialysis and renal transplantation. Despite the fact that its incidence has been declining in recent years, the current epidemic of obesity and diabetes is anticipated to reverse this trend and result in a disproportionate number of diabetics with end-stage renal disease, potentially reaching 70% by 2015 [1]. Diabetic individuals with nephropathy have a significantly increased morbidity and premature mortality primarily due to accelerated macrovascular cardiovascular disease, such as coronary heart disease and stroke. In addition to morbidity and mortality associated with DKD, the disease has major societal impact because of the enormous financial burden associated with renal replacement therapy. The increasing number of patients with end-stage renal disease and the associated socioeconomic burden necessitates the identification of cellular and molecular pathways involved in the development and progression of DKD. This should impact adequate classification, prognosis and treatment. Epidemiological studies investigating the causative factors demonstrate that

Decreasing trends in incidence and prevalence of renal replacement therapy in Croatia from 2000 to 2009.

BackgroundRecent studies have indicated stabilization in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in a number of European countries, the USA, and Japan. The aim of this study was to provide an update on the incidence and prevalence trends of RRT in Croatia over the past decade.MethodsData from the Croatian Registry of Renal Replacement therapy from 2000 to 2009 were analysed. Trends in incidence and prevalence were examined using the Poisson regression and Joinpoint regression analysis.ResultsThe total adjusted incidence rate of RRT for ESRD increased from 106.1 per million population (pmp) in 2000 to 140.4 pmp in 2004, at annual percentage change (APC) 7.0% [95% confidence interval (CI) 1.8, 12.6]. From 2004 to 2009, there was no rise in incidence [APC −1.0 (95% CI −4.5, 2.6)]. Continuous growth in incidence was present only in males [APC 2.6 (95% CI 0.9, 4.4)], in patients 65 years and older [APC 5.5 (95% CI 3.4, 7.6)], in patients with diabetes [APC 2.4 (95% CI 0.5, 4.4)], hypertension/renovascular disease [APC 6.1 (95% CI 1.6, 10.8)] and unknown/missing diagnosis [APC13.8 (95% CI 9.0, 18.8)]. The total adjusted prevalence rate rose from 598.7 pmp in 2000 to 785.6 pmp in 2004, at an annual rise of 7.5% (95% CI 5.8, 9.3). In the 2004–09 period, the growth of RRT slowed to APC 2.4 (95% CI 1.2, 3.5), and reached 890.8 pmp in 2009.ConclusionsAfter a rapid increase in the incidence of RRT in Croatia from 2000 to 2004, the incidence rate has stabilized during the 2004–09 period. The stabilization of incidence is followed by a reduction in the growth in prevalence rate. The stabilization of RRT incidence could be attributed to the successful prevention and treatment of cardiovascular diseases that simultaneously improved renal survival.

Five-year experience of peritoneal dialysis catheter placement

BackgroundPeritoneal dialysis (PD) is a widely used renal replacement therapy for end-stage renal disease (ESRD) patients. Using laparoscopic guidance for PD catheter placement, we have designed a safe method that resulted in a reduction in catheter migration. MethodsWe retrospectively reviewed 250 consecutive patients who underwent PD catheter placement from January 2005 to December 2009. The patients were divided into two groups: the conventional open surgery group and the laparoscopic group. All patients received Tenckhoff straight catheters. In the laparoscopic group, the catheter was additionally fixed to the ventral abdominal wall. Data were collected and a statistical analysis was performed to compare patient characteristics, surgical complications and catheter removal between the groups. ResultsOverall surgical complications in the laparoscopic group were lower than those in the conventional group (3.8% vs. 19.4%, p < 0.001), and the majority of catheter migrations and omental wraps occurred in the conventional group. Patients in the conventional group had higher American Society of Anesthesiologists scores than those in the laparoscopic group. There was no difference in the incidence of previous abdominal operation or follow-up periods in the groups. ConclusionOur laparoscopy-assisted PD catheter insertion method using an intraperitoneal fixation loop is safeand can be a valuable tool in prevention of catheter migration and omental wraps.

Intravenous renal cell transplantation for rats with acute and chronic renal failure

Acute kidney injury (AKI) and chronic renal failure (CKD) are the most challenging problems in nephrology. Multiple therapies have been attempted but these interventions have minimal effects on the eventual outcomes, and all too often the result is end-stage renal disease (ESRD). The only effective therapy for ESRD is renal transplantation but only a small fraction of patients receive transplants. In this work we introduce a novel approach to transplantation designed to regenerate kidneys afflicted by severe AKI or CKD: intravenous renal cell transplantation (IRCT) with adult rat primary renal cells reprogrammed to express the SAA gene localized and engrafted in kidneys of rat recipients that had severe AKI or CKD. IRCT significantly resolved renal dysfunction and limited kidney damage, inflammation, and fibrosis. Severe CKD was successfully improved by IRCT using kidney cells from donor rats or by renal cell self-donation in a form of autotransplantation. We propose that IRCT with adult primary renal cells reprogrammed to express the SAA gene can be used to effectively treat AKI and CKD.

Live‐Donor Nephrectomy

Six decades after its first implementation, kidney transplantation remains the optimal therapy for end-stage renal disease requiring dialysis. Despite the incontrovertible mortality reduction and cost-effectiveness of kidney transplantation, the greatest remaining barrier to treatment of end-stage renal disease is organ availability. Although the waiting list of patients who stand to benefit from kidney transplantation grows at a rate proportional to the overall population and proliferation of diabetes and hypertension, the pool of deceased-donor organs available for transplantation experiences minimal to no growth. Because the kidney is uniquely suited as a paired organ, the transplant community's answer to this shortage is living donation of a healthy volunteer's kidney to a recipient with end-stage renal disease. This review details the history and evolution of living-donor kidney transplantation in the United States as well as advances the next decade promises. Laparoscopic donor nephrectomy has overcome many of the obstacles to living donation in terms of donor morbidity and volunteerism. Known donor risks in terms of surgical and medical morbidity are reviewed, as well as the ongoing efforts to delineate and mitigate donor risk in the context of accumulating recipient morbidity while on the waiting list.

Cost of two different therapies for end-stage renal disease in northwest China

AbstractCurrently, the growing number of end-stage renal disease patients in developing countries consumes a greater proportion of healthcare budget, and increasing attention is being focused on the cost-effectiveness of the procedure. We aimed to assess the cost-effectiveness of living-related renal transplantation (RTx) as compared with that for hemodialysis (HD) and identify medical factors associated with charges for RTx in northwestern China. This study was a retrospective analysis of 372 patients on regular HD and 122 living-related kidney transplant recipients on regular follow-up for at least 3 years in northwestern China. All data on charges included HD procedure, RTx procedure, the cost for donor operation, immunosuppression, and follow-up medicare. The average annual cost to all patients on HD and kidney recipients during the first 3 years after RTx was $14482/$31027, $13502/$11038, and $13382/$10243, respectively. The three variables were found to be significant in predicting increased costs for RTx: diltiazem administration, acute rejection and infection complications. We concluded that from the second year on, RTx in China was more effective and less costly than dialysis treatment, although recipients without diltiazem administration and with acute rejection or infection proved costlier during the first year after transplantation.