Treatment Of Kidney Failure Research Articles

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 2.

: Coping with chronic kidney disease (CKD) is challenging for many people, since symptoms often don't appear until the disease is advanced and the patient is close to requiring dialysis. This two-part article aims to provide nurses with the basic information necessary to assess and manage patients with CKD. Part 1, which appeared last month, offered an overview of the disease, described identification and etiology, and discussed ways to slow disease progression. Part 2 addresses disease complications and treatment for kidney failure.

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 1.

: The burden of chronic kidney disease (CKD) is rising both in this country and worldwide. An estimated 10% to 15% of U.S. adults are currently living with CKD. Reducing the CKD burden requires a systematic, interdisciplinary approach to care. The greatest opportunities to reduce the impact of CKD arise early, when most patients are being followed in primary care; yet many clinicians are inadequately educated on this disease. Nurses are well positioned to facilitate the implementation of collaborative care. This two-part article aims to provide nurses with the basic information necessary to assess and manage patients with CKD. Part 1 offers an overview of the disease, describes identification and etiology, and discusses ways to slow disease progression. Part 2, which will appear next month, addresses disease complications and treatment of kidney failure.

Effects of Expanded Hemodialysis Therapy on Clinical Outcomes.

The invention of dialysis has been a phenomenal advance in the treatment of kidney failure. The introduction of artificial kidneys in clinical care remains one of the most successful lifesaving interventions in modern medicine. Its glory, however, has been tempered by poor long-term outcomes and a negative qualitative impact on the lives of patients who suffer from an extremely complex, burdensome, and restricted life on dialysis. There remains a huge gap in patient well-being and outcomes between artificial kidney treatments and kidney transplantation. The inadequacy of dialysis, at least in part, is due to the chronic accumulation of organic retention solutes of middle and large molecules in chronic kidney disease, which are poorly removed by current dialytic treatment modalities. Incremental benefits observed through alternative strategies such as high volume hemodiafiltration, high frequency, and expanded hemodialysis (HD) schedules have had limited success, due to a host of organizational, complex technology need and human factor barriers. Expanded HD (HDx) therapy offers a novel blood purification technology, with the use of high retention onset (HRO) membranes designed to achieve a superior spectrum of solute waste removal in uremia. Limited studies have demonstrated the potential benefit of HRO membranes in reducing cardiovascular risk, vascular calcification, and inflammation commonly associated with the "residual uremic syndrome" and patient symptom burden. Robust and efficient clinical trials are now required to establish the rationale and impact of HDx therapy in driving improvements in both physician- and patient-directed clinical goals and outcomes in dialysis.

First Implantation of Silicon Nanopore Membrane Hemofilters.

An implantable hemofilter for the treatment of kidney failure depends critically on the transport characteristics of the membrane and the biocompatibility of the membrane, cartridge, and blood conduits. A novel membrane with slit-shaped pores optimizes the trade-off between permeability and selectivity, enabling implanted therapy. Sustained (3-8) day function of an implanted parallel-plate hemofilter with minimal anticoagulation was achieved by considering biocompatibility at the subnanometer scale of chemical interactions and the millimeter scale of blood fluid dynamics. A total of 400 nm-thick polysilicon flat sheet membranes with 5-8 nm × 2 micron slit-shaped pores were surface-modified with polyethylene glycol. Hemofilter cartridge geometries were refined based on computational fluid dynamics models of blood flow. In an uncontrolled pilot study, silicon filters were implanted in six class A dogs. Cartridges were connected to the cardiovascular system by anastamoses to the aorta and inferior vena cava and filtrate was drained to collection pouches positioned in the peritoneum. Pain medicine and acetylsalicylic acid were administered twice daily until the hemofilters were harvested on postoperative days 3 (n = 2), 4 (n = 2), 5 (n = 1), and 8 (n = 1). No hemofilters were thrombosed. Animals treated for 5 and 8 days had microscopic fractures in the silicon nanopore membranes and 20-50 ml of transudative (albumin sieving coefficient θalb ~ 0.5 - 0.7) fluid in the collection pouches at the time of explant. Shorter experimental durations (3-4 days) resulted in filtration volumes similar to predictions based on mean arterial pressures and membrane hydraulic permeability and (θalb ~ 0.2 - 0.3), similar to preimplantation measurements. In conclusion, a detailed mechanistic and materials science attention to blood-material interactions allows implanted hemofilters to resist thrombosis. Additional testing is needed to determine optimal membrane characteristics and identify limiting factors in long-term implantation.

Growing Kidney Tissue from Stem Cells: How Far from “Party Trick” to Medical Application?

The successful generation of kidney-like structures from human pluripotent stem cells, although slower to come than other tissue types, brings the hope of new therapies. While the demand for alternative treatments for kidney failure is acute, huge challenges remain to move these exciting but preliminary results toward clinical use.

Going Upstream: Coordination to Improve CKD Care.

Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre-emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings.

Calidad de vida del adulto con insuficiencia renal crónica, una mirada bibliográfica

El objetivo fue describir la calidad de vida de pacientes con disminución de la función renal. Como materiales y métodos se realizó una revisión bibliográfica en las bases de datos (Pubmed, biblioteca virtual de salud, Scielo, Lilacs, Redalyc y Google académico), utilizando descriptores como: calidad de vida / Relaciones Enfermero-Paciente / insuficiencia renal/enfermedad crónica. Se seleccionaron 52 artículos que midieran calidad de vida, de estos se excluyeron aquellas bibliografías con más de 6 años de antigüedad, los estudios que prevalecieron fueron los descriptivos. Los resultados arrojaron que: la dimensión de calidad de vida más afectada es la física; de las tres modalidades de tratamiento para la insuficiencia renal, la que más afecta la calidad de vida del paciente es la hemodiálisis, el instrumento validado y más utilizado para medir calidad de vida en individuos con enfermedades crónicas es el SF-36. Como conclusiones: La calidad de vida de los pacientes con insuficiencia renal crónica se ve afectada, por lo que están sujetos a cambios en su estilo de vida que van de la mano con el tratamiento sustitutivo renal y sus complicaciones, además, presentan deterioro de la función física, mental, emocional, laboral y espiritual

Disparities in worldwide treatment of kidney failure

Dialysis and kidney transplantation transformed medical care for patients with kidney failure, but these renal replacement therapies (RRTs) are unavailable to most patients who need them worldwide. Chronic kidney disease is now the 18th leading cause of death worldwide.1 Accurate estimation of the number of people with kidney failure receiving RRT and forecasting of future trends is essential for planning services and programmes to address kidney failure worldwide.

Sitting Here in Limbo: The Saga of End-Stage Renal Failure and Kidney Transplantation in the United States

This paper aims to evaluate the role that personal appeals for organ donations have played throughout the history of transplantation, with particular attention to the diverse relationships such appeals have had with public policy regarding organ transplantation — at times seeming to animate policy developments, while at other times assuming an antagonistic role vis-a-vis the medical and legal establishments — and the further ethical issues implicated by the advent of social media as a tool to facilitate these exchanges. In Part I, I will recount the history of modern treatment for kidney disease, and how its development set up a paradigm that deeply entwined the federal government and the medical establishment. I will discuss the complex history of the earliest widely-used treatment for kidney failure — dialysis — paying special attention to the issues of scarcity and allocation that have complicated this treatment since the opening of the first long-term dialysis clinics in the early 1960s. I will discuss how the success of kidney transplantation created new problems of supply and demand that resemble those associated with dialysis in the past. I will recount the history of legislation related to kidney disease and organ donation, including a discussion of the role that personal emotional appeals have played in shaping public policy related to the treatment of kidney disease, even before transplantation became the preferred method of treatment. In Part II, I will provide statistics to illustrate the gravity of the issues that characterize our current system of regulating organ transplantation. Then, I will describe the values that motivate our organ donation and allocation system, and the conflicts they can engender. In Part III, I aim to further elucidate the profound moral issues implicated in organ transplantation by discussing the experience of having end stage renal disease, and relating the reality of this experience to an analysis of the rhetoric surrounding kidney transplantation in the United States. Part IV will address various issues concerning directed donations from living organ donors. First, I will discuss the notable absence of regulation with regard to organ donations from living donors, explaining why this regulatory gap exists, and how it has led to further controversy and dysfunction within the organ transplantation system. Second, I will discuss concerns unique to living kidney donation, and how the medical and legal establishments have responded to these concerns in crafting the transplant process as it operates today. Next, I will analyze trends in living donation, specifically the increasing popularity of non-related directed donations. I will discuss the ethical issues implicated in this trend, including the permissibility of directed donation, how certain types of directed donation conflict with the values that constitute the backbone of our current organ transplantation system, and the question of risk to both donor and recipient. I will then specifically address the role of social media and the Internet in facilitating this trend, and the ways in which new social media platforms to facilitate living donation may serve to exacerbate inequalities in organ allocation. In Part V, I will propose a way to harness the power of social media in order to facilitate increased donation, and make several suggestions for improving our policy regarding living organ donation.

FutureMatch: Combining Human Value Judgments and Machine Learning to Match in Dynamic Environments

The preferred treatment for kidney failure is a transplant; however, demand for donor kidneys far outstrips supply. Kidney exchange, an innovation where willing but incompatible patient-donor pairs can exchange organs- — via barter cycles and altruist-initiated chains —provides a life-saving alternative.Typically, fielded exchanges act myopically, considering only the current pool of pairs when planning the cycles and chains. Yet kidney exchange is inherently dynamic, with participants arriving and departing. Also, many planned exchange transplants do not go to surgery due to various failures. So, it is important to consider the future when matching. Motivated by our experience running the computational side of a large nationwide kidney exchange, we present FutureMatch, a framework for learning to match in a general dynamic model. FutureMatch takes as input a high-level objective (e.g., "maximize graft survival of transplants over time'') decided on by experts, then automatically (i) learns based on data how to make this objective concrete and (ii) learns the ``means'' to accomplish this goal — a task, in our experience, that humans handle poorly. It uses data from all live kidney transplants in the US since 1987 to learn the quality of each possible match; it then learns the potentials of elements of the current input graph offline (e.g., potentials of pairs based on features such as donor and patient blood types), translates these to weights, and performs a computationally feasible batch matching that incorporates dynamic, failure-aware considerations through the weights. We validate FutureMatch on real fielded exchange data. It results in higher values of the objective. Furthermore, even under economically inefficient objectives that enforce equity, it yields better solutions for the efficient objective (which does not incorporate equity) than traditional myopic matching that uses the efficiency objective.

Recent advances in immunosuppression for kidney transplantation

Objective To perform a systematic review on the recent advances in immunosuppression for kidney transplantation and how these recent strategies over the past decades have led to significant improvements in the field of renal transplantation. Data sources MEDLINE, EMBASE, and Cochrane databases were searched. The search was performed on 1 November 2013 and included articles published ahead of print, with no language restrictions. Study selection The initial search presented 500 articles, of which 20 fulfilled the inclusion criteria. The articles studied whether transplantation is the ideal treatment for kidney failure, presenting details on graft immunology and the mechanism of action of immunosuppressants, with a focus on novel mechanisms. Data synthesis Because of heterogeneity in the postoperative follow-up periods and outcome measures reported, it was not possible to pool the data and carry out a meta-analysis. Comparisons were performed by a structured review. Conclusion Excellent outcomes have been achieved in the field of renal transplantation. A significant reduction in acute rejection has been achieved at many renal transplant centers using currently available immunosuppressives, consisting of an induction agent, a calcineurin inhibitor, and an antiproliferative agent with or without a corticosteroid. Despite improvements with these regimens, chronic allograft injury and adverse events still persist. The perfect immunosuppressive regimen would limit or eliminate calcineurin inhibitors and/or corticosteroid toxicity while resulting in enhanced allograft outcomes. The aim of this review is to consolidate the published evidence of the effectiveness and safety of investigational immunosuppressive agents in renal transplant recipients.

Novel heparin-mimicking polymer brush grafted carbon nanotube/PES composite membranes for safe and efficient blood purification

Nowadays, polymeric membrane based hemodialysis is considered to be the most practical approach for the treatment of kidney failure. To develop advanced hemodialysis membrane integrated with favorable blood and cell compatibilities and efficient blood purification ability, novel biocompatible composite membranes consisting of heparin-mimicking polymer brush functionalized carbon nanotubes (f-CNTs) and polyethersulfone (PES) are designed. Firstly, surface initiated atom transfer polymerization (SI-ATRP) is applied to synthesize heparin-mimicking polymer brush (contained the sodium styrene sulfonate (SS) and methyl ether methacrylate (EGMA) units) grafted CNT. Then, the f-CNT/PES composite membranes are prepared by a liquid–liquid phase separation technique. Scanning electron microscopy (SEM) and atomic force microscopy (AFM) results indicated that the f-CNT would not cause severe damage on the membrane morphologies. Systemic protein ultrafiltration experiment indicated that the heparin-mimicking composite membranes owned satisfied antifouling property and protein rejection ratio. Further blood compatibility evaluation revealed that the composite membranes had decreased protein adsorption, prolonged clotting time, and suppressed platelet adhesion compared to pristine PES membrane. The results of human embryonic hepatocytes (LO-2) culture revealed that the cyto-compatibility of the modified membrane was enhanced by the blending of heparin mimicking polymer functionalized CNT. Furthermore, with the addition of f-CNT, the composite membranes showed remarkably increased removal efficiency of uremic toxin. In general, the fabricated heparin-mimicking f-CNT/PES composite membranes exhibited anti-fouling ability in ultrafiltration, excellent blood and cell compatibility and efficient toxic molecules removal ratio, thus present great potential for various applications, such as hemodialysis and bio-artificial liver support. Furthermore, the proposed method might forward the fabrication of advanced hemodialysis membrane by integrating functional nanomaterials and bioactive polymers.

Lineage tracing reveals distinctive fates for mesothelial cells and submesothelial fibroblasts during peritoneal injury.

Fibrosis of the peritoneal cavity remains a serious, life-threatening problem in the treatment of kidney failure with peritoneal dialysis. The mechanism of fibrosis remains unclear partly because the fibrogenic cells have not been identified with certainty. Recent studies have proposed mesothelial cells to be an important source of myofibroblasts through the epithelial-mesenchymal transition; however, confirmatory studies in vivo are lacking. Here, we show by inducible genetic fate mapping that type I collagen-producing submesothelial fibroblasts are specific progenitors of α-smooth muscle actin-positive myofibroblasts that accumulate progressively in models of peritoneal fibrosis induced by sodium hypochlorite, hyperglycemic dialysis solutions, or TGF-β1. Similar genetic mapping of Wilms' tumor-1-positive mesothelial cells indicated that peritoneal membrane disruption is repaired and replaced by surviving mesothelial cells in peritoneal injury, and not by submesothelial fibroblasts. Although primary cultures of mesothelial cells or submesothelial fibroblasts each expressed α-smooth muscle actin under the influence of TGF-β1, only submesothelial fibroblasts expressed α-smooth muscle actin after induction of peritoneal fibrosis in mice. Furthermore, pharmacologic inhibition of the PDGF receptor, which is expressed by submesothelial fibroblasts but not mesothelial cells, attenuated the peritoneal fibrosis but not the remesothelialization induced by hypochlorite. Thus, our data identify distinctive fates for injured mesothelial cells and submesothelial fibroblasts during peritoneal injury and fibrosis.

Can a combined screening/treatment programme prevent premature failure of renal transplants due to chronic rejection in patients with HLA antibodies: study protocol for the multicentre randomised controlled OuTSMART trial

BackgroundRenal transplantation is the best treatment for kidney failure, in terms of length and quality of life and cost-effectiveness. However, most transplants fail after 10 to 12 years, consigning patients back onto dialysis. Damage by the immune system accounts for approximately 50% of failing transplants and it is possible to identify patients at risk by screening for the presence of antibodies against human leukocyte antigens. However, it is not clear how best to treat patients with antibodies. This trial will test a combined screening and treatment protocol in renal transplant recipients.Methods/DesignRecipients >1 year post-transplantation, aged 18 to 70 with an estimated glomerular filtration rate >30 mL/min will be randomly allocated to blinded or unblinded screening arms, before being screened for the presence of antibodies. In the unblinded arm, test results will be revealed. Those with antibodies will have biomarker-led care, consisting of a change in their anti-rejection drugs to prednisone, tacrolimus and mycophenolate mofetil. In the blinded arm, screening results will be double blinded and all recruits will remain on current therapy (standard care). In both arms, those without antibodies will be retested every 8 months for 3 years. The primary outcome is the 3-year kidney failure rate for the antibody-positive recruits, as measured by initiation of long-term dialysis or re-transplantation, predicted to be approximately 20% in the standard care group but <10% in biomarker-led care. The secondary outcomes include the rate of transplant dysfunction, incidence of infection, cancer and diabetes mellitus, an analysis of adherence with medication and a health economic analysis of the combined screening and treatment protocol. Blood samples will be collected and stored every 4 months and will form the basis of separately funded studies to identify new biomarkers associated with the outcomes.DiscussionWe have evidence that the biomarker-led care regime will be effective at preventing graft dysfunction and expect this to feed through to graft survival. This trial will confirm the benefit of routine screening and lead to a greater understanding of how to keep kidney transplants working longer.Trial registrationCurrent Controlled Trials ISRCTN46157828.

Renal transplantation in antineutrophil cytoplasmic antibody-associated vasculitis

This review aims to provide a state-of-the-art perspective on the role of kidney transplantation in cases of end-stage kidney disease due to antineutrophil cytoplasmic antibody (ANCA) vasculitis. We focus on patient and graft survival in recent years, timing of transplant, impact of ANCA status, and relapse of vasculitis in the allograft. Graft and patient outcome compare very favorably with other causes of kidney failure and several recent studies have indicated that these outcomes have improved further in recent years. Relapse of vasculitis posttransplant appears to be lower in the modern era of transplant induction. There may be an excess mortality in those transplanted less than 1 year after induction of vasculitis remission, so it is probably wise to wait for this period before proceeding with the graft. ANCA status at transplant does not appear to influence outcome. Kidney transplantation is an excellent treatment for kidney failure due to vasculitis, although one must never lose sight of the cause of the original vasculitic kidney failure in the event of clinical deterioration of an allograft recipient, even if the diagnosis of ANCA vasculitis was many years previously.

Age and treatment of kidney failure

This review discusses issues related to treatment of chronic kidney disease, and kidney failure in particular, among older adults. A substantial proportion of older adults have chronic kidney disease and progress to kidney failure. There is considerable variability in treatment practices for advanced kidney disease among older adults, and evidence that treatment decisions such as dialysis initiation may be made without adequate preparation. When initiated, survival among older adults on chronic dialysis remains poor, and is associated with a significant decline in functional status. There is also evidence to suggest that dialysis initiation may not reflect overall treatment goals of elderly patients, but rather a lack of clear communication between patients and health practitioners, and underdeveloped conservative care programs in many centers. Kidney failure is common among older adults. When considering treatment options for kidney failure, patient priorities, preferences, and symptoms should be taken into account, using a shared decision-making approach.

Renal disease more prevalent and problematic for Aboriginal peoples

Aboriginal peoples in Canada are far more likely to require treatment for kidney failure and end-stage renal disease than other Canadians, but don’t fare as well following dialysis and have lower rates of kidney transplantation, according to a new report from the Canadian Institute for Health

Treatment of kidney failure is age dependent

Treatment of kidney failure is age dependent

Advance care planning: the journey of changing hospital culture in an in-centre dialysis unit

The mortality rate for patients with end stage renal disease is comparable to or higher than many cancer diagnoses. While dialysis provides life-sustaining treatment, kidney failure is irreversible and is...

PMD25 Comparison of Statistical Methods Used to Model Health Care Costs by Dialysis Modality in the Treatment of Kidney Failure

PMD25 Comparison of Statistical Methods Used to Model Health Care Costs by Dialysis Modality in the Treatment of Kidney Failure