Type Of Renal Replacement Therapy Research Articles

Implementation of a Renal Replacement Therapy Simulation to Strengthen Essential Pharmacist Skills

Objective. To assess third-year pharmacy students' knowledge and application of renal pharmacotherapy using a renal replacement therapy (RRT) simulation. Methods. A simulation was developed that involved three stations related to RRT: peritoneal dialysis, continuous renal replacement therapy (CRRT), and hemodialysis. Stations involved demonstration of each modality, literature searches for drug information questions related to renal dosing with written recommendations, and utilization of an electronic medical record (EMR) to develop a verbal Situation, Background, Assessment, Recommendation (SBAR) for a patient with chronic kidney disease (CKD). Pre- and post-simulation assessments regarding therapeutic knowledge of RRT was used. Results. All 174 students completed the pre- and post-simulation assessments over the course of two years. Student performance indicated significant improvement in overall knowledge based on the assessments with significant overall differences in questions relating to indications for RRT, type of RRT indicated for hemodynamic instability, and agents used to maintain circuit patency. Overall inter-class differences were also identified at baseline and specifically for the questions regarding indications for RRT and agents used to maintain circuit patency. Both classes showed significant improvement in overall knowledge based on the post-simulation assessments. Debrief sessions and course evaluations indicated student satisfaction with the simulation experience. Students reported that the experience met the simulation objectives. Conclusion. Participation in an RRT simulation allowed pharmacy students to apply knowledge and skills learned didactically related to renal pharmacotherapy.

Why Potential Living Kidney Donors Do Not Proceed for Donation: A Single-Center Experience

BackgroundLiving donor kidney transplantation is the best type of renal replacement therapy. However, large numbers of potential living kidney donors (LKDs) are declined because of various reasons. The aim of this study is to define and quantify the reasons for declining potential LKDs. MethodsAll potential LKDs evaluated at our center between September 2008 and December 2016 were reviewed. Data were collected from the electronic database. ResultsA total of 2090 potential LKDs were evaluated, with an average age of 32 years (range, 18–67 years) and men constituting 72.6%. A total of 675 (32.3%) were accepted for donor nephrectomy. Living kidney donation did not proceed in 830 (39.7%): 661 (79.6%) because of donor-related reasons and 169 (20.4%) because of recipient-related reasons. Donor-related reasons included medical contraindications (61.7%), immunological barriers (23.1%), surgical contraindications (7.9%), and psychosocial reasons (7.3%). A total of 585 (28.0%) potential LKDs voluntarily withdrew themselves at variable time points during the evaluation process, even after being accepted for donation. Male and young (18–35 years) potential LKDs were more likely to withdraw compared with female and older (>35 years) potential LKDs (34.3% vs 11.4%, P < .005 and 29.6% vs 24.5%, P = .02, respectively). ConclusionsDespite the large number of potential LKDs, medically complex donors are increasing, and a significant proportion decided to withdraw at some point during the evaluation process. The latter highlights the need to increase public awareness about living donation, to perform more careful initial screening and targeted educational programs, and to provide continuous support for potential LKDs.

OUTCOMES OF SEPTIC PATIENTS REQUIRING RENAL REPLACEMENT THERAPY: A SINGLE CENTER ANALYSIS

SESSION TITLE: Critical Care Sepsis SESSION TYPE: Original Investigations PRESENTED ON: 10/07/2018 07:30 AM - 08:30 AM PURPOSE: The prevalence of acute kidney injury (AKI) - defined as an increase of serum creatinine of at least 1.5-1.9 times the baseline or an increase of at least 0.3 mg/dL from baseline - among critically ill patients is approximately 40-57%. Due to advancements in treatment strategies, renal replacement therapy (RRT) is becoming a common element of the intensive care setting, with about 13% of patients with AKI in the intensive care unit receiving RRT during their treatment course. Several studies have demonstrated that AKI in non-selected critically ill patients is associated with high mortality rates (some report as high as 80%), as well as other complications including development of end stage renal disease (ESRD) requiring long term dialysis. We sought to explore outcomes specifically of septic patients with AKI requiring new renal replacement therapy in our inner-city university hospital. METHODS: A retrospective chart analysis was performed of patients with a diagnosis of sepsis and/or septic shock who were treated with at least one form of RRT during the time period of 1/2009 – 5/2017 at Hahnemann University Hospital in Philadelphia, PA. We included adults (at least 18 yrs of age) who required new initiation of RRT. Exclusion criteria included any patient who had received RRT previously, patients with history of renal transplant and those with other reasons for renal injury other than sepsis. A total of 100 subjects were included in the study. We examined multiple data points including demographics, type of RRT, acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores. The outcomes we observed for included length of RRT, length of hospital stay, renal recovery and 5, 30, 60 and 90-day mortality rates. RESULTS: Average APACHE II and SOFA scores among the entire cohort were 22.2 and 10.2, respectively. 76% of subjects received continuous RRT only, 9% of subjects received intermittent hemodialysis only, and 15% received a combination of both. Overall survival rate among all included subjects at 90 days was 23%. 5-day mortality rate was 11%, 30-day mortality rate was 58%, 60-day mortality rate was 72% and total 90-day mortality rate was 77%. Of the mortalities, 1 subject (1.2%) recovered renal function and was removed from renal replacement therapy prior to death. Of the surviving subjects, 74% (17/23) had renal recovery with 6 subjects (26%) requiring long term dialysis upon conclusion of their hospital course. CONCLUSIONS: Sepsis and septic shock with AKI requiring new RRT is associated with significant mortality rates. In surviving patients, renal recovery is possible as only a minority of survivors developed end stage renal disease. CLINICAL IMPLICATIONS: Our results coincide with the current paradigm that AKI requiring RRT in critically ill patients is a significant prognostic indicator associated with poor outcomes. DISCLOSURES: No relevant relationships by Willis Ko, source=Web Response No relevant relationships by Ciro Rincon-Prieto, source=Web Response No relevant relationships by Michael Stephen, source=Web Response No relevant relationships by John Woytanowski, source=Web Response

Survivability of hospitalized chronic kidney disease (CKD) patients with moderate to severe estimated glomerular filtration rate (eGFR) after experiencing adverse drug reactions (ADRs) in a public healthcare center: a retrospective 3 year study

BackgroundAccurate identification and routine preventive practices are crucial steps in lessening the incidence of medications and patients related adverse drug reactions (ADRs).MethodsThree years retrospective study was conducted among chronic kidney disease (CKD) patients at multi-wards in a tertiary healthcare center. Data collected included demographic characteristics, physical examination results, comorbid conditions, laboratory tests and medications taken. Only medication prescribed during the hospital stay were considered in this study.ResultsFrom this study only one ADR incident was definitely preventable and majority of other ADRs (88.3%) were possibly preventable. Type of renal replacement therapy (p = 0.023) and stages of renal function (p = 0.002) were significantly associated with survivability of the hospitalized CKD patients after ADRs. Highest percentage of mortality based on categories were 50–59 years (20.0%), male (16.3%), Indian ethnicity (23.7%), obese (15.0%), smoking (17.1%), consumes alcohol (17.4%), conservative management of renal disease (19.5%) and renal function of < 15 mL/min/1.73m2. Overall survivability using Kaplan-Meier analysis reported a significant difference of 18-day survival rate between patients undergoing hemodialysis and patients conservatively managing their renal disease. The 18 days survival rate of patients undergoing hemodialysis, peritoneal dialysis and conservative management were 94.9%, 91.7% and 75.1% respectively. Eighteen days survival rate of patients with renal functions of 30–59 mL/min/1.73m2, 15–29 mL/min/1.73m2 and < 15 mL/min/1.73m2 were 87.4%, 69.8% and 88.6% respectively. Similarly, Cox regression analysis revealed that renal replacement therapy was the only factor significantly contributed to ADRs related mortality. CKD patients whom conservatively managed renal disease or/and with renal function of < 15 mL/min/1.73m2 had 5.61 and 5.33 higher mortality risk respectively.ConclusionMajority of the reported ADRs were possibly preventable. Renal replacement therapy and/or renal function were significant risk factors for mortality due to ADRs among hospitalized CKD patients stages 3 to 5. Clinician engagement, intensive resources and regular updates aided with online monitoring technology are needed for enhancing care and prevention of ADRs among CKD patients.

The physiology of uric acid and the impact of end-stage kidney disease and dialysis.

Uric acid-mediated biological effects are milieu dependent. In a physiological milieu, serum uric acid serves as an antioxidant; when homeostasis is perturbed, divergent effects are observed depending on the clinical context. Several epidemiologic studies indicated the presence of a direct relationship between higher concentrations of serum uric acid and cardiovascular mortality; yet not all studies support this conclusion. Although high serum levels of uric acid are associated with higher mortality in patients with nondialysis-dependent chronic kidney disease and perhaps in those with end-stage kidney disease receiving peritoneal dialysis, the opposite relationship is seen in patients with end-stage kidney disease on hemodialysis. This review discusses the pathologic mechanisms associated with elevated serum uric acid levels by clinical context; examines the interplay between uric acid metabolism and modality of renal replacement therapy; and presents hypotheses to rationalize thedisparate associations between incremental levels of serum uric acid and survival across the continuum of kidney disease and by type of renal replacement therapy.

Renal replacement Therapy in Saskat chewan: A population based analysis

Aim: Chronic kidney disease is a critical condition with considerable public health implications. It affects a significant proportion of the general population and when progressive, has an increasing influence on morbidity and mortality. The main purpose of this study was to explore the distribution and trends of renal replacement therapy and vascular access practice patterns among Saskatchewan end stage renal disease patients. Material and Method: This is a registry-based retrospective observational study. Prevalence of patient’s on renal replacement therapy in the Canadian Organ Replacement Register who has information for renal replacement therapy from 2006 to 2016 in the province of Saskatchewan. The composite of demographics, mortality, type of renal replacement therapy, type of vascular access and important blood markers ranges were recorded among both haemodialysis and peritoneal dialysis patients. Results: From 2006 through 2016, a total of 2103 patients with mean age of 69.52±13.2 initiated renal replacement therapy in Saskatchewan. Among those patients, over half of the patients were female (62%). Majority of the patients were Caucasians and Aboriginals. Nearly two third of them were overweight and obese. Less than half developed end stage renal diseases secondary to diabetes and 14.9% had a primary diagnosis of glomerulonephritis. At the end of 2015, prevalence of end-stage kidney disease patients was 1330 in the Saskatchewan. During 2006 to 2016, 72.3% received haemodialysis, 22.8% received peritoneal dialysis, and, catheter was the most frequently used dialysis access method (64.6%). Conclusion: An increasing number of patients with advanced renal disease are being initiated on long-term dialysis every year. Haemodialysis and peritoneal dialysis are the two main types of dialysis provided under renal care programs. Alarmingly, in Saskatchewan, catheter was the most frequently used dialysis access method. Keywords: End Stage Renal Disease; Renal Replacement Therapy; Vascular Access; Saskatchewan.

Eosinophilic Inflammation in Peritoneal Fibrosis Patients Undergoing Peritoneal Dialysis.

Renal replacement therapy is vital for patients with chronic renal failure. Each type of renal replacement therapy has its own characteristics, and patients select it according on their living environment or conception of quality of life. Under the recent medical environment in Japan, economic burden of dialysis is another concern. For patients with chronic renal failure, the outcome of dialysis is vital. How to prevent or control side effects and complications is also important. One type of dialysis treatment is called peritoneal dialysis. Complications from long-term peritoneal dialysis include encapsulating peritoneal sclerosis (EPS), which can lead to life-threatening intestinal obstruction. Here, we hope to prevent the incidence of EPS through examining new possibilities in the pathogenesis during peritoneal dialysis and considering countermeasures. Membrane dialysis is a treatment methodology that makes use of the semipermeable function of body membranes. When the composition of the peritoneal dialysate is adjusted, it also removes waste products and adjusts water level. Chemical stimuli of peritoneal dialysate on peritonea can trigger inflammation and, when long-lasting, the latter is considered to cause EPS. For the body, chemical stimuli are invasive. Damaged body tissues have a capacity to repair themselves. The innate immune system is known to work in response to nonspecific stimulation, and so it is well conceivable that it is active in the abdominal cavity under peritoneal dialysis. Among many inflammatory cells involved in the innate immune system, we focus on the role of eosinophils to consider the possibility of unknown pathogenesis. Key Messages: Eosinophilic inflammation may cause EPS.

Testosterone deficiency in dialysis patients: Differences according to the dialysis techniques

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. MethodsThe cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3–10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. ResultsMean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; p<0.001) and time on dialysis (Rho −0.412; p=0.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. ConclusionsCirculating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor—namely the dialysis technique—may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination.

Déficit de testosterona en los pacientes en diálisis: diferencias según la técnica de diálisis

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. MethodsThe cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3–10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anaemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. ResultsMean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; P<.001) and time on dialysis (Rho −0.412; P=.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. ConclusionsCirculating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor —namely the dialysis technique— may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination.

Assessment of quality of life in patients undergoing hemodialysis using WHOQOL-BREF questionnaire: a multicenter study.

BackgroundAssessment of quality of life (QOL) of patients with end-stage renal disease has become increasingly important, both in order to evaluate the influence of the disease on patients and the type of renal replacement therapy they require. Therefore, in this study, we aimed to assess QOL in patients undergoing hemodialysis and evaluated the effects of various sociodemographic factors affecting QOL of such patients in Nepal.MethodsA cross-sectional study was conducted among 150 patients with chronic kidney disease undergoing hemodialysis at two major centers in Nepal. Demographic data including age, sex, ethnicity, educational status, marital status, employment, income, duration of illness, and duration on hemodialysis were collected. QOL was assessed using the World Health Organization Quality of life (WHOQOL-BREF) questionnaire. Four domains (physical, psychological, social, and environmental) and two items (overall perception of QOL and health) of the WHOQOL-BREF were the primary end points of this study. Bivariate relationship between sociodemographic factors and QOL scores were analyzed using independent samples t-test and one-way analysis of variance. Multiple linear regression analysis was performed to determine independent predictors of QOL.ResultsFollowing QOL scores were recorded: environmental domain (53.17±15.59), psychological domain (51.23±18.61), social domain (49.86±21.64), and physical domain (45.93±16.90). Older age was associated with a better QOL score in the social domain (p=0.005), and employed patients scored better in the environmental domain (p=0.019). Unemployed patients and those of the Terai/Madhesi ethnic group had significantly low scores in overall perception of health (p<0.05) as compared to other groups. Low income status and increased duration on hemodialysis were found to be the only independent negative predictors of QOL in patients with hemodialysis (p<0.05).ConclusionPatients with chronic kidney disease on dialysis had overall low QOL scores in all four domains. Age, ethnicity, employment status, income, and duration on hemodialysis affected one or more domains of QOL in such patients. Low income status and increased duration on hemodialysis were the only independent negative predictors of QOL of patients on maintenance hemodialysis.

Bioactive lipids derived from arachidonic acid metabolism in different types of renal replacement therapy

IntroductionMetabolism and plasma concentration of lipids and lipid-derived compounds play an important role in kidney physiology and pathological processes. The component of membrane phospholipids − arachidonic acid (AA) and its active derivatives − eicosanoids are involved in the development of hypertension, diabetes, inflammation and may contribute to progression of chronic kidney disease (CKD). The purpose of the study was to determine, whether the type of renal replacement therapy has an effect on eicosanoids metabolism. Materials and methodsThe study included 145 patients with CKD: on conservative treatment (n=68), on peritoneal dialysis (PD) (n=23) and undergoing chronic haemodialysis (HD) (n=54). The concentrations of TXB2, 20-HETE, 8-epi-PGF2α in platelet poor plasma (PPP) were determined using the ELISA method and 5-HETE, 12-HETE, 15-HETE were measured using the RP-HPLC. ResultsThe concentrations of TXB2 in HD group, both before (2.28±0.72ng/mL) and after (1.49±0.63ng/mL) haemodialysis treatment differed significantly from PD group (57.76±6.13ng/mL). Haemodialysis session led to the significant decrease in TXB2 plasma concentration (p=0.046). 20-HETE concentrations in HD group (113.55±107.54pg/mL and 199.54±142.98pg/mL before and after haemodialysis, respectively) were significantly higher than in CKD 3–5 group (8.96±12.66pg/mL) and PD group (47.78±34.07pg/mL). The highest concentration of 12-HETE was obtained in PD patients (3.58±3.99ng/mL) and differed significantly from HD group after haemodialysis (0.97±0.28ng/mL) and CKD3-5 group (1.06±0.52ng/mL). The concentrations of 5-HETE, 15-HETE and 8-epi-PGF2α-III did not differ significantly among examined groups. ConclusionsThe concentrations of active AA metabolites depend on the mode of renal replacement therapy and are associated with intensity of oxidative stress. They might be considered as potential indicators of kidney damage.

Monitoring and complications during neonatal/pediatric ECMO run

Extracorporeal membrane oxygenation (ECMO) is a commonly used form of mechanical circulatory support in children with congenital or acquired heart disease, and cardiac failure refractory to conventional medical treatments.1 The cardiac output is partially or completely provided by the ECMO machine. To assess how much support is needed at any given time, a constant balance of oxygen delivery and oxygen consumption is required. Permanent monitoring of flow, hemoglobin, arterial, and mixed venous saturations are key elements to provide the needed understanding and continuous guidance of body requirements, aiming at controlling and maintaining optimal management of the ECMO patient. Although ECMO is lifesaving in many circumstances, it bares challenges and certain risks of complications. Despite bioline-coated circuits, anticoagulation is required. Measurement of activated clotting time (ACT) and activated partial thromboplastin time (APTT) are both used to guide anticoagulation, but it is unclear which method is the best, and constant monitoring of the hemoglobin level allows the early detection of internal and external bleeding.2 For children, sedation and analgesia, most often in combination with paralysis, is unavoidable for a smooth ECMO run. On the other hand, with such treatment on board, it is almost impossible to assess the neurological status of the patient on ECMO. Different monitoring tools, such as cerebral near infrared spectroscopy (NIRS) and serial brain ultrasound studies, are used to estimate brain integrity and function, but further research is needed to show which methods are the most practical and useful to achieve a favorable outcome.3 Nutrition in critically ill children is known to be crucial but debated how to achieve as the gut perfusion can be impaired and therefore the risk of necrotizing enterocolitis (NEC) is increased. It is discussed if somatic perfusion by NIRS monitoring can help to avoid NEC.4 The kidney function is often impaired in these critically ill children and careful monitoring of kidney function and urine output leads the decision when to start which type of renal replacement therapy for renal clearance and/or fluid removal. Techniques available include peritoneal dialysis or continuous renal replacement therapy (CRRT) incorporated with the ECMO circuit. Medication dosing is under discussion in many centers as the circulatory volume is higher than normal. Adjustment of medication dosing could consequently be of great importance. Close monitoring of medications where toxic levels can be reached is crucial to avoid further damage to the patient's organ functions.

A study of continuous renal replacement therapy and acute peritoneal dialysis in hemodynamic unstable patients

Objective:The objective of the following study was to assess the outcome of continuous renal replacement therapy (CRRT) and acute peritoneal dialysis (PD) in dialysis-requiring renal failure in patients with hemodynamic instability.Materials and Methods:A retrospective analysis of all the patients who received CRRT and acute PD over a period of 1 year at our institute, a tertiary care center, was done for diagnosis, type of renal replacement therapy (RRT), and survival outcome. The indications for administering either of the therapy were usual indications of doing hemodialysis with the presence of hemodynamic instability (systolic blood pressure <90 mm of Hg even with inotropes).Results:Forty patients, 22 in CRRT and 18 in acute PD group were studied. All these patients required inotropes to maintain desired blood pressure. Twenty-five (62.5%) patients had acute kidney injury (AKI), and 15 (37.5%) had chronic kidney disease (CKD) superimposed over other primary diagnosis. A total of 8 (20%) patients (4 in CRRT, 4 in acute PD) survived at the time of discharge from hospital. The mean age of survivors was approximately a decade less than nonsurvivors (P = 0.15). Overall, there were no survivors in CKD group and all the patients who survived at the time of discharge from hospital had underlying AKI (P = 0.016).Conclusion:This study showing comparable survival outcome in acute PD and CRRT gives evidence that either of the modalities can be adopted in hemodynamically unstable patients requiring RRT depending on the resources available.

Intermittent Hemodialysis Low Intensity vs. on Line Hemodiafiltration in Critically Ill Patients with Sepsis and Acute Kidney Injury. Choosing the Best Treatment in a Developing Country

Introduction: Acute kidney injury is a serious condition in critically ill patients with sepsis, in Ecuador the prevalence is about of 10% and has high undocumented mortality rate. The type of renal replacement therapy used is also very discussed in countries that have several treatment options. Many developing regions don’t have continuous treatments available for these patients. Objective: The aim of the study was to demonstrate advantages of treatment with on-line hemodiafiltration (own scheme) versus intermittent hemodialysis high flux low intensity in patients with sepsis and acute kidney injury. Primary outcomes evaluated were: mortality, vasoactive drugs, mechanical ventilation dependence and permanence at intensive care unit. Results: Cohort and tracing study in patients with sepsis and acute kidney injury. Two groups undergoing treatment for intermittent hemodialysis high flux low intensity (Group A: n 35) vs. on line hemodiafiltration (Group B: n 30). General mortality was 49.2%, (Group A: 60% vs. group B: 36.6% p=0.061). APACHE 2 and SOFA index in both groups were similar (p=0.26 and 0.98 respectively). Time intensive care unit stay (GA: 16.7; GB: 9.9 p=0.044), vasoactive drugs dependence (GA: 9; GB: 4.1 p=0.084), mechanical ventilation dependence (GA: 11.2; GB: 6.5 p=0.12). Conclusion: On line hemodiafiltration showed benefits statiscally significative in intensive care unit stay, in relation to vasoactive drugs, mechanical ventilation dependence showed beneficies but weren´t significatives. The mortality wasn't statistically significative. Results showed advantages in on line hemodiafiltration with our own scheme in critically ill patients with sepsis.

The association of urinary sodium excretion and the need for renal replacement therapy in advanced chronic kidney disease: a cohort study

BackgroundRestriction of dietary sodium is routinely recommended for patients with chronic kidney disease (CKD). Whether or not sodium intake is associated with the progression of CKD and mortality remains controversial. We evaluated the association of urinary sodium excretion (as a surrogate for sodium intake) on the need for renal replacement therapy and mortality in patients with advanced CKD.MethodsWe conducted a retrospective study of patients followed at a CKD clinic of a tertiary care hospital from January 2010 to December 2012. Adult patients with advanced CKD (estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m2) were included. Using a time-to-event analysis, we examined the association of urinary sodium excretion as a continuous and also as a categorical variable (categorized as low sodium diet - LSD (<100 mEq/day), medium sodium diet - MSD (100–150 mEq/day), and high sodium diet - HSD (>150 mEq/day) and the outcomes of interest. The primary outcome was defined as composite of progression to end-stage renal disease requiring any type of renal replacement therapy and mortality. The secondary outcome was change in eGFR/year.Results341 patients (82 LSD, 116 MSD and 143 HSD) were included in the study (mean follow up of 1.5 years) with a mean eGFR decline of 2.7 ml/min/1.73 m2/year. 105 patients (31 %) required renal replacement therapy and 10 (3 %) died. There was no association between urinary sodium excretion and change in the eGFR or need for renal replacement therapy and mortality in crude or adjusted models (unadjusted HR 1.002; 95%CI 1.000–1.004, adjusted HR 1.001; 95%CI 0.998–1.004).ConclusionIn patients with advanced CKD (eGFR < 30 ml/min/1.73 m2), sodium intake does not appear to impact the progression of CKD to end-stage renal disease; however, more definitive studies are needed.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-016-0338-z) contains supplementary material, which is available to authorized users.

Incidence of tuberculosis is high in chronic kidney disease patients in South East England and drug resistance common

The risk of tuberculosis (TB) is significantly increased in chronic kidney disease (CKD). Data on TB in CKD in the UK are sparse; most information stems from countries with high background prevalence. The aim of this study was to estimate the incidence of TB in CKD patients in South East London and to describe the epidemiology, treatment, and outcome. CKD patients with TB between 1994 and 2010 were identified retrospectively. Data were collected on type of renal replacement therapy, the method of TB diagnosis, disease site, treatment regimens, and risk factors. Forty patients were identified of whom 67.5% had CKD stages IV–V. Sixty-five percent were from non-UK born ethnic minorities. Median time from diagnosis of CKD to TB development was 12 months (range 0–192 months). Cumulative incidence of TB was 1267/100,000 [95% confidence interval (CI): 630–1904; 85 × background UK rate] in hemodialysis patients; 398/100,000 (95% CI: 80–1160; 26 × background UK rate) in peritoneal dialysis; and 522/100,000 (CI: 137–909; 35 × background UK rate) in transplant recipients. Sixty-three percent of patients had pulmonary TB and 25% of patients with culture-positive TB had resistant isolates. Fifty percent of patients were immunosuppressed due to drugs, diabetes, and/or retroviral disease. Treatment regimens were according to recent national guidance in 73% of cases. Seventy-six percent of patients experienced side effects. Greater awareness of risk factors, drug resistance, treatment regimens, and potential side effects is needed.

Clinical features and mortality of patients on renal replacement therapy receiving polymyxin B

There are no clinical data for polymyxin B (PMB) in patients on renal replacement therapy (RRT). The aim of this study was to evaluate the characteristics of patients on RRT receiving PMB and to identify predictors of 30-day mortality, with special focus on dosage. A multicentre prospective cohort study including patients aged ≥18 years treated with PMB for ≥48h while on any type of RRT was performed. In total, 88 patients were evaluated, including 34 (38.6%) on continuous venovenous haemodialysis (CVVH) and 54 (61.4%) on intermittent haemodialysis. Most patients (81.8%) received recommended doses between 1.5mg/kg/day and 3.0mg/kg/day. The 30-day mortality was 51.1% (45/88 patients). There was no significant association of dose (in mg/kg) with mortality. A PMB average daily dose ≥200mg was predictive of decreased 30-day mortality in the multivariate model (hazard ratio=0.35, 95% confidence interval 0.14–0.90; P=0.03), whilst CVVH (P=0.04), higher Charlson co-morbidity index (P=0.02) and Acute Physiology and Chronic Health Evaluation (APACHE) II score (P=0.04), and Pseudomonas aeruginosa infection (P=0.001) were independent risk factors for mortality. The results were not changed by the inclusion of patient weight or dose (in mg/kg) in the model, although the latter was significantly correlated with total daily dose. This is the first clinical study to show that higher doses of PMB are associated with lower mortality in patients on RRT.

Platelet - derived CD154 antigen in patients with chronic kidney disease

IntroductionCD154 is a surface glycoprotein present on activated platelets, lymphocytes and mast cells. It mediates the transmission of information between cells and initiates an inflammatory response. The interaction of CD154 with its receptor CD40 leads to increase in concentrations of soluble forms of both molecules (sCD154, sCD40), which has an important prognostic value in cardiovascular complications. The metabolic disorders in chronic kidney disease (CKD), chronic inflammation, increased oxidative stress and type of renal replacement therapy may influence on the balance of sCD154/sCD40 in plasma and blood platelets. The purpose of the reasearch was to analyse the concentrations of sCD154 antigen and sCD40 receptor in platelet pure plasma (PPP) and platelet rich plasma (PRP) of patients with CKD treated conservatively, haemodialysed and on petitoneal dialysis. MethodsThe group examined comprised 141 patients with chronic kidney disease: in pre-dialysis stage (n = 68), haemodialysed (n = 38) and on peritoneal dialysis (n = 35). The concentrations of sCD154 and sCD40 in PRP and PPP were determined with an ELISA method. The biochemical parameters were obtained using colorimetric method. ResultsThe concentrations of sCD154 and sCD40 in PPP and PRP in examined group were significantly different depending on the method of renal replacement therapy. The haemodialysis procedure caused a significant increase in sCD40 concentration in PRP. The concentrations of sCD40 and sCD154 were correlated with lipid parameters. ConclusionsThe type of renal replacement therapy influences on platelet activation which may be a factor contributing to increased cardiovascular complications in patients suffering from CKD.

Different Risk of Common Gastrointestinal Disease Between Groups Undergoing Hemodialysis or Peritoneal Dialysis or With Non-End Stage Renal Disease: A Nationwide Population-Based Cohort Study.

Peritoneal dialysis (PD) is one type of renal replacement therapy, but potential peritoneal damage and gastrointestinal (GI) tract adverse effects during long-term exposure to bio-incompatible dialysate remain a concern. Although GI disease frequently occurs in dialysis patients, whether the risk of GI diseases differs among PD and hemodialysis (HD) or non-uremic groups is still uncertain.In this retrospective cohort study, data were obtained from the National Health Insurance Research Database, which includes almost all dialysis patients in Taiwan. Between 2000 and 2009, a total of 1791 PD and 8955 HD incident patients were enrolled and matched for age and sex or for propensity score. In addition, a comparison cohort of 8955 non-uremic patients was also selected. Individuals were monitored for the occurrence of common GI diseases until 2010, and data were analyzed using several different models.Generally speaking, the results showed that the risk of gastroesophageal reflux, intestinal obstruction or adhesions, and abdominal hernia was significantly higher in the PD group, whereas the risk of peptic ulcer disease and lower GI diverticula and bleeding was significantly greater in the HD group. Meanwhile, the risk of mesenteric ischemia, liver cirrhosis, and acute pancreatitis was higher in dialysis patients, but was not significantly different between the PD and HD groups; moreover, the risk of appendicitis in the PD group appeared to be lower than that in the HD group.In conclusion, dialysis patients have a higher risk of most common GI diseases, and PD and HD modalities are associated with different GI diseases.

Australia and New Zealand Dialysis and Transplant Registry

The ANZDATA Registry includes all patients treated with renal replacement therapy (RRT) throughout Australia and New Zealand. Funding is predominantly from government sources, together with the non-government organization Kidney Health Australia. Registry operations are overseen by an Executive committee, and a Steering Committee with wide representation. Data is collected from renal units throughout Australia and New Zealand on a regular basis, and forwarded to the Registry. Areas covered include demographic details, primary renal disease, type of renal replacement therapy, process measures, and a variety of outcomes. From this data collection a number of themes of work are produced. These include production of Registry reports with an extensive range of national and regional data, a suite of quality assurance reports, key process indicator (KPI) reports, and data sets for a variety of audit and research purposes. The various types of information from the ANZDATA Registry are used in a wide variety of areas, including health services planning, safety and quality programs, and clinical research projects.