Withdrawal Of Renal Replacement Therapy Research Articles

Commentary on the NICE guideline on renal replacement therapy and conservative management

BackgroundNICE Guideline NG107, “Renal replacement therapy and conservative management” (Renal replacement therapy and conservative management (NG107); 2018:1–33) was published in October 2018 and replaced the existing NICE guideline CG125, “Chronic Kidney Disease (Stage 5): peritoneal dialysis” (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, “Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure”(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including “Haemodialysis” (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, “Peritoneal Dialysis in Adults and Children” (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and “Planning, Initiation & withdrawal of Renal Replacement Therapy” (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline).There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.

Biomarkers upon discontinuation of renal replacement therapy predict 60-day survival and renal recovery in critically ill patients with acute kidney injury.

There is no consensus on the specific indications for weaning critically ill patients with acute kidney injury (AKI) off renal replacement therapy (RRT). This study aimed to explore the prognostic value of several biomarkers measured upon discontinuation of RRT for their value in predicting 60-day survival and renal recovery in an effort to add knowledge to the decision-making process regarding RRT withdrawal. We prospectively enrolled 102 patients with AKI who required RRT from the intensive care unit. Serum osteopontin (sOPN), serum interleukin 6 (sIL-6), serum cystatin C (sCysC), sIL-18, serum neutrophil gelatinase-associated lipocalin and urinary IL-18 and urinary neutrophil gelatinase-associated lipocalin were measured upon discontinuation of RRT. Patients were followed up at 60 days for survival and renal recovery. Patients who survived showed lower levels of all serum and urinary biomarkers. Serum OPN (OR 1.029, 95% CI 1.013-1.047, P = 0.001), diabetes (OR 23.157, 95% CI 4.507-118.981, P < 0.001) and APACHE II score (OR 1.308, 95% CI 1.121-1.527, P = 0.001) were independent predictors of 60-day mortality. Patients whose sOPN values fell within the highest and middle tertiles showed 5.25- and 2.31-fold increased risks of mortality, respectively, compared with that of patients in the lowest tertile. The addition of sOPN to the clinical model resulted in significant net reclassification improvement of 0.453 (P = 0.026) and an integrated discriminative index of 0.155 (P = 0.032). Lower levels of sOPN and sIL-6 were associated with greater odds of 60-day survival (AUC 0.812 and 0.741). The AUC value for predicting survival reached its highest level when all biomarkers were combined with urine output (UO) and urinary and serum creatinine upon discontinuation of RRT (0.882). Lower sCysC performed as well as higher UO in predicting 60-day renal recovery with the greatest AUC of 0.743. Upon discontinuation of RRT, serum and urinary biomarkers, particularly sOPN, may predict 60-day survival and renal recovery in critically ill patients with AKI. The serum levels of OPN, IL-6 and CysC may be useful when considering withdrawal of RRT on the basis of conventional indicators.

Renouncement of renal replacement therapy: withdrawal and refusal.

Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.

Traditional and novel reference index for the withdrawal of renal replacement therapy in patients with acute kidney injury

Acute kidney injury (AKI) is a serious clinical problem with high morbidity and mortality. Renal replacement therapy (RRT) is an important tool for treating patients with AKI. The 2011 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for AKI points out that RRT should be discontinued when renal function has recovered enough to meet the body needs or when RRT is no longer consistent with treatment goals. However, the specific reference index of weaning RRT is unclear. The guiding roles of traditional indicators such as urine output (> 400 mL/24 h), serum creatinine (SCr, decreasing trend), creatinine clearance (CCr, > 20 mL/min), and novel biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL), hepatocyte growth factor (HGF), interleukins (IL-6, IL-10), kidney injury molecule-1 (KIM-1), kynurenic acid, etc. for discontinuation of RRT in AKI patients were reviewed. Particularly, the importance of biomarkers for this purpose was highlighted.

Hemodialysis for the treatment of dabigatran‐associated bleeding: a case report and systematic review

Dabigatran, a direct thrombin inhibitor, is effective for the treatment of venous thromboembolism and the prevention of stroke and systemic embolism resulting from atrial fibrillation. The most effective way of reversing the anticoagulant effect of dabigatran in patients who have bleeding complications is unknown. To document the clinical outcomes of patients undergoing renal replacement therapy (RRT) for dabigatran-associated bleeding. We searched MEDLINE and EMBASE up to May 2015. Articles were selected if the patients presented with dabigatran-associated bleeding, underwent RRT for dabigatran removal, and reported an effect on bleeding. The search yielded 22 studies representing 35 unique patient cases. The median patient age was 74.1years (range, 56-94years). Thirteen patients (37.1%) were female, and 32 (91.4%) patients received dabigatran for atrial fibrillation. Twenty-three patients (65.7%) underwent intermittent hemodialysis, 10 patients (28.6%) underwent continuous RRT (CRRT), and two patients underwent both intermittent hemodialysis and CRRT. Following RRT, there were significant reductions in dabigatran concentrations (P=0.001). Rebound of the dabigatran concentration was reported in 12 (57.1%) patients following cessation of RRT. Hemostasis was reportedly achieved in 24 patients (70.6%), and 10 patients (29.4%) died because of bleeding. In patients with dabigatran-associated bleeding, RRT appears to be effective in reducing dabigatran concentrations, and in case reports this has been associated with a reduction in the duration and/or severity of bleeding. However, a rebound in concentrations may be seen following withdrawal of RRT, suggesting that a prolonged course of RRT may be more effective.

Getting prospective recipients ready: the transplant work-up

Journal of Renal NursingVol. 4, No. 2 ClinicalGetting prospective recipients ready: the transplant work-upObaayaa Buahin, David CurranObaayaa BuahinSearch for more papers by this author, David CurranSearch for more papers by this authorObaayaa Buahin; David CurranPublished Online:29 Sep 2013https://doi.org/10.12968/jorn.2012.4.2.60AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesBell J, Ross K (2002) Kidney Transplant Recipient Referral and Evaluation. http://findarticles.com/p/articles/mi_m0ICF/is_5_29/ai_n18614411/pg_3/ (accessed 20 March 2012) Google ScholarBuckman R (2005) Breaking bad news: the S.P.I.K.E.S strategy. Community Oncology 2(2): 138–42 Crossref, Google ScholarDudley C, Harden P (2011) Assessment of the Potential Kidney Transplant Recipient. www.renal.org/Libraries/Guidelines/Assessment_of_the_Potential_Kidney_Transplant_Recipient_-_Final_Version_12_January_2011.sflb.ashx (accessed 13 March 2012) Google ScholarFarrington K, Warwick G (2009) Planning, initiating, and withdrawal of Renal Replacement Therapy – Clinical Practice Guidelines. http://www.renal.org/Clinical/GuidelinesSection/RenalReplacementTherapy.aspx (accessed 20 March 2012) Google ScholarGore JL, Pham PT, Danovitch GM, Wilkinson AH, Rosenthal JT, Lipshutz JS (2006) American Journal of Transplantation 6(2): 357–63 Google ScholarKasiske BL, Snyder JJ, Matas M et al. (2002) Pre-emptive kidney transplantation: The advantage and the advantaged. Journal of American Society of Nephrologists 13: 1358–64 Crossref, Google ScholarKaufman DB, Batuman V (2012) Renal transplantation (Medical) workup http;//emedicine.medscape.com/article/429314-workupdownloaded26/01/2012 Google ScholarMorton J, Blok G, Reidi J, Dalen J, Morley M (2000) Enhancing communication skills with bereaved relatives. Anaesthetic & Intensive Care Google ScholarShallcross J (2002) Nursing Management of patients for greater renal transplant success Prof Nurse 17(12): 725–8 Google Scholar FiguresReferencesRelatedDetails 1 March 2012Volume 4Issue 2ISSN (print): 2041-1448ISSN (online): 2052-2894 Metrics History Published online 29 September 2013 Published in print 1 March 2012 Information© MA Healthcare LimitedKeywordsRenal replacement therapyTransplant assessmenttransplant work-up npre-transplant checklistPDF download

Multiple myeloma and renal failure: one center's experience

Renal involvement remains a major complication of multiple myeloma, particularly in advanced disease. A retrospective analysis was performed of the modes of presentation, treatment and outcome of all patients with multiple myeloma treated in our renal unit between 1987 and 1996. Thirty-four patients were identified: in 26 (76%) the diagnosis of myeloma was made only after referral. Light chains were the most common paraprotein in both serum and urine. Twenty-one (62%) patients underwent renal biopsy: myeloma cast nephropathy was the predominant histological finding in 16 cases. Thirty-one (91%) patients had severe renal failure (GFR < 20 mL/min), with 28 (82%) requiring dialysis within 2 weeks of admission. Despite treatment of presumed precipitating causes of acute deterioration in renal function, only 1 of these 28 patients subsequently became independent of dialysis. Most had advanced stage myeloma: 29 (85%) were Durie-Salmon stage II or III Hypercalcemia, sepsis and pathological fractures were the principal complications. Median survival overall was 5 months. The main causes of death were withdrawal of renal replacement therapy (overwhelming myeloma, severe debilitation) and sepsis. Nineteen (56%) patients received long-term (> 1 month) renal replacement therapy with a median survival of 8 months. However, five of these (26%) have survived for more than 12 months on dialysis and report a good quality of life.

Withdrawal of renal replacement therapy

Withdrawal of renal replacement therapy

Withdrawal of renal replacement therapy

Withdrawal of renal replacement therapy

Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964–1993

Termination of renal replacement therapy (RRT) is common in North America and Australia but is considered to be rare in Europe. In order to review the phenomenon of RRT termination in all patients treated in Newcastle upon Tyne between 1964 and 1993 a retrospective study of clinical case notes was undertaken. In all RRT patients sex, age at start of RRT, renal diagnosis and history of RRT were recorded. In addition, mortality data and marital and residential status were recorded in all patients who died, and Karnofsky index, bodyweight, complications, history of bereavement, place of death, overall survival, survival after withdrawal of treatment, other medical problems, higher mental function and surgical history in all patients stopping treatment. 1639 patients started RRT between 1964 and September 1993 inclusive. Eighty-eight patients were identified in whom death was a result of treatment being stopped (17% of all deaths). The first was in 1985. In these patients, age was greater (62 vs 47 years, P < 0.001) and diabetes was more prevalent (15 vs 7%, P < 0.03) than in the total RRT population. The Karnofsky index was 70 at the start and 33 at withdrawal of treatment (P < 0.001). The Karnofsky index at the start of RRT was weakly related to that at withdrawal and overall survival (r = 0.36 and 0.28 respectively, P < 0.01). The Karnofsky index at treatment withdrawal correlated with the following survival (r = 0.40, P < 0.001). The median survival of patients stopping treatment was significantly lower than in all RRT patients (16 vs 74 months, P < 0.001) and the majority survived less than 2 years. After dialysis withdrawal the median survival was 8 days, 15 patients survived 3 days or less and 19 more than 10 days. The majority (80%) received terminal care in hospital. At treatment withdrawal 11 patients were demented and 34 showed signs of early dementia. Seventy-eight patients (89%) stopped treatment as a consequence of multiple medical problems. The possibility of dialysis withdrawal was raised by physicians in 50.5%, the patient in 23.8% and the patients' relatives in 21.9% of cases. Four patients (3.8%) committed suicide. Death from dialysis termination is a relatively common cause of death in RRT patients in Newcastle upon Tyne. These patients are older with a higher prevalence of diabetes. In 89% of cases the decision to stop treatment was related to multiple medical problems with a recent deterioration. Physicians raised the issue of withdrawal in the majority of cases and most patients subsequently received terminal care in hospital.

Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993

Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993