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1
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McIntyre CW, Jain A. Dialysis and cognitive impairment. Nat Rev Nephrol 2025:10.1038/s41581-025-00960-3. [PMID: 40275017 DOI: 10.1038/s41581-025-00960-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2025] [Indexed: 04/26/2025]
Abstract
People with chronic kidney disease who require maintenance dialysis characteristically experience accelerated and aggravated cognitive decline compared with those with advanced kidney disease who are not receiving this form of kidney replacement therapy. This effect is inadequately appreciated, but of crucial importance to patients, their carers and the health-care systems that support them. Although many of the comorbid conditions prevalent in this patient population have the potential to affect brain structure and function, an evolving body of evidence indicates that the dialysis therapy itself has a central role in the pathophysiology of progressive cognitive impairment. Both haemodialysis and peritoneal dialysis are associated with structural and functional changes in the brain that can lead to characteristic short-term symptoms, such as headache, confusion, delirium and brain fog, as well as long-term reductions in cognitive functional ability. Here, we explore the mechanisms, both established and putative, underlying these effects and consider approaches to addressing this issue with both single and complex therapeutic interventions.
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Affiliation(s)
- Chris W McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, London, Ontario, Canada.
- Departments of Medicine, Medical Biophysics and Paediatrics, Western University, London, Ontario, Canada.
| | - Arsh Jain
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, London, Ontario, Canada
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Reaves AC, Weiner DE, Sarnak MJ. Home Dialysis in Patients with Cardiovascular Diseases. Clin J Am Soc Nephrol 2024; 19:1646-1655. [PMID: 38198166 PMCID: PMC11637708 DOI: 10.2215/cjn.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
Kidney failure with replacement therapy and cardiovascular disease are frequently comorbid. In patients with kidney failure with replacement therapy, cardiovascular disease is a major contributor to morbidity and mortality. Conventional thrice-weekly in-center dialysis confers risk factors for cardiovascular disease, including acute hemodynamic fluctuations and rapid shifts in volume and solute concentration. Home hemodialysis and peritoneal dialysis (PD) may offer benefits in attenuation of cardiovascular disease risk factors primarily through improved volume and BP control, reduction (or slowing progression) of left ventricular mass, decreased myocardial stunning, and improved bone and mineral metabolism. Importantly, although trial data are available for several of these risk factors for home hemodialysis, evidence for PD is limited. Among patients with prevalent cardiovascular disease, home hemodialysis and PD may also have potential benefits. PD may offer particular advantages in heart failure given it removes volume directly from the splanchnic circulation, thus offering an efficient method of relieving intravascular congestion. PD also avoids the risk of blood stream infections in patients with cardiac devices or venous wires. We recognize that both home hemodialysis and PD are also associated with potential risks, and these are described in more detail. We conclude with a discussion of barriers to home dialysis and the critical importance of interdisciplinary care models as one component of advancing health equity with respect to home dialysis.
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Affiliation(s)
- Allison C Reaves
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Nie Y, Lin L, Yang Q, Hu J, Sun M, Xiang F, Cao X, Yu J, Wang Y, Teng J, Ding X, Shen B, Zhang Z. Mitochondrial Dysfunction and Ion Imbalance in a Rat Model of Hemodialysis-Induced Myocardial Stunning. Biomedicines 2024; 12:2402. [PMID: 39457714 PMCID: PMC11504215 DOI: 10.3390/biomedicines12102402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 10/16/2024] [Accepted: 10/17/2024] [Indexed: 10/28/2024] Open
Abstract
Background/Objectives: Hemodialysis-induced myocardial stunning (HIMS) is a frequent complication in patients undergoing maintenance hemodialysis, characterized by transient left ventricular dysfunction due to ischemic episodes. Mitochondrial dysfunction and fluctuations in key ions such as potassium (K+) and calcium (Ca2+) are implicated in the pathogenesis of HIMS. This study aims to investigate the role of mitochondrial dysfunction and the protective potential of mitochondrial ATP-sensitive potassium channels (mitoKATP) in mitigating HIMS. Methods: A 5/6 nephrectomy rat model was established to mimic chronic kidney disease and the subsequent HIMS. The effects of mitoKATP channel modulators were evaluated by administering diazoxide (DZX), a mitoKATP opener, and 5-hydroxydecanoate (5-HD), a mitoKATP blocker, before hemodialysis. Mitochondrial function was assessed by measuring membrane potential, ATP synthase activity, and intramitochondrial Ca2+ levels. Myocardial function was evaluated using speckle tracking echocardiography. Results: Rats undergoing hemodialysis exhibited significant reductions in left ventricular strain and synchrony. DZX administration significantly improved mitochondrial function and reduced myocardial strain compared to controls. Conversely, 5-HD worsened mitochondrial swelling and disrupted myocardial function. Higher K+ and Ca2+ concentrations in the dialysate were associated with improved mitochondrial energy metabolism and myocardial strain. Conclusions: Mitochondrial dysfunction and ion imbalances during hemodialysis are key contributors to HIMS. The activation of mitoKATP channels provides mitochondrial protection and may serve as a potential therapeutic strategy to mitigate HIMS.
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Affiliation(s)
- Yuxin Nie
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Liyu Lin
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
- Department of Nephrology, Zhongshan Hospital (Xiamen), Fudan University, No. 668 Jinhu Road, Xiamen 361015, China
- Nephrology Clinical Quality Control Center of Xiamen, No. 668 Jinhu Road, Xiamen 361015, China
| | - Qiang Yang
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Jiachang Hu
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Minmin Sun
- Department of Echocardiography, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China;
- Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China
| | - Fangfang Xiang
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Xuesen Cao
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Jinbo Yu
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Yaqiong Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Jie Teng
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
- Department of Nephrology, Zhongshan Hospital (Xiamen), Fudan University, No. 668 Jinhu Road, Xiamen 361015, China
- Nephrology Clinical Quality Control Center of Xiamen, No. 668 Jinhu Road, Xiamen 361015, China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
- Department of Nephrology, Zhongshan Hospital (Xiamen), Fudan University, No. 668 Jinhu Road, Xiamen 361015, China
- Nephrology Clinical Quality Control Center of Xiamen, No. 668 Jinhu Road, Xiamen 361015, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
| | - Zhen Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; (Y.N.); (L.L.); (Q.Y.); (J.H.); (F.X.); (X.C.); (J.Y.); (Y.W.); (J.T.); (X.D.)
- Shanghai Key Laboratory of Kidney and Blood Purification, No. 180 Fenglin Road, Shanghai 200032, China
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McIntyre CW. Update on Hemodialysis-Induced Multiorgan Ischemia: Brains and Beyond. J Am Soc Nephrol 2024; 35:653-664. [PMID: 38273436 PMCID: PMC11149050 DOI: 10.1681/asn.0000000000000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024] Open
Abstract
Hemodialysis is a life-saving treatment for patients with kidney failure. However, patients requiring hemodialysis have a 10-20 times higher risk of cardiovascular morbidity and mortality than that of the general population. Patients encounter complications such as episodic intradialytic hypotension, abnormal perfusion to critical organs (heart, brain, liver, and kidney), and damage to vulnerable vascular beds. Recurrent conventional hemodialysis exposes patients to multiple episodes of circulatory stress, exacerbating and being aggravated by microvascular endothelial dysfunction. This promulgates progressive injury that leads to irreversible multiorgan injury and the well-documented higher incidence of cardiovascular disease and premature death. This review aims to examine the underlying pathophysiology of hemodialysis-related vascular injury and consider a range of therapeutic approaches to improving outcomes set within this evolved rubric..
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Affiliation(s)
- Christopher W McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, London, Ontario, Canada, and Departments of Medicine, Medical Biophysics and Pediatrics, Western University, London, Ontario, Canada
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Thompson S, Stickland MK, Wilund K, Gyenes GT, Bohm C. Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps? Can J Cardiol 2023; 39:S335-S345. [PMID: 37597748 DOI: 10.1016/j.cjca.2023.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023] Open
Abstract
Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.
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Affiliation(s)
- Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Kenneth Wilund
- Department of Kinesiology and Community Health, University of Illinois, Urbana, Illinois, USA
| | - Gabor T Gyenes
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Clara Bohm
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
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Peng YK, Tai TS, Wu CY, Tsai CY, Lee CC, Chen JJ, Hsiao CC, Chen YC, Yang HY, Yen CL. Clinical outcomes between elderly ESKD patients under peritoneal dialysis and hemodialysis: a national cohort study. Sci Rep 2023; 13:16199. [PMID: 37758848 PMCID: PMC10533893 DOI: 10.1038/s41598-023-43476-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
With ageing populations, new elderly end-stage kidney disease (ESKD) cases rise. Unlike younger patients, elderly ESKD patients are less likely to undergo kidney transplant, and therefore the decision of receiving peritoneal dialysis (PD) and hemodialysis (HD) is more crucial. A total of 36,852 patients, aged more than 65, who were newly diagnosed with ESKD and initiated renal replacement therapy between 2013 and 2019 were identified. These patients were categorized into two groups: the PD group and the HD group according to their long-term renal replacement treatment. After propensity score matching, the PD group (n = 1628) displayed a lower incidence of major adverse cardiac and cerebrovascular events (MACCE) (10.09% vs. 13.03%, hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.66-0.83), malignancy (1.23% vs. 2.14%, HR: 0.55, 95% CI: 0.40-0.76), and MACCE-associated mortality (1.35% vs. 2.25%, HR: 0.62, 95% CI: 0.46-0.84) compared to the HD group (n = 6512). However, the PD group demonstrated a higher rate of infection (34.09% vs. 24.14%, HR: 1.28, 95% CI: 1.20-1.37). The risks of all-cause mortality and infection-associated mortality were not different. This study may provide valuable clinical information to assist elderly ESKD patients to choose HD or PD as their renal replacement therapy.
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Affiliation(s)
- Yu-Kai Peng
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzong-Shyuan Tai
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Chao-Yi Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chung-Ying Tsai
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Cheng-Chia Lee
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chieh-Li Yen
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Echocardiogram screening in pediatric dialysis and transplantation. Pediatr Nephrol 2023; 38:957-974. [PMID: 36114889 PMCID: PMC9925481 DOI: 10.1007/s00467-022-05721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022]
Abstract
Transthoracic echocardiography is commonly used to identify structural and functional cardiac abnormalities that can be prevalent in childhood chronic kidney failure (KF). Left ventricular mass (LVM) increase is most frequently reported and may persist post-kidney transplant especially with hypertension and obesity. While systolic dysfunction is infrequently seen in childhood chronic KF, systolic strain identified by speckle tracking echocardiography has been frequently identified in dialysis and it can also persist post-transplant. Echocardiogram association with long-term outcomes has not been studied in childhood KF but there are many adult studies demonstrating associations between increased LVM, systolic dysfunction, strain, diastolic dysfunction, and cardiovascular events and mortality. There has been limited study of interventions to improve echocardiogram status. In childhood, improved blood pressure has been associated with better LVM, and conversion from hemodialysis to hemodiafiltration has been associated with better diastolic and systolic function. Whether long-term cardiac outcomes are also improved with these interventions is unclear. Echocardiography is a well-established technique, and regular use in childhood chronic KF seems justified. A case can be made to extend screening to include speckle tracking echocardiography and intradialytic studies in high-risk populations. Further longitudinal studies including these newer echocardiogram modalities, interventions, and long-term outcomes would help clarify recommendations for optimal use as a screening tool.
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Cullis B. Peritoneal dialysis for acute kidney injury: back on the front-line. Clin Kidney J 2022; 16:210-217. [PMID: 36755845 PMCID: PMC9900590 DOI: 10.1093/ckj/sfac201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Indexed: 11/12/2022] Open
Abstract
Peritoneal dialysis (PD) for acute kidney injury (AKI) has been available for nearly 80 years and has been through periods of use and disuse largely determined by availability of other modalities of kidney replacement therapy and the relative enthusiasm of clinicians. In the past 10 years there has been a resurgence in the use of acute PD globally, facilitated by promotion of PD for AKI in lower resource countries by nephrology organizations effected through the Saving Young Lives program and collaborations with the World Health Organisation, the development of guidelines standardizing prescribing practices and finally the COVID-19 pandemic. This review highlights the history of PD for AKI and looks at misconceptions about efficacy as well as the available evidence demonstrating that acute PD is a safe and lifesaving therapy with comparable outcomes to other modalities of treatment.
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Azar R, Desitter A, Guillou M, Schricke J, Geeraert M. Peritoneal dialysis in patients with refractory congestive heart failure. BULLETIN DE LA DIALYSE À DOMICILE 2022. [DOI: 10.25796/bdd.v5i1.64603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chronic heart failure is a growing problem. Despite progress in its management, many patients become refractory to therapies including diuretic resistance, major congestion, and worsening renal function. The only alternative to get rid of excess water and sodium is ultrafiltration, which can be achieved via hemodialysis or peritoneal dialysis (PD). The majority of studies have shown multiple benefits of PD as an improvement in functional class, a reduction in hospitalization leading to increased quality of life, and even a reduction in mortality. Being a home dialysis technique, it is more favorably accepted by patients. It remains necessary to confirm these potential positive outcomes and to identify patients who would benefit the most from this treatment in the era of new therapies available to date.
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Kunin M, Beckerman P. The Peritoneal Membrane—A Potential Mediator of Fibrosis and Inflammation among Heart Failure Patients on Peritoneal Dialysis. MEMBRANES 2022; 12:membranes12030318. [PMID: 35323792 PMCID: PMC8954812 DOI: 10.3390/membranes12030318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/06/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Abstract
Peritoneal dialysis is a feasible, cost-effective, home-based treatment of renal replacement therapy, based on the dialytic properties of the peritoneal membrane. As compared with hemodialysis, peritoneal dialysis is cheaper, survival rate is similar, residual kidney function is better preserved, fluid and solutes are removed more gradually and continuously leading to minimal impact on hemodynamics, and risks related to a vascular access are avoided. Those features of peritoneal dialysis are useful to treat refractory congestive heart failure patients with fluid overload. It was shown that in such patients, peritoneal dialysis improves functional status and quality of life, reduces hospitalization rate, and may decrease mortality rate. High levels of serum proinflammatory cytokines and fibrosis markers, among other factors, play an important part in congestive heart failure pathogenesis and progression. We demonstrated that those levels decreased following peritoneal dialysis treatment in refractory congestive heart failure patients. The exact mechanism of beneficial effect of peritoneal dialysis in refractory congestive heart failure is currently unknown. Maintenance of fluid balance, leading to resetting of neurohumoral activation towards a more physiological condition, reduced remodeling due to the decrease in mechanical pressure on the heart, decreased inflammatory cytokine levels and oxidative stress, and a potential impact on uremic toxins could play a role in this regard. In this paper, we describe the unique characteristics of the peritoneal membrane, principals of peritoneal dialysis and its role in heart failure patients.
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Affiliation(s)
- Margarita Kunin
- Correspondence: ; Tel.: +97-235-302-581; Fax: 97-235-302-582
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Kuo G, Chen JJ, Cheng YL, Fan PC, Lee CC, Chang CH. Comparison between peritoneal dialysis and hemodialysis on kidney function recovery in incident kidney failure: A nationwide cohort study. Semin Dial 2022; 35:278-286. [PMID: 35028979 DOI: 10.1111/sdi.13050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/18/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with kidney failure who start dialysis have a chance of kidney function recovery. Whether the initial dialysis modality affects the possibility of recovery is not fully understood. METHODS We included patients diagnosed with kidney failure requiring dialysis during 2001-2013 from the Taiwan National Health Insurance Research Database. We excluded diabetic and elderly patients. Kidney function recovery was defined as not receiving dialysis therapy for longer than 3 months. The primary outcome was kidney function recovery, and the secondary outcome was all-cause mortality during a 3-year follow up. RESULTS A total of 12,619 patients was eligible for analysis, with 981 received PD and 11,638 received HD. Total 620 patients had kidney function recovery during a 3-year follow up, which represented 4.9% of the entire cohort. After propensity score matching, the PD groups were more likely to experience kidney function recovery (subdistribution hazard ratio [SHR]: 1.64, 95% confidence interval [CI]: 1.19-2.25). The risk of all-cause mortality between groups did not significantly differ (hazard ratio [HR]: 1.23, 95% CI: 0.89-1.70). CONCLUSION The study found that in nonelderly, nondiabetic patients who received inadequate predialysis nephrology care before kidney failure, PD is associated with a higher chance of kidney function recovery.
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Affiliation(s)
- George Kuo
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ya-Lien Cheng
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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12
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Jabbour E, Fütterer C, Zach S, Kälsch AI, Keese M, Rahbari NN, Krämer BK, Schwenke KG. Implantation of a peritoneal dialysis catheter in patients with ESRD using local anesthesia and Remifentanil. PLoS One 2021; 16:e0259351. [PMID: 34735524 PMCID: PMC8568152 DOI: 10.1371/journal.pone.0259351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 10/18/2021] [Indexed: 01/18/2023] Open
Abstract
Study objective The main objective of this study is to test the feasibility of the local anesthetic (LA) Mepivacaine 1% and sedation with Remifentanil as the primary anesthetic technique for the insertion of a peritoneal dialysis (PD) catheter, without the need to convert to general anesthesia. Methods We analyzed 27 consecutive end-stage renal disease (ESRD) patients who underwent the placement of a peritoneal catheter at our center between March 2015 and January 2019. The procedures were all performed by a general or vascular surgeon, and the postoperative care and follow-up were all conducted by the same peritoneal dialysis team. Results All of the 27 subjects successfully underwent the procedure without the need of conversion to general anesthesia. The catheter was deemed prone to usage in all patients and was found to be leak-proof in 100% of the patients. Conclusion This study describes a safe and successful approach for insertion of a PD catheter by combined infiltration of the local anesthetic Mepivacaine 1% and sedation with Remifentanil. Hereby, ESRD patients can be treated without general anesthesia, while ensuring functionality of the PD catheter.
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Affiliation(s)
- Elizabeth Jabbour
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Carsten Fütterer
- Department of Anesthesiology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Zach
- Department of Vascular Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anna-Isabelle Kälsch
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Transplantation Center, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Keese
- Department of Vascular Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Transplantation Center, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N. Rahbari
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bernhard K. Krämer
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Transplantation Center, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for Angioscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Kay G. Schwenke
- Department of Vascular Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Transplantation Center, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- * E-mail:
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13
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Albakr RB, Bargman JM. A Comparison of Hemodialysis and Peritoneal Dialysis in Patients with Cardiovascular Disease. Cardiol Clin 2021; 39:447-453. [PMID: 34247757 DOI: 10.1016/j.ccl.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The high prevalence of cardiovascular disease is caused by the traditional cardiovascular risk factors common among end-stage renal disease patients, and nontraditional risk factors attributed to underlying kidney disease, including chronic inflammation, anemia, bone mineral disease, and the dialysis procedure itself. Individualization of the treatment of cardiovascular disease in end-stage renal disease that could impact the underlying mechanisms of the cardiovascular diseases is important to improve outcomes. This article reviews and compares hemodialysis and peritoneal dialysis in association with different cardiovascular diseases affecting dialysis patients, including hypertension, coronary artery disease, myocardial stunning, cardiac arrhythmias, heart failure, and the cardiorenal syndrome.
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Affiliation(s)
- Rehab B Albakr
- Division of Nephrology, University of Toronto, University Health Network, 200 Elizabeth Street 8N-840, Toronto, ON M5G 2C4, Canada; Division of Nephrology, College of Medicine, King Saud University, King Khalid Street, Riyadh-Al-Diriyah 12372, Saudi Arabia
| | - Joanne M Bargman
- Division of Nephrology, University of Toronto, University Health Network/Toronto General Hospital, 200 Elizabeth Street, 8N-840, Toronto, Ontario M5G 2C4, Canada.
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14
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Peritoneal Dialysis Following Left Ventricular Assist Device Placement and Kidney Recovery: A Case Report. Kidney Med 2021; 3:438-441. [PMID: 34136789 PMCID: PMC8178477 DOI: 10.1016/j.xkme.2020.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acute kidney injury (AKI) complicates up to 50% of left ventricular assist device (LVAD) placements and up to 30% of these patients require dialysis. Despite advances in LVAD technology since the first-generation devices, the risk for AKI remains high. We present a case of a woman in her 50s with previously stable stage C heart failure who developed critical cardiogenic shock and resultant AKI. She required continuous kidney replacement therapy both before and after placement of an LVAD. Following multiple inpatient and outpatient hemodialysis sessions complicated by hypotension, she was transitioned to peritoneal dialysis (PD). She tolerated PD well, and her kidney function continued to improve during the following weeks. After 6 weeks of outpatient PD, she recovered kidney function, allowing for cessation of dialysis. PD is a good option for patients with advanced heart failure who receive an LVAD due to gentler ultrafiltration, decreased risk for bacteremia, and better preservation of kidney function as compared with hemodialysis.
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15
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Mineralocorticoid Receptor Antagonist Use in Heart Failure With Reduced Ejection Fraction and End-Stage Renal Disease Patients on Dialysis: A Literature Review. Cardiol Rev 2021; 28:107-115. [PMID: 31985521 DOI: 10.1097/crd.0000000000000286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Mineralocorticoid receptor antagonists (MRAs) are known to have a proven mortality benefit in heart failure with reduced ejection fraction (HFrEF) without kidney disease. As patients with end-stage renal disease (ESRD) requiring either peritoneal dialysis or hemodialysis were excluded in clinical trials of HFrEF, the data are scant on the appropriate use of MRAs in this population. The unknown efficacy, along with concerns of adverse effects such as hyperkalemia, has limited the willingness of clinicians to consider using MRAs in these patients. However, it is unclear whether the risk of hyperkalemia is present if a patient is oliguric or anuric. Current guidelines recommend against the use of MRAs in patients with chronic kidney disease, but do not address the use of MRAs in patients requiring dialysis. This article will review the epidemiology of heart failure in ESRD, the pathophysiological derangements of the renin-angiotensin-aldosterone system in patients with kidney disease, and the results from case series and trials of the use of MRAs in ESRD with HFrEF. Although limited to several small trials using MRAs in peritoneal and hemodialysis patients with or without HFrEF, the current literature appears to show the potential for clinical benefits with little risk.
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16
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Goto J, Forsberg U, Jonsson P, Matsuda K, Nilsson B, Nilsson Ekdahl K, Henein MY, Stegmayr BG. Interdialytic weight gain of less than 2.5% seems to limit cardiac damage during hemodialysis. Int J Artif Organs 2020; 44:539-550. [PMID: 33339470 PMCID: PMC8366174 DOI: 10.1177/0391398820981385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aims: To investigate if a single low-flux HD induces a rise in cardiac biomarkers and if a change in clinical approach may limit such mechanism. Material and methods: A total of 20 chronic HD patients each underwent three different study-dialyses. Dialyzers (low-flux polysulfone, 1.8 sqm) had been stored either dry or wet (Wet) and the blood level in the venous chamber kept low or high. Laboratory results were measured at baseline, 30 and 180 min, adjusted for the effect of fluid shift. Ultrasound measured microemboli signals (MES) within the return line. Results: Hemodialysis raised cardiac biomarkers (p < 0.001): Pentraxin 3 (PTX) at 30 min (by 22%) and at 180 min PTX (53%), Pro-BNP (15%), and TnT (5%), similarly for all three HD modes. Baseline values of Pro-BNP correlated with TnT (rho = 0.38, p = 0.004) and PTX (rho = 0.52, p < 0.001). The changes from pre- to 180 min of HD (delta-) were related to baseline values (Pro-BNP: rho = 0.91, p < 0.001; TnT: rho = 0.41, p = 0.001; PTX: rho = 0.29, p = 0.027). Delta Pro-BNP (rho = 0.67, p < 0.001) and TnT (rho = 0.38, p = 0.004) correlated with inter-dialytic-weight-gain (IDWG). Biomarkers behaved similarly between the HD modes. The least negative impact was with an IDWG ⩽ 2.5%. Multiple regression analyses of the Wet-High mode does not exclude a relation between increased exposure of MES and factors such as release of Pro-BNP. Conclusion: Hemodialysis, independent of type of dialyzer storage, was associated with raised cardiac biomarkers, more profoundly in patients with higher pre-dialysis values and IDWG. A limitation in IDWG to <2.5% and prolonged ultrafiltration time may limit cardiac strain during HD, especially in patients with cardiovascular risk.
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Affiliation(s)
- Junko Goto
- Institute of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden.,Department of Emergency and Critical Care Medicine, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Ulf Forsberg
- Institute of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden.,Department of Internal Medicine, Skellefteå County Hospital, Skellefteå, Sweden
| | - Per Jonsson
- Institute of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | - Kenichi Matsuda
- Department of Emergency and Critical Care Medicine, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Bo Nilsson
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Kristina Nilsson Ekdahl
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Linnaeus Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Michael Y Henein
- Institute of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | - Bernd G Stegmayr
- Institute of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
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17
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Molnar AO, Bota SE, Garg AX, Ouédraogo A, Dixon SN, Naylor K, Oliver M, Sood MM. Dialysis Modality and Mortality in Heart Failure: A Retrospective Study of Incident Dialysis Patients. Cardiorenal Med 2020; 10:452-461. [PMID: 33238287 DOI: 10.1159/000511168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Prior studies reported lower mortality with hemodialysis (HD) compared to peritoneal dialysis (PD) in patients with heart failure (HF). We examined mortality rate by initial dialysis modality in incident dialysis patients with a history of HF using contemporary data and methods that ensure comparable HD and PD groups. METHODS Retrospective cohort study using administrative databases in Ontario, Canada. Adults (age 50-80) with a history of HF who initiated maintenance dialysis between April 1, 2007 and March 31, 2016 were included. We excluded patients typically ineligible for PD as an initial modality (dialysis start in hospital, dementia, long-term care facility residency). We determined the cause-specific hazard ratio (transplant as a competing event) between initial dialysis modality (HD vs. PD) and all-cause mortality using an intention-to-treat approach. RESULTS We included 2,199 patients with HF who initiated maintenance dialysis (77% HD and 23% PD). There were 1,152 (67.8%) and 340 (68.1%) mortality events over a median follow-up of 2.4 and 2.5 years in the HD and PD groups, respectively. Patients initiating HD versus PD was not associated with the mortality rate (adjusted hazard ratio 1.0, 95% CI 0.9-1.1). Similar results were seen in analyses censoring at modality switches and treating modality as time-varying. CONCLUSIONS We found no difference in mortality by initial dialysis modality. Our data support the current practice of selecting dialysis modality based on patient preference for patients with pre-existing HF.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada, .,ICES, Toronto, Ontario, Canada,
| | | | - Amit X Garg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | | | | | - Matthew Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Manish M Sood
- ICES, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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18
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Abstract
There is a well-established yet unexplained high prevalence of cardiovascular morbidity and mortality in individuals with end-stage kidney disease receiving dialysis. Potential causes include changes in cardiac structure and function, with increased left ventricular mass index as the best established cardiac structural change associated with this increase in mortality. However, in recent years, new echocardiographic and cardiac magnetic resonance imaging techniques have emerged that may provide novel markers that may better explain the mechanisms underlying the cardiovascular morbidity and mortality observed in end-stage kidney disease. This review outlines advances in cardiac imaging and the current status of imaging modalities, including echocardiography, cardiac magnetic resonance imaging, and cardiac positron emission tomography, to identify dialysis patients at high risk for cardiovascular mortality.
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Affiliation(s)
- Jeff Kott
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Nathaniel Reichek
- Cardiac Imaging Program and Research Department, St. Francis Hospital-The Heart Center, Roslyn, NY
- Division of Cardiology, Department of Medicine, Stony Brook University, Stony Brook, NY
- Department of Biomedical Engineering, School of Engineering and Applied Mathematics, Stony Brook University, Stony Brook, NY
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Leonard Arbeit
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Sandeep K. Mallipattu
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, NY
- Renal Section, Northport VA Medical Center, Northport, NY
- Address for Correspondence: Sandeep K. Mallipattu, MD, Department of Medicine/Nephrology, Stony Brook University, 100 Nicolls Rd, HSCT16-080E, Stony Brook, NY 11794-8176.
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19
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Eroglu E, Heimbürger O, Lindholm B. Peritoneal dialysis patient selection from a comorbidity perspective. Semin Dial 2020; 35:25-39. [PMID: 33094512 DOI: 10.1111/sdi.12927] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 12/17/2022]
Abstract
Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.
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Affiliation(s)
- Eray Eroglu
- Division of Nephrology, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey.,Division of Renal Medicine and Baxter Novum, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olof Heimbürger
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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20
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Candellier A, Hénaut L, Morelle J, Choukroun G, Jadoul M, Brazier M, Goffin É. Aortic stenosis in patients with kidney failure: Is there an advantage for a PD-first policy? Perit Dial Int 2020; 41:158-167. [DOI: 10.1177/0896860820941371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Aortic stenosis (AS) is the most common valvular disease. It is twice as prevalent in patients with kidney failure as compared to the general population. In addition, AS progresses at a faster rate and is associated with a higher risk of death and poorer quality of life in patients on dialysis. Chronic kidney disease–mineral and bone disorder (CKD-MBD), inflammation, and hemodynamic disturbances contribute to the pathophysiology and progression of AS. Whether the type of dialysis modality, that is, hemodialysis (HD) versus peritoneal dialysis (PD), has a differential impact on the development and progression of AS in patients with kidney failure remains debated. Recent data indicate that the prevalence of valvular calcifications might be lower and the development of AS delayed in PD patients, as compared to those treated with HD. This could be accounted for by several mechanisms including reduced valvular shear stress, better preservation of residual kidney function (with better removal of protein-bound uremic toxins and CKD-MBD profile), and lower levels of systemic inflammation. Given the high morbidity and mortality rates related to interventional procedures in the population with kidney failure, surgical and transcatheter aortic valve replacement should be considered in selected patients with severe AS. Strategies slowing down the progression of aortic valve remodeling should remain the cornerstone in the management of individuals with kidney failure and mild to moderate AS. This review explores the potential benefits of PD in patients with kidney failure and AS and provides some clues to help clinicians in the decision-making process when options for kidney replacement therapy are considered in patients with AS.
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Affiliation(s)
- Alexandre Candellier
- Division of Nephrology, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
- UR UPJV 7517, MP3CV, CURS, Amiens, France
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Gabriel Choukroun
- Division of Nephrology, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
- UR UPJV 7517, MP3CV, CURS, Amiens, France
| | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | | | - Éric Goffin
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
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21
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Chrysohoou C, Bougatsos G, Magkas N, Skoumas J, Kapota A, Kopelias J, Bliouras N, Tsioufis K, Petras D, Tousoulis D. Peritoneal dialysis as a therapeutic solution in elderly patients with cardiorenal syndrome and heart failure: A case-series report. Hellenic J Cardiol 2020; 61:73-77. [PMID: 31055051 DOI: 10.1016/j.hjc.2019.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The aim of this work was to evaluate the impact of peritoneal dialysis (PD) on venous congestion, right ventricular function, pulmonary artery systolic pressure (PASP), and clinical functional status in elderly patients with cardiorenal syndrome (CRS) and chronic heart failure (HF). METHODS A case series of 21 (17 males, age 70 ± 11 years) consecutive patients with HF along with diuretic resistance and right ventricular dysfunction (median renal failure duration 60 months, range 13-287 months, mean ejection fraction 36 ± 11%) having been engaged in PD; 76% of the patients were under automated peritoneal dialysis (APD), whereas the rest were under continuous ambulatory PD (CAPD). Patients' PASP and central venous pressure (CVP) - through compression sonography - and body weight were evaluated before initiating the PD program and at 6 and 12 months. RESULTS During the follow-up period, the mortality rate was 8 deaths out of 21 patients (38%) A significant reduction by 29.9% in PASP levels (p = 0.013) and by 42% in CVP levels (p < 0.001), and in right ventricular function assessed by tricuspid annulus tissue Doppler velocity (p = 0.04) was observed, whereas patients' weight increased by 3.7% (p = 0.001). New York Heart Association class improved in 12 patients, whereas in the remaining patients, it remained constant (p = 0.046). In 8 patients, complications were reported (mainly presence of Staphylococcus aureus). In conclusion, PD seems to confer a substantial benefit in clinical status, which is in line with improvement in venous congestion and right ventricular systolic pressure among elderly patients with HF along with CRS.
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Affiliation(s)
- Christina Chrysohoou
- First Cardiology Clinic, School of Medicine, Hippokratio Hospital, University of Athens, Athens, Greece.
| | - George Bougatsos
- Peritoneal Dialysis Unit Nephrology Clinic, Hippokration Hospital, Athens, Greece
| | - Nikos Magkas
- First Cardiology Clinic, School of Medicine, Hippokratio Hospital, University of Athens, Athens, Greece
| | - John Skoumas
- First Cardiology Clinic, School of Medicine, Hippokratio Hospital, University of Athens, Athens, Greece
| | - Athanasia Kapota
- Peritoneal Dialysis Unit Nephrology Clinic, Hippokration Hospital, Athens, Greece
| | - John Kopelias
- Peritoneal Dialysis Unit Nephrology Clinic, Hippokration Hospital, Athens, Greece
| | | | - Konstantinos Tsioufis
- First Cardiology Clinic, School of Medicine, Hippokratio Hospital, University of Athens, Athens, Greece
| | - Dimitris Petras
- Peritoneal Dialysis Unit Nephrology Clinic, Hippokration Hospital, Athens, Greece
| | - Dimitris Tousoulis
- First Cardiology Clinic, School of Medicine, Hippokratio Hospital, University of Athens, Athens, Greece
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22
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Glavinovic T, Hurst H, Hutchison A, Johansson L, Ruddock N, Perl J. Prescribing high-quality peritoneal dialysis: Moving beyond urea clearance. Perit Dial Int 2020; 40:293-301. [PMID: 32063213 DOI: 10.1177/0896860819893571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Urea removal in peritoneal dialysis (PD) has been a primary measure of dialysis adequacy, but its utility remains limited due to its poor correlation with the clearance of other important uraemic retention solutes and the low certainty of evidence relating peritoneal urea clearance and survival of individuals doing PD. Indeed, clearances of other uraemic solutes, electrolyte imbalances, hypoalbuminaemia and nutritional status, may provide a more holistic measure of dialysis adequacy when evaluating individuals on PD in addition to focusing on person-centred outcomes. Here, we review the history of the urea and creatinine-centric approach to dialysis adequacy and explore the potential importance of other uraemic retention solutes, electrolyte disturbances, phosphorus control, peritoneal protein losses and hypoalbuminaemia, as well as nutritional management to promote a broader multidimensional concept of clearance for PD.
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Affiliation(s)
- Tamara Glavinovic
- Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Helen Hurst
- Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Trust, UK
| | - Alastair Hutchison
- Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Trust, UK
| | - Lina Johansson
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Jeffrey Perl
- Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, St. Michael's Hospital and the Keenan Research Center, Li Ka Shing Knowledge Institute, University of Toronto, Ontario, Canada
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23
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Eriguchi R, Obi Y, Soohoo M, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. Racial and Ethnic Differences in Mortality Associated with Serum Potassium in Incident Peritoneal Dialysis Patients. Am J Nephrol 2019; 50:361-369. [PMID: 31522173 PMCID: PMC6856395 DOI: 10.1159/000502998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/25/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Abnormalities in serum potassium are risk factors for sudden cardiac death and arrhythmias among dialysis patients. Although a previous study in hemodialysis patients has shown that race/ethnicity may impact the relationship between serum potassium and mortality, the relationship remains unclear among peritoneal dialysis (PD) patients where the dynamics of serum potassium is more stable. METHODS Among 17,664 patients who started PD between January 1, 2007 and December 31, 2011 in a large US dialysis organization, we evaluated the association of serum potassium levels with all-cause and arrhythmia-related deaths across race/ethnicity using time-dependent Cox models with adjustments for demographics. We also used restricted cubic spline functions for serum potassium levels to explore non-linear associations. RESULTS Baseline serum potassium levels were the highest among Hispanics (4.2 ± 0.7 mEq/L) and lowest among non-Hispanic blacks (4.0 ± 0.7 mEq/L). Among 2,949 deaths during the follow-up of median 2.2 (interquartile ranges 1.3-3.2) years, 683 (23%) were arrhythmia-related deaths. Overall, both hyperkalemia and hypokalemia (i.e., serum potassium levels >5.0 and <3.5 mEq/L, respectively) were associated with higher all-cause and arrhythmia-related mortality. In a stratified analysis according to race/ethnicity, the association of hypokalemia with all-cause and arrhythmia-related mortality was consistent with an attenuation for arrhythmia-related mortality in non-Hispanic blacks. Hyperkalemia was associated with all-cause and arrhythmia-related mortality in non-Hispanic whites and non-Hispanic blacks, but no association was observed in Hispanics. CONCLUSION Among incident PD patients, hypokalemia was consistently associated with all-cause and arrhythmia-related deaths irrespective of race/ethnicity. However, while hyperkalemia was associated with both death outcomes in non-Hispanic blacks and whites, it was not associated with either death outcome in Hispanic patients. Further studies are needed to demonstrate whether different strategies should be followed for the management of serum potassium levels according to race/ethnicity.
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Affiliation(s)
- Rieko Eriguchi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA
- Department Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA,
- Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA,
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24
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Al-Hwiesh AK, Abdul-Rahman IS, Al-Audah N, Al-Hwiesh A, Al-Harbi M, Taha A, Al-Shahri A, Ghazal S, Amir R, Al-Audah N, Mansour H, El-Mansouri M, El-Salamony TS, Nasr El-Din MA, Noor A, Al-Elq Z, Alzahir ZH, Alzawad NA. Tidal peritoneal dialysis versus ultrafiltration in type 1 cardiorenal syndrome: A prospective randomized study. Int J Artif Organs 2019; 42:684-694. [DOI: 10.1177/0391398819860529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of peritoneal dialysis in patients with acute decompensated heart failure complicated by acute cardiorenal syndrome. Methods: We randomly assigned a total of 88 patients with type 1 acute cardiorenal syndrome to a strategy of ultrafiltration therapy (44 patients) or tidal peritoneal dialysis (44 patients). The primary endpoint was the change from baseline in the serum creatinine level and left ventricular function represented as ejection fraction, as assessed 72 and 120 h after random assignment. Patients were followed for 90 days after discharge from the hospital. Results: Ultrafiltration therapy was inferior to tidal peritoneal dialysis therapy with respect to the primary endpoint of the change in the serum creatinine levels at 72 and 120 h ( p = 0.041) and ejection fraction at 72 and 120 h after enrollment ( p = 0.044 and p = 0.032), owing to both an increase in the creatinine level in the ultrafiltration therapy group and a decrease in its level in the tidal peritoneal dialysis group. At 120 h, the mean change in the creatinine level was 1.4 ± 0.5 mg/dL in the ultrafiltration therapy group, as compared with 2.4 ± 1.3 mg/dL in the tidal peritoneal dialysis group ( p = 0.023). At 72 and 120 h, there was a significant difference in weight loss between patients in the ultrafiltration therapy group and those in the tidal peritoneal dialysis group ( p = 0.025). Net fluid loss was also greater in tidal peritoneal dialysis patients ( p = 0.018). Adverse events were more observed in the ultrafiltration therapy group ( p = 0.007). At 90 days post-discharge, tidal peritoneal dialysis patients had fewer rehospitalization for heart failure (14.3% vs 32.5%, p = 0.022). Conclusion: Tidal peritoneal dialysis is a safe and effective means for removing toxins and large quantities of excess fluid from patients with intractable heart failure. In patients with cardiorenal syndrome type 1, the use of tidal peritoneal dialysis was superior to ultrafiltration therapy for the preservation of renal function, improvement of cardiac function, and net fluid loss. Ultrafiltration therapy was associated with a higher rate of adverse events.
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Affiliation(s)
- Abdullah K Al-Hwiesh
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Ibrahiem Saeed Abdul-Rahman
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Nadia Al-Audah
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Amani Al-Hwiesh
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Mousa Al-Harbi
- Division of Cardiology, Department of Internal Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | | | - Abdulla Al-Shahri
- Division of Cardiology, Department of Internal Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Sami Ghazal
- Division of Cardiology, Department of Internal Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Rawan Amir
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Nehad Al-Audah
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Hany Mansour
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Mohammad El-Mansouri
- Division of Cardiology, Department of Internal Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Tamer S El-Salamony
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Mohammed A Nasr El-Din
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Abdulsalam Noor
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Zainab Al-Elq
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Zainab H Alzahir
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Noor A Alzawad
- Division of Nephrology, Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
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25
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Moist LM, McIntyre CW. Cerebral Ischemia and Cognitive Dysfunction in Patients on Dialysis. Clin J Am Soc Nephrol 2019; 14:914-916. [PMID: 31010937 PMCID: PMC6556724 DOI: 10.2215/cjn.00400119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Louise M Moist
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and .,Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Christopher W McIntyre
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and.,Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
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26
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Marants R, Qirjazi E, Grant CJ, Lee TY, McIntyre CW. Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling. J Am Soc Nephrol 2019; 30:1086-1095. [PMID: 31053638 DOI: 10.1681/asn.2018121194] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Residual renal function (RRF) confers survival in patients with ESRD but declines after initiating hemodialysis. Previous research shows that dialysate cooling reduces hemodialysis-induced circulatory stress and protects the brain and heart from ischemic injury. Whether hemodialysis-induced circulatory stress affects renal perfusion, and if it can be ameliorated with dialysate cooling to potentially reduce RRF loss, is unknown. METHODS We used renal computed tomography perfusion imaging to scan 29 patients undergoing continuous dialysis under standard (36.5°C dialysate temperature) conditions; we also scanned another 15 patients under both standard and cooled (35.0°C) conditions. Imaging was performed immediately before, 3 hours into, and 15 minutes after hemodialysis sessions. We used perfusion maps to quantify renal perfusion. To provide a reference to another organ vulnerable to hemodialysis-induced ischemic injury, we also used echocardiography to assess intradialytic myocardial stunning. RESULTS During standard hemodialysis, renal perfusion decreased 18.4% (P<0.005) and correlated with myocardial injury (r=-0.33; P<0.05). During sessions with dialysis cooling, patients experienced a 10.6% decrease in perfusion (not significantly different from the decline with standard hemodialysis), and ten of the 15 patients showed improved or no effect on myocardial stunning. CONCLUSIONS This study shows an acute decrease in renal perfusion during hemodialysis, a first step toward pathophysiologic characterization of hemodialysis-mediated RRF decline. Dialysate cooling ameliorated this decline but this effect did not reach statistical significance. Further study is needed to explore the potential of dialysate cooling as a therapeutic approach to slow RRF decline.
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Affiliation(s)
- Raanan Marants
- Department of Medical Biophysics, Western University, London, Canada.,Robarts Research Institute, Western University, London, Canada
| | - Elena Qirjazi
- The Lilibeth Caberto Kidney Clinical Research Unit and
| | - Claire J Grant
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Canada.,Robarts Research Institute, Western University, London, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Christopher W McIntyre
- Department of Medical Biophysics, Western University, London, Canada; .,The Lilibeth Caberto Kidney Clinical Research Unit and.,Lawson Health Research Institute, London Health Sciences Centre, London, Canada.,Division of Nephrology, London Health Sciences Centre, London, Canada; and
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27
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Selby NM, Kazmi I. Peritoneal dialysis has optimal intradialytic hemodynamics and preserves residual renal function: Why isn't it better than hemodialysis? Semin Dial 2018; 32:3-8. [PMID: 30352482 DOI: 10.1111/sdi.12752] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Rates of cardiovascular mortality are disproportionately high in patients with end stage kidney disease receiving dialysis. However, it is now generally accepted that patient survival is broadly equivalent between the two most frequently used forms of dialysis, in-center hemodialysis (HD) and peritoneal dialysis (PD). This equivalent patient survival is notable when considering how specific aspects of HD have been shown to contribute to morbidity and mortality. These include more rapid loss of residual renal function (RRF), HD-induced myocardial and cerebral ischemia, and risk factors associated with the intermittent delivery of HD. Potential mechanisms specific to PD that may drive cardiovascular disease include the metabolic consequences of excessive absorption of glucose and glucose degradation products (GDPs), inadequate volume control, and high rates of hypokalemia. The aim of this review is to compare and contrast the different drivers of adverse outcomes between the dialysis modalities, as greater understanding of this may help in patient-centered decision-making when considering options for renal replacement therapy.
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Affiliation(s)
- Nicholas M Selby
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Renal Medicine, Royal Derby Hospital, Derby, UK
| | - Isma Kazmi
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Renal Medicine, Royal Derby Hospital, Derby, UK
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28
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Edmonston D, Morris JD, Middleton JP. Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4. Adv Chronic Kidney Dis 2018; 25:454-467. [PMID: 30309463 DOI: 10.1053/j.ackd.2018.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 12/17/2022]
Abstract
Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.
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Abstract
BACKGROUND Peritoneal dialysis (PD) is one of the corner stones of renal replacement therapy and should be strongly considered if preemptive kidney transplantation is not available. SUMMARY There are several initiatives that may help the growth in the use of PD around the world. First, PD is an underused and valuable option in patients with heart failure and the chronic cardiorenal syndrome, especially in those with frequent hospitalizations despite optimal medical therapy. To identify these patients, an interdisciplinary approach of nephrologists and cardiologists is needed. These patients and other CKD patients with significant residual kidney function may do well with a regimen employing fewer than the usual number of bag exchanges, referred to as "incremental" dialysis. Second, acute kidney injury (AKI) is a worldwide burden with high morbidity and mortality, especially in low income countries. To reach the goal of zero preventable deaths caused by AKI by 2025 endorsed by the International Society of Nephrology, PD is the therapy of choice for treatment in this setting. Third, although dextrose has served well as the osmotic agent in PD solutions, there has been a continuous search for alternative agents. Hyperbranched polyglycerol might be such an osmole. Finally, to obviate the need for production and delivery of bags of PD solution, the development of home-generated dialysate is of interest. Key Message: The future of PD lies not only in accruing experience from the past decades, but also in staying open to other uses.
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30
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Chen T, Hassan HC, Qian P, Vu M, Makris A. High-Sensitivity Troponin T and C-Reactive Protein Have Different Prognostic Values in Hemo- and Peritoneal Dialysis Populations: A Cohort Study. J Am Heart Assoc 2018; 7:JAHA.117.007876. [PMID: 29478023 PMCID: PMC5866329 DOI: 10.1161/jaha.117.007876] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Dialysis patients have an exceedingly high mortality rate. Biomarkers may be useful tools in risk stratification of this population. We evaluated the prognostic value of high‐sensitivity cardiac troponin T (hs‐cTnT) and CRP (C‐reactive protein) in predicting adverse outcomes in stable hemodialysis and peritoneal dialysis (PD) patients. Variability in hs‐cTnT was also examined. Methods and Results A retrospective cohort study included 574 dialysis patients (hemodialysis 347, PD 227). Outcomes examined included mortality and major adverse cardiovascular events, with median follow‐up of 3.5 years. hs‐cTnT was an independent predictor of both outcomes in hemodialysis and PD patients. Increased risk only became significant when hs‐cTnT reached quintile 3 (>49 ng/L). Area under the receiver operating curve analysis showed that the addition of hs‐cTnT to clinical parameters significantly improved its prognostic performance for mortality in PD patients (P=0.002). CRP was an independent predictor of both outcomes in PD patients only. Only CRP in the highest quintile (>16.8 mg/L) was associated with increased risk. hs‐cTnT remained relatively stable for the whole follow‐up period for hemodialysis patients, whereas for PD patients, hs‐cTnT increased by 23.63% in year 2 and 29.13% in year 3 compared with baseline (P<0.001). Conclusions hs‐cTnT and CRP are useful tools in predicting mortality and major adverse cardiovascular events in hemodialysis and PD patients. Given that hs‐cTnT levels increase over time in PD patients, interval monitoring may be valuable for risk assessment. In contrast, hs‐cTnT in hemodialysis patients has little interval change and progress monitoring is not indicated.
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Affiliation(s)
- Titi Chen
- The University of Sydney, Camperdown, New South Wales, Australia .,Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia.,The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Hicham C Hassan
- Department of Nephrology, Wollongong Hospital, Wollongong, New South Wales, Australia.,University of Wollongong, New South Wales, Australia
| | - Pierre Qian
- The University of Sydney, Camperdown, New South Wales, Australia.,Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Monica Vu
- The University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Angela Makris
- Department of Renal Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia.,University of New South Wales, Kensington, New South Wales, Australia
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31
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Kazory A. Fluid overload as a major target in management of cardiorenal syndrome: Implications for the practice of peritoneal dialysis. World J Nephrol 2017; 6:168-175. [PMID: 28729965 PMCID: PMC5500454 DOI: 10.5527/wjn.v6.i4.168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/23/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
Congestion is an integral component of cardiorenal syndrome and portends an adverse impact on the outcomes. Recent studies suggest that congestion has the ability of modulating the interactions between the kidney and the heart in this setting. Peritoneal dialysis (PD) is a home-based therapeutic modality that is not only offered to patients with end-stage renal disease to provide solute clearance and ultrafiltration, but it has also been used in patients with refractory heart failure and fluid overload to help optimize volume status. Several uncontrolled studies and case series have so far evaluated the role of PD in management of hypervolemia for patients with heart failure. They have generally reported favorable results in this setting. However, the data on the outcomes of patients with end-stage renal disease and concomitant heart failure is mixed, and the proposed theoretical advantages of PD might not translate into improved clinical endpoints. Congestion is prevalent in this patient population and has a significant effect on their survival. As studies suggest that a significant subset of patients with end-stage renal disease who receive PD therapy are hypervolemic, suboptimal management of congestion could at least in part explain these conflicting results. PD is a highly flexible therapeutic modality and the choice of techniques, regimens, and solutions can affect its ability for optimization of fluid status. This article provides an overview of the currently available data on the role and clinical relevance of congestion in patients with cardiorenal syndrome and reviews potential options to enhance decongestion in these patients.
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32
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Kim HJ, Park JT, Han SH, Yoo TH, Park HC, Kang SW, Kim KH, Ryu DR, Kim H. The pattern of choosing dialysis modality and related mortality outcomes in Korea: a national population-based study. Korean J Intern Med 2017; 32. [PMID: 28651309 PMCID: PMC5511949 DOI: 10.3904/kjim.2017.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/AIMS Since comorbidities are major determinants of modality choice, and also interact with dialysis modality on mortality outcomes, we examined the pattern of modality choice according to comorbidities and then evaluated how such choices affected mortality in incident dialysis patients. METHODS We analyzed 32,280 incident dialysis patients in Korea. Patterns in initial dialysis choice were assessed by multivariate logistic regression analyses. Multivariate Poisson regression analyses were performed to evaluate the effects of interactions between comorbidities and dialysis modality on mortality and to quantify these interactions using the synergy factor. RESULTS Prior histories of myocardial infarction (p = 0.031), diabetes (p = 0.001), and congestive heart failure (p = 0.003) were independent factors favoring the initiation with peritoneal dialysis (PD), but were associated with increased mortality with PD. In contrast, a history of cerebrovascular disease and 1-year increase in age favored initiation with hemodialysis (HD) and were related to a survival benefit with HD (p < 0.001, both). While favoring initiation with HD, having Medical Aid (p = 0.001) and male gender (p = 0.047) were related to increased mortality with HD. Furthermore, although the severity of comorbidities did not inf luence dialysis modality choice, mortality in incident PD patients was significantly higher compared to that in HD patients as the severity of comorbidities increased (p for trend < 0.001). CONCLUSIONS Some comorbidities exerted independent effects on initial choice of dialysis modality, but this choice did not always lead to the best results. Further analyses of the pattern of choosing dialysis modality according to baseline comorbid conditions and related consequent mortality outcomes are needed.
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Affiliation(s)
- Hyung Jong Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeong-Cheon Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Hoon Kim
- Department of Public Health, Korea University Graduate School, Seoul, Korea
- Correspondence to Hyunwook Kim, M.D. Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: +82-2-2019-3310 Fax: +82-2-3463-3882 E-mail:
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, Tissue Injury Defense Research Center, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyunwook Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Correspondence to Hyunwook Kim, M.D. Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: +82-2-2019-3310 Fax: +82-2-3463-3882 E-mail:
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33
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Pirkle JL, Comeau ME, Langefeld CD, Russell GB, Balderston SS, Freedman BI, Burkart JM. Effects of weight-based ultrafiltration rate limits on intradialytic hypotension in hemodialysis. Hemodial Int 2017. [PMID: 28643378 DOI: 10.1111/hdi.12578] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION High ultrafiltration (UF) rates can result in intradialytic hypotension and are associated with increased mortality. The effects of a weight-based UF rate limit on intradialytic hypotension and the potential for unwanted fluid weight gain and hospitalizations for volume overload are unknown. METHODS This retrospective cohort study examined 123 in-center hemodialysis patients at one facility who transitioned to 13 mL/kg/h maximum UF rates. Patients were studied for an 8 week UF rate limit exposure period and compared to the 8-week period immediately prior, during which the cohort served as its own historical control. The primary outcomes were frequency of intradialytic hypotension events and percentage of treatments with a hypotension event. FINDINGS The delivered UF rate was lower during the exposure compared to the baseline period (mean UF rate 7.90 ± 4.45 mL/kg/h vs. 8.92 ± 5.64 mL/kg/h; P = 0.0005). The risk of intradialytic hypotension was decreased during the exposure compared to baseline period (event rate per treatment 0.0569 vs. 0.0719, OR 0.78 [95% CI 0.62-1.00]; P = 0.0474), as was the risk of having a treatment with a hypotension event (percentage of treatments with event 5.2% vs. 6.8%, OR 0.75 [95% CI 0.58-0.96]; P = 0.0217). Subgroup analyses demonstrated that these findings were attributable to patients with high baseline UF rates. Statistically significant differences in all-cause or volume overload-related hospitalization were not observed during the exposure period. DISCUSSION A weight-based UF rate limit of 13 mL/kg/h was associated with a decrease in the rate of intradialytic hypotension events among in-center hemodialysis patients.
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Affiliation(s)
- James L Pirkle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mary E Comeau
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carl D Langefeld
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory B Russell
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John M Burkart
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Shen JI, Saxena AB, Montez-Rath ME, Chang TI, Winkelmayer WC. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use and cardiovascular outcomes in patients initiating peritoneal dialysis. Nephrol Dial Transplant 2017; 32:862-869. [PMID: 27190342 DOI: 10.1093/ndt/gfw053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 02/22/2016] [Indexed: 11/14/2022] Open
Abstract
Background Data on the effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in reducing cardiovascular (CV) risk in patients undergoing peritoneal dialysis (PD) are limited. We investigated the association between ACEI/ARB use and CV outcomes in patients initiating PD. Methods In this observational cohort study, we identified from the United States Renal Data System all adult patients who initiated PD from 2007 to 2011 and participated in Medicare Part D, a federal prescription drug benefits program, for the first 90 days of dialysis. Patients who filled a prescription for an ACEI or ARB in those 90 days were considered users. We applied Cox regression to an inverse probability of treatment weighted cohort to estimate the hazard ratios (HRs) for the combined outcome of death, ischemic stroke or myocardial infarction (MI) and each outcome individually. Results Among 4879 patients, 2063 (42%) used an ACEI/ARB. Patients were followed up for a median of 1.2 years. We recorded 1771 events, for a composite rate of 25 events per 100 person-years. ACEI/ARB use (versus nonuse) was associated with a reduced risk of the composite outcome {HR 0.84 [95% confidence interval (CI) 0.76-0.93]}, all-cause mortality [HR 0.83 (95% CI 0.75-0.92)] and CV death [HR 0.74 (95% CI 0.63-0.87)], but not MI [HR 0.88 (95% CI 0.69-1.12)] or ischemic stroke [HR 1.06 (95% CI 0.79-1.43)]. Results were similar in as-treated analyses. In a subgroup analysis, we did not find any effect modification by residual renal function. Conclusions ACEI/ARB use is common in patients initiating PD and is associated with a lower risk of fatal CV outcomes.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W. Carson St., C-1 Annex, Torrance, CA, USA.,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Anjali B Saxena
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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35
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Bevilacqua MU, Turnbull L, Saunders S, Er L, Chiu H, Hill P, Singh RS, Levin A, Copland MA, Jamal A, Brumby C, Dunne O, Taylor PA. Evaluation of A 12-Month Pilot of Long-Term and Temporary Assisted Peritoneal Dialysis. Perit Dial Int 2017; 37:307-313. [DOI: 10.3747/pdi.2016.00201] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/20/2016] [Indexed: 11/15/2022] Open
Abstract
Background Peritoneal dialysis (PD) is challenging for patients with functional limitations, and assisted PD can support these patients, but previous reports of assisted PD have not examined the role of temporary assisted PD and had difficulty identifying adequate comparator cohorts. Methods Peritoneal Dialysis Assist (PDA), a 12-month pilot of long-term and temporary assisted PD was completed in multiple PD centers in British Columbia, Canada. Continuous cycler PD (CCPD) patients were identified for PDA by standardized criteria, and service could be long-term or temporary/respite. The PDA program provided daily assistance with cycler dismantle and setup, but patients remained responsible for cycler connections and treatment decisions. Outcomes were compared against both the general CCPD population and patients who met PDA criteria but were not enrolled (PDA-eligible). Results Fifty-three PDA patients had an 88% 1-year death- and transplant-censored technique survival that was similar to the general CCPD cohort (84%) and PDA-eligible cohort (86%). The PDA cohort had lower peritonitis rates (0.18 episodes/patient-year vs 0.22 and 0.36, respectively), but higher hospitalization (55% vs 34% and 35%, respectively). Long-term PDA cost approximately CDN$15,000/year in addition to existing dialysis costs. A total of 8/11 respite PDA patients (73%) returned to self-care PD after a median PDA use of 29 days, which costs $1,250/patient. Conclusions Peritoneal Dialysis Assist provides effective support to functionally-limited CCPD patients and yields acceptable clinical outcomes. The program costs less than transfer to HD or long-term care, which represents cost minimization for failing self-care PD patients. Respite PDA provides effective temporary support; most patients returned to self-care PD and service was cost-effective compared with alternatives of hospitalization or transfer to HD.
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Affiliation(s)
- Micheli U. Bevilacqua
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Linda Turnbull
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Sushila Saunders
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Lee Er
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Helen Chiu
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Penny Hill
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Rajinder S. Singh
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver, BC, Canada; and British Columbia Provincial Renal Agency, Vancouver, BC, Canada
| | - Michael A. Copland
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Abeed Jamal
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Catherine Brumby
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Orla Dunne
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul A. Taylor
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Wang IK, Lu CY, Lin CL, Liang CC, Yen TH, Liu YL, Sung FC. Comparison of the risk of de novo cardiovascular disease between hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Int J Cardiol 2016; 218:219-224. [PMID: 27236118 DOI: 10.1016/j.ijcard.2016.05.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of the study was to compare the risk of de novo cardiovascular disease (CVD) between hemodialysis (HD) and peritoneal dialysis (PD) in patients with incident end-stage renal disease (ESRD). METHODS From a Taiwanese universal insurance claims database, we identified 45309 incident ESRD patients without preexisting CVD from 2000 to 2010. Using the propensity score matching method, we included 6516 patients in HD and PD groups, respectively. All patients were followed up until the end of 2011. The Cox proportional hazards regression model was employed to calculate the impact of dialysis modality on the risk of new onset cardiovascular events including ischemic heart disease, and congestive heart failure (CHF). RESULTS No difference was observed in the overall risk of de novo ischemic heart disease between the propensity score-matched HD and PD groups (HD versus PD, adjusted hazard ratio [HR]: 1.03, 95% confidence interval [CI]: 0.86-1.22). However, HD was associated with a higher risk of de novo CHF (adjusted HR: 1.29, 95% CI: 1.13-1.47) than PD was. The risk of de novo CHF was particularly high in the first year under dialysis treatment for propensity score-matched HD patients, compared to PD patients. CONCLUSIONS No difference was observed in the overall risk of de novo major ischemic heart events between HD and PD patients. However, HD was associated with a higher risk of de novo CHF than PD in the first year under dialysis treatment.
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Affiliation(s)
- I-Kuan Wang
- Graduate Institute of Clinical Medical Science, China Medical University College of Medicine, Taichung, Taiwan; Department of Internal Medicine, China Medical University College of Medicine, Taichung, Taiwan; Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Chi-Yu Lu
- Department of Biochemistry, College of Medicine Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Chia Liang
- Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Tzung-Hai Yen
- Division of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yao-Lung Liu
- Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Fung-Chang Sung
- Graduate Institute of Clinical Medical Science, China Medical University College of Medicine, Taichung, Taiwan; Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.
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Stegmayr BG. Sources of Mortality on Dialysis with an Emphasis on Microemboli. Semin Dial 2016; 29:442-446. [DOI: 10.1111/sdi.12527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Bernd G. Stegmayr
- Department Public Health and Clinical Medicine; Division of Nephrology; Umeå University; Umeå Sweden
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Y-Hassan S. Acute, repetitive and chronic Takotsubo syndrome in patients with chronic kidney disease: Sympathetic reno-cardial syndrome. Int J Cardiol 2016; 222:874-880. [PMID: 27522391 DOI: 10.1016/j.ijcard.2016.07.278] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/18/2016] [Accepted: 07/30/2016] [Indexed: 02/07/2023]
Abstract
Heart failure and cardiovascular death are common in patients with chronic kidney disease (CKD) and extremely prevalent in patients undergoing dialysis. It has been shown that the excess of cardiovascular mortality in this patient population is not fully accounted for by the traditional cardiovascular risk factors. Substantial evidence exists for the presence of sympathetic over-activity in patients with dialytic and non-dialytic CKD. Several studies have also been reported on reversible segmental left ventricular wall motion abnormality consistent with myocardial stunning in association with dialysis especially hemodialysis. In the literature, the most acceptable underpinning hypothesis for the myocardial stunning in CKD is "demand myocardial ischemia". However, the occurrence of cardiac sympathetic over-activation-disruption and repeated reversible myocardial stunning in patients with CKD can be compared to that occurring in acute Takotsubo syndrome where local cardiac sympathetic disruption may cause acute regional circumferential pattern of myocardial stunning. In this manuscript, converging evidences suggestive for the fact that acute, repetitive, and chronic TS may be one of the important causes of cardiac morbidity including myocardial stunning and heart failure and mortality in patients with CKD are provided.
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Affiliation(s)
- Shams Y-Hassan
- Karolinska University Hospital, Huddinge, Department of Cardiology, S-141 86 Stockholm, Sweden.
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39
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Rivara MB, Mehrotra R. New-Onset Diabetes in Peritoneal Dialysis Patients - Which Predictors Really Matter? Perit Dial Int 2016; 36:243-6. [PMID: 27230599 DOI: 10.3747/pdi.2015.00251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA
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40
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Geerse DA, Meynen FMCJ, Gelens MA, Kooman JP, Cornelis T. Systemic Capillary Leak Syndrome after Influenza Vaccination in a Peritoneal Dialysis Patient. ARCH ESP UROL 2015; 35:772-3. [PMID: 26703855 DOI: 10.3747/pdi.2014.00194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- D A Geerse
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - F M C J Meynen
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M A Gelens
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Cornelis
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
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Results in Assisted Peritoneal Dialysis: A Ten-Year Experience. Int J Nephrol 2015; 2015:712539. [PMID: 26600950 PMCID: PMC4639672 DOI: 10.1155/2015/712539] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 09/10/2015] [Indexed: 11/17/2022] Open
Abstract
Background/Aims. Peritoneal dialysis is a successful renal replacement therapy (RRT) for old and dependent patients. We evaluated the clinical outcomes of an assisted peritoneal dialysis (aPD) program developed in a Portuguese center. Methods. Retrospective study based on 200 adult incident patients admitted during ten years to a PD program. We included all 17 patients who were under aPD and analysed various parameters, including complications with the technique, hospitalizations, and patient and technique survival. Results. The global peritonitis rate was lower in helped than in nonhelped patients: 0.4 versus 0.59 episodes/patient/year. The global hospitalization rate was higher in helped than in nonhelped patients: 0.67 versus 0.45 episodes/patient/year (p = NS). Technique survival in helped patients versus nonhelped patients was 92.3%, 92.3%, 83.1%, and 72.7% versus 91.9%, 81.7%, and 72.1%, and 68.3%, at 1, 2, 3, and 4 years, respectively (p = NS), and patient survival in helped patients versus nonhelped patients was 93.3%, 93.3%, 93.3%, and 74.7% versus 95.9% 93.7%, 89%, and 82% at 1, 2, 3, and 4 years, respectively (p = NS). Conclusions. aPD offers an opportune, reliable, and effective home care alternative for patients with no other RRT options.
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Vanholder RC, Eloot S, Glorieux GLRL. Future Avenues to Decrease Uremic Toxin Concentration. Am J Kidney Dis 2015; 67:664-76. [PMID: 26500179 DOI: 10.1053/j.ajkd.2015.08.029] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 08/19/2015] [Indexed: 01/13/2023]
Abstract
In this article, we review approaches for decreasing uremic solute concentrations in chronic kidney disease and in particular, in end-stage renal disease (ESRD). The rationale to do so is the straightforward relation between concentration and biological (toxic) effect for most toxins. The first section is devoted to extracorporeal strategies (kidney replacement therapy). In the context of high-flux hemodialysis and hemodiafiltration, we discuss increasing dialyzer blood and dialysate flows, frequent and/or extended dialysis, adsorption, bioartificial kidney, and changing physical conditions within the dialyzer (especially for protein-bound toxins). The next section focuses on the intestinal generation of uremic toxins, which in return is stimulated by uremic conditions. Therapeutic options are probiotics, prebiotics, synbiotics, and intestinal sorbents. Current data are conflicting, and these issues need further study before useful therapeutic concepts are developed. The following section is devoted to preservation of (residual) kidney function. Although many therapeutic options may overlap with therapies provided before ESRD, we focus on specific aspects of ESRD treatment, such as the risks of too-strict blood pressure and glycemic regulation and hemodynamic changes during dialysis. Finally, some recommendations are given on how research might be organized with regard to uremic toxins and their effects, removal, and impact on outcomes of uremic patients.
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Affiliation(s)
| | - Sunny Eloot
- Nephrology Department, University Hospital, Gent, Belgium
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Afshinnia F, Zaky ZS, Metireddy M, Segal JH. Reverse Epidemiology of Blood Pressure in Peritoneal Dialysis Associated with Dynamic Deterioration of Left Ventricular Function. Perit Dial Int 2015; 36:154-62. [PMID: 26293842 DOI: 10.3747/pdi.2014.00264] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/07/2015] [Indexed: 12/15/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND Reverse epidemiology of blood pressure (BP) in end-stage kidney disease (ESKD) is manifested as higher mortality at lower blood pressure. We hypothesize that this phenomenon is partially mediated by deterioration of cardiac structure and function. ♦ METHODS Seventy-seven prevalent ESKD patients starting renal replacement therapy on peritoneal dialysis (PD) from 2007 to 2012 were evaluated for the primary outcome of all-cause mortality. Longitudinal data were obtained from 1,930 patient-encounters including monthly clinic BP and serial echocardiograms. Generalized linear mixed models using data from the last observation moving backward, and time-to-event analysis using time-varying Cox-survival models to estimate mortality risk at different blood pressure categories were applied. ♦ RESULTS There were 39 males (50.6%). Mean age was 51 years (standard deviation [SD] = 15). During follow-up, 20 patients (25%) died. As compared to systolic blood pressure (SBP) of 140-159 mmHg, unadjusted risk of mortality was 7.3 (95% confidence interval [CI]: 1.5-35.7, p = 0.008) at level < 120 mmHg. Systolic BP trended down to an average of 117 mmHg prior to death in non-survivors as compared to 141 mmHg in survivors (p < 0.05). In non-survivors, percentage with concentric left ventricular hypertrophy (LVH) decreased by 20% at the expense of a 20% reciprocal increase in eccentric hypertrophy associated with a 30% increase in percentage with low ejection fraction (EF) (< 50%). After adjusting for EF, risk of mortality at SBP < 120 mmHg attenuated to 3.4 (95% CI: 0.7-17.7, p = 0.14). ♦ CONCLUSION We conclude that higher mortality associated with lower BP may be mediated in part by worsening heart function in ESKD patients receiving PD.
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Affiliation(s)
- Farsad Afshinnia
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Ziad S Zaky
- Division of Nephrology, Glickman Urology & Nephrology Institute, Cleveland Clinic, Ohio, United States
| | - Manasa Metireddy
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan H Segal
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
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45
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Großekettler L, Schmack B, Schwenger V. [Cardiorenal syndrome: limits of heart failure therapy]. Herz 2014; 38:569-77. [PMID: 23740085 DOI: 10.1007/s00059-013-3847-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The cardiorenal syndrome is an interdisciplinary challenge with increasing health economic relevance. Renal failure is a strong predictor for mortality in patients with severe congestive heart failure (CHF) and CHF is one of the fastest increasing morbidities in western countries. For successful therapy a close cooperation between cardiology und nephrology is required. Moreover, a good compliance of the patient is needed to improve symptoms and to reduce the frequency of cardiac decompensation. A broad cardiological and nephrological evaluation and consideration of optimal conservative options according to national and international guidelines are essential. However, a renal replacement therapy might be helpful in patients with refractory heart failure even if they are not dialysis-dependent. In cases of acute heart and renal failure an intensive care management might be necessary to reduce volume overload with the help of extracorporeal ultrafiltration or a dialysis modality. Nevertheless, in cases of chronic refractory CHF peritoneal dialysis should be preferred. The first analysis of the registry of the German Society of Nephrology (http://www.herz-niere.de) confirmed that there is a benefit for health-related quality of life in chronic CHF patients treated with peritoneal dialysis.
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Affiliation(s)
- L Großekettler
- Sektion Nephrologie, Medizinische Universitätsklinik Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Deutschland,
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Davies S, Lally F, Satchithananda D, Kadam U, Roffe C. Extending the role of peritoneal dialysis: can we win hearts and minds? Nephrol Dial Transplant 2014; 29:1648-54. [DOI: 10.1093/ndt/gfu001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Abstract
Peritoneal dialysis is now a well established, mature treatment modality for advanced chronic kidney disease. The medium term (at least 5 year) survival of patients on peritoneal dialysis is currently equivalent to that of those on haemodialysis, and is particularly good in patients who are new to renal replacement therapy and have less comorbidity. Nevertheless the modality needs to keep pace with the constantly evolving challenges associated with the provision and delivery of health care. These challenges, which are gradually converging at a global level, include ageing of the population, multimorbidity of patients, containment of cost, increasing self care and environmental issues. In this context, peritoneal dialysis faces particular challenges that include multiple barriers to the therapy and unsatisfactory and poorly defined technique survival as well as limitations relating to intrinsic aspects of the therapy, such as peritoneal membrane longevity and hypoalbuminaemia. To move the therapy forward and favourably influence health-care policy, the peritoneal dialysis community needs to integrate their research effort more effectively by undertaking clinically meaningful studies-with a strong focus on technique survival--that are supported by multidisciplinary expertise in patient-centred outcomes, study design and analysis.
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Affiliation(s)
- Simon J Davies
- Department of Nephrology, University Hospital of North Staffordshire, Newcastle Road, Stoke on Trent, Staffordshire ST4 6QG, UK.
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48
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Bargman JM. Peritoneal dialysis should be the first choice for renal replacement therapy in the elderly. Semin Dial 2012; 25:668-70. [PMID: 23078027 DOI: 10.1111/sdi.12013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Joanne M Bargman
- Home Peritoneal Dialysis Program, University Health Network, Toronto, Canada.
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49
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McIntyre CW, Rosansky SJ. Starting dialysis is dangerous: how do we balance the risk? Kidney Int 2012; 82:382-7. [DOI: 10.1038/ki.2012.133] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
After broad cardiological and nephrological evaluation and consideration of optimal conservative options according to national and international guidelines, renal replacement therapy might be helpful in patients with refractory heart failure even if they are not dialysis-dependent. This is even more important as renal failure is a strong predictor for mortality in patients with severe congestive heart failure (CHF) and CHF is one of the fastest growing morbidities in western countries. Although peritoneal dialysis (PD) is frequently used in patients with CHF its role remains unclear. Acute chronic volume overload in refractory CHF is still an unresolved clinical problem. In patients with acute heart and renal failure with need of management in an intensive care unit, extracorporeal ultrafiltration or a dialysis modality should be preferred. In patients with chronic refractory CHF, volume overload and renal failure, peritoneal dialysis should be the therapy of choice. Due to the limited data available, treatment and outcome parameters should be recorded in the registry of the German Society of Nephrology (http://www.herz-niere.de).
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Affiliation(s)
- V Schwenger
- Sektion Nephrologie, Medizinische Universitätsklinik Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Deutschland.
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