Current clinical practice in adapted automated peritoneal dialysis (aAPD)—A prospective, non-interventional study

Adapted automated peritoneal dialysis (aAPD), comprising a sequence of dwells with different durations and fill volumes, has been shown to enhance both ultrafiltration and solute clearance compared to standard peritoneal dialysis with constant time and volume dwells. The aim of this non-interventional study was to describe the different prescription patterns used in aAPD in clinical practice and to observe outcomes characterizing volume status, dialysis efficiency, and residual renal function over 1 year. Prevalent and incident, adult aAPD patients were recruited during routine clinic visits, and aAPD prescription, volume status, residual renal function and laboratory data were documented at baseline and every quarter thereafter for 1 year. Treatments were prescribed according to the nephrologist’s medical judgement in accordance with each center’s clinical routine. Of 180 recruited patients, 160 were analyzed. 27 different aAPD prescription patterns were identified. 79 patients (49.4%) received 2 small, short dwells followed by 3 long, large dwells. During follow-up, volume status changed only marginally, with visit mean values ranging between 1.59 (95% confidence interval: 1.19; 1.99) and 1.97 (1.33; 2.61) L. Urine output and creatinine clearance decreased significantly, accompanied by reductions in ultrafiltration and Kt/V. 25 patients (15.6%) received a renal transplant and 15 (9.4%) were changed to hemodialysis. Options for individualization offered by aAPD are actually used in practice for optimized treatment. Changes observed in renal function and dialysis efficiency measures reflect the natural course of chronic kidney disease. No safety events were observed during the study period.

Сardiorenal Syndrome in Patients on Renal Replacement Therapy

In this chapter authors discusses cardiorenal relationships in patients with renal replacement therapy (RRT) which are considered as a separate type of cardiorenal syndrome (CRS). Frequency and severity of CRS in patients on dialysis are correlated with quantity of years of the dialysis treatment; depend on quality of dialysis regimen and level of residual renal function. RRT-associated cardiac pathology are including left ventricular hypertrophy, ischemic cardiomyopathy, congestive heart failure, coronary atherosclerosis and calcinosis, severe arrhythmias. The article analyzes role of malnutrition and dialysis-induced cachexia, bio-incompatibility of dialysis membranes, oxidative stress and inflammation, arterio-venous fistula, decrease of residual renal function in the development of dialysis-induced CRS. The review examines the mechanisms of progressive myocardial ischemia induced by dialysis: myocardial stunning, hemodialysis-induced hypotension, uremic small vessel disease. Prevention of dialysis-induced CRS includes a choice of the optimal RRT method (peritoneal dialysis or hemodialysis), соntrol of dialysis regimen, residual renal function, biocompatibility of membrane, inflammatory markers, body mass index, serum level albumin, phosphate, calcium, parathyroid hormone, fibroblast growth factor-23. Electrocardiogram, ultrasonic monitoring and coronarography reveals indications for соnservative cardioprotective therapy and angioplasty interventions, including coronary artery bypass surgery and cardiac pacemaker implantation, in patients with dialysis-induced CRS.

Plasma fibrinogen as a predictor of residual renal function in patients undergoing peritoneal dialysis

Background： Inflammatory markers are powerful predictors of prognosis in patients undergoing peritoneal dialysis (PD). Plasma fibrinogen (FIB), an inflammatory marker, is considered an independent predictor of cardiovascular events and mortality in PD patients. However, little is known about the association between FIB and residual renal function (RRF) in PD patients. Material/Methods: We reviewed the clinical data of patients who started PD between January 2012 and December 2020 at the First Affiliated Hospital of Wenzhou Medical University. This study covered 472 patients in total. Residual renal function (RRF) was determined by a 24-hour urine collection and calculated from the average of creatinine and urea clearance. Clinical and biochemical data at the initiation of peritoneal dialysis was collected as baseline data. Results: The median follow-up duration was 31.55 (20.43-49.00) months. The RRF reduction rate was significantly greater in patients in the high-fibrinogen group (fibrinogen >4.0 g/L) compared with those in the control group (fibrinogen ≤4.0 g/L; 0.13 ± 0.15 mL/min/month/1.73m2 vs. 0.088 ± 0.10 mL/min/month/1.73m2; p<0.001). Using multiple linear regression analysis and adjusting for other risk factors, high FIB was an independent predictor of rapid RRF decline (P=0.033). The Cox proportional hazard model and the competing risk model revealed that an elevated plasma FIB level (HR=1.219, 95%CI 1.058-1.404; SHR=1.154, 95%CI 1.012-1.317) was independent factors for the progression to anuria. Conclusions: We demonstrated that a higher plasma fibrinogen level was significantly associated with a higher rate of RRF decline, and hyperfibrinogenemia was an independent risk factor for anuria in PD patients.

High-Salt Diet Accelerated the Decline of Residual Renal Function in Patients With Peritoneal Dialysis

Objective: This study aims to investigate the relationship between dietary salt intake and residual renal function in peritoneal dialysis (PD) patients.Methods: The daily salt intake of the patients was calculated based on a 3 day dietary record. Sixty-two patients were divided into three groups: 33 patients in the low salt intake group (salt intake &lt;6.0 g/day), 17 in the medium salt intake group (salt intake 6.0 to &lt;8.0 g/day), and 12 in the high salt intake group (salt intake ≥8.0 g/day). Regular follow-up was conducted every 3 months. Urine volume, peritoneal ultrafiltration volume, and other clinical indicators were recorded. Biochemical indexes were detected to evaluate the changes in residual renal function and peritoneal function during follow-up.Results: A positive correlation between dietary sodium intake and sodium excretion was found. During 12-month follow-up, a decrease of residual renal function showed a significant difference among the three groups (p = 0.041) (15.3 ± 27.5 vs. 12.5 ± 11.5 vs. 32.9 ± 18.4 L/W/1.73 m2 in the low-, medium-, and high salt intake groups, respectively). Consistently, a higher decline of residual renal function (adjusted β, 20.37; 95% CI, 2.83, 37.91) was found in participants with high salt intake (salt intake ≥8 g/day) compared with those in non-high salt intake.Conclusion: Our study showed that the sodium excretion by peritoneal dialysis was positively correlated with dietary sodium intake in PD patients. The high salt intake diet (salt intake ≥8 g/day) may lead to a faster decline of residual renal function in PD patients.

Effects of Roxadustat on the Anemia and Iron Metabolism of Patients Undergoing Peritoneal Dialysis

Background: We investigated the effects of roxadustat on the anemia, iron metabolism, peritoneal membrane function, and residual renal function; and determined the factors associated with the administration of roxadustat in patients who were undergoing peritoneal dialysis.Methods: We retrospectively analyzed the changes in hemoglobin, serum ferritin, transferrin saturation (TSAT), 4-h dialysate/plasma creatinine, and renal weekly urea clearance over the 24 weeks following the change from an erythropoiesis-stimulating agent (ESA) to roxadustat in 16 patients who were undergoing peritoneal dialysis and had anemia (Roxadustat group). Twenty-three peritoneal dialysis patients who had anemia and continued ESA served as a control group (ESA group).Results: There were no significant differences in hemoglobin, serum ferritin, TSAT, 4-h dialysate/plasma creatinine, or renal weekly urea clearance between the two groups at baseline. The hemoglobin concentration was significantly higher in the Roxadustat group than in the ESA group after 24 weeks (11.6 ± 1.0 g/dL vs. 10.3 ± 1.1 g/dL, p &lt; 0.05), whereas the ferritin concentration and TSAT were significantly lower (139.5 ± 102.0 ng/mL vs. 209.2 ± 113.1 ng/mL, p &lt; 0.05; and 28.1 ± 11.5% vs. 44.8 ± 10.4%, p &lt; 0.05, respectively). The changes in 4-h dialysate/plasma creatinine and renal weekly urea clearance did not differ between the two groups. Linear regression analysis revealed that the serum potassium concentration correlated with the dose of roxadustat at 24 weeks (standard coefficient = 0.580, p = 0.019).Conclusion: Roxadustat may improve the anemia and reduce the serum ferritin and TSAT of the peritoneal dialysis patients after they were switched from an ESA, without association with peritoneal membrane function or residual renal function.

MANEJO Y SEGUIMIENTO CLÍNICO DE PACIENTE CON SINDROME DE ALPORT FASE IV

Introduction Alport syndrome (AS) is a hereditary disease of the basement membranes caused by mutations in type IV collagen. This disease is characterized by the presence of progressive hereditary nephropathy associated with sensory deafness, as well as ocular lesions. AS has an incidence of 1 in every 50,000 live births, constituting 1 to 2% of the cause of chronic kidney disease (CKD) in Europe and 3% of CKD in the American pediatric population; it is considered to be the cause of terminal uremia in 0.6 to 4.6% of terminal patients in the United States and Europe. At the moment there is no casuistry in this regard in Ecuador. At present there is no specific treatment for Alport Syndrome, however the drugs Angiotensin Converting Enzyme Inhibitors (ACEI) and angiotensin II receptor antagonists (ARBs) have demonstrated efficacy and safety over blocking the system. renin angiotensin aldosterone, thus reducing the presence of proteinuria and slowing the deterioration of CKD. Case description A 28-year-old male patient with a personal history of HT and 6-member SA relatives: 2 nephews, 1 brother and 3 carrier nieces. The physical examination revealed the presence of moderate bilateral hearing loss. He presents kidney disease from the age of 10 without adequate control. Alport Syndrome was diagnosed in 2012 by means of a renal biopsy, evidence of hematuria and by family history. He is currently receiving Hemodialysis treatment in a daily short session modality, which consists of 5 weekly sessions from Monday to Friday of 2 hours each; he is kept under hypotensive treatment of 10mg QD of Amlodipine (Calcium Channel Blocker), and 10mg BID of Carvedilol (Beta Blocker), together with 12.5mg BID of Losartan (Angiotensin II Receptor Antagonist), The patient was followed up throughout the year 2020 until January 2021, calculating the Glomerular Filtration Rate month by month to be able to show whether there is a significant progressive deterioration of his residual kidney function. Conclusion It is mentioned that the residual renal function has not been affected thanks to the control of the Arterial Hypertension of the patient where an ARA II drug (Losartan) is added, which slows the progressive renal deterioration that is typical of Alport Syndrome. The incorporation of the patient to the modality of daily short session of hemodialysis has helped to have a compensation of the renal function, obtaining a continuous clearance, resembling the function of a healthy kidney as closely as possible. In order for a hemodialysis treatment to have better results compensating for residual renal function, consecutive and longer sessions should be established, however this is a complicated issue depending on the availability of time and tolerance of the patient.

Efficacy and safety of furosemide for prevention of intradialytic hypotension in haemodialysis patients: protocol for a multicentre randomised controlled trial

IntroductionIntradialytic hypotension (IDH) is a frequent and serious complication of maintaining haemodialysis (HD) patients and associated with subsequent cardiovascular events and higher mortality. Furosemide is commonly used in non-dialysis chronic kidney disease patients and can effectively manage the volume and blood pressure. However, these agents are often discontinued on initiation of dialysis. Two large observational studies have demonstrated that furosemide can lower the rate of IDH episodes. However, there is still no randomised controlled trial (RCT) to investigate the efficacy and safety of furosemide for prevention of IDH in HD patients. The purpose of this study was to assess the efficacy of furosemide in reducing IDH in HD patients with residual renal function.Methods and analysisA two-arm, parallel, multicente RCT will be conducted at 12 hospitals in China. An estimated sample of 560 HD patients will be recruited. Eligible patients will be randomly assigned to treatment group (patients receive oral furosemide 80 mg/day; after a 2-week treatment, if their urine volume is less than 400 mL/day, the dose of furosemide is adjusted to 160 mg/day) and blank control group via a central randomisation system using 1:1 ratio. The primary outcome is the occurrence of IDH. Outcome assessors and data analysts will be blinded and participants will be asked not to reveal their allocation to assessors. The outcome analyses will be performed both on the intention-to-treat, which includes all patients randomised, and per-protocol population, which includes eligible patients who adhere to the planned treatment and follow-ups.Ethics and disseminationThe trial protocol has been approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (2019.385)Results will be presented at national and international conferences and published in peer-reviewed journals.Trial registration numberChiCTR2000039724.

Association of Urinary Dickkopf-3 with Residual Renal Function Decline in Patients Undergoing Peritoneal Dialysis

Background and Objectives: Urinary levels of dickkopf-3 (DKK-3) are associated with poor renal survival in patients with non-dialytic chronic kidney disease. However, it remains unknown whether urinary DKK-3 levels can predict residual renal function (RRF) decline in patients undergoing peritoneal dialysis (PD). Therefore, we investigated the correlation between urinary levels of DKK-3 and the subsequent rate of RRF decline in PD patients. Materials and Methods: This study included 36 PD patients who underwent multiple peritoneal equivalent tests during 2011–2021. The relationship between baseline clinical characteristics and the subsequent annual rate of Kt/V decline was investigated. Results: The annual rate of renal Kt/V decline was 0.29 (range: 0.05–0.48), which correlated with renal Kt/V (r = 0.55, p = 0.0005) and 24 h urinary DKK-3 excretion (r = 0.61, p < 0.0001). Similarly, 24 h urinary DKK-3 excretion (β = 0.44, p = 0.0015) and renal Kt/V (β = 0.38, p = 0.0059) were independently associated with the annual rate of renal Kt/V decline in multivariate analyses. Conclusions: Urinary DKK-3 assessment may help identify PD patients at a high risk of RRF decline.