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1.
Sodium and water handling during hemodialysis: new pathophysiologic insights and management approaches for improving outcomes in end-stage kidney disease.
Canaud, B, Kooman, J, Selby, NM, Taal, M, Francis, S, Kopperschmidt, P, Maierhofer, A, Kotanko, P, Titze, J
Kidney international. 2019;(2):296-309
Abstract
Space medicine and new technology such as magnetic resonance imaging of tissue sodium stores (23NaMRI) have changed our understanding of human sodium homeostasis and pathophysiology. It has become evident that body sodium comprises 3 main components. Two compartments have been traditionally recognized, namely one that is circulating and systemically active via its osmotic action, and one slowly exchangeable pool located in the bones. The third, recently described pool represents sodium stored in skin and muscle interstitium, and it is implicated in cell and biologic activities via local hypertonicity and sodium clearance mechanisms. This in-depth review provides a comprehensive view on the pathophysiology and existing knowledge gaps of systemic hemodynamic and tissue sodium accumulation in dialysis patients. Furthermore, we discuss how the combination of novel technologies to quantitate tissue salt accumulation (e.g., 23NaMRI) with devices to facilitate the precise attainment of a prescribed hemodialytic sodium mass balance (e.g., sodium and water balancing modules) will improve our therapeutic approach to sodium management in dialysis patients. While prospective studies are required, we think that these new diagnostic and sodium balancing tools will enhance our ability to pursue more personalized therapeutic interventions on sodium and water management, with the eventual goal of improving dialysis patient outcomes.
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2.
[Dialysis monitoring: peritoneal equilibrium test, regional citrate anticoagulation and residual renal function].
Bargnoux, AS, Barguil, Y, Zaoui, E, Jean, G, Cristol, JP
Annales de biologie clinique. 2019;(4):391-396
Abstract
The SFBC working group aimed to deal with biological tests outside the French nomenclature that may be useful for the follow-up of dialysis patients. Our discussion was divided into 3 parts: 1) evaluation of peritoneal membrane characteristics; 2) monitoring of renal replacement therapy using regional citrate anticoagulation; 3) estimation of residual renal function (RRF). International recommendations underline the importance of assessing peritoneal membrane characteristics for peritoneal dialysis prescription. This peritoneal equilibrium test requires the measurement in dialysate of the following parameters: glucose, urea, creatinine and sodium. As part of the monitoring of continuous renal replacement therapy using regional citrate anticoagulation, the determination of ionized calcium assay is essential according to national and international guidelines to ensure a balance between effective anticoagulation and appropriate calcium levels. Finally, the RRF plays a key role in the dialysis adequacy and patient survival. European and international recommendations highlight the potential interest of RRF in peritoneal dialysis and hemodialysis. The RRF corresponds to the mean of urinary urea and creatinine clearance, assessed from a urine collection with measurement of urinary urea.
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3.
Benefit-risk balance of native vitamin D supplementation in chronic hemodialysis: what can we learn from the major clinical trials and international guidelines?
Bentata, Y
Renal failure. 2019;(1):607-615
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Abstract
For some years, there has been a great renewal of interest in native vitamin D and its major involvement in osseous and non-osseous effects in the organism. Patients in chronic hemodialysis (CHD) constitute a specific population with different physiopathologic characteristics and needs, since morbidity and mortality are strongly correlated with vitamin D insufficiency. Vitamin D supplementation raises very pertinent questions for which we have only partial answers and we lack solid scientific proof to establish certain truths. Thus, we try through this mini-review to analyze the results of the main randomized clinical trials conducted during the last decade, and to discuss international guidelines concerning native vitamin D supplementation in CHD patients. Seven double-blind randomized clinical trials have evaluated native Vitamin D supplementation in CHD patients. These clinical trials began between 2007 and 2013 and studied relatively small samples of patients with an average of 50. All of these trials are important, but do not provide sufficient scientific proof concerning the advantages, consequences, and secondary effects of native vitamin D supplementation in CHD. None of the European, American, English, Asian, Australian, or Canadian recommendations have specified the targets, doses, duration, or the molecule of vitamin D supplementation in the patient on CHD. In 2017, the long-awaited KDIGO recommendations were published and despite the results of clinical trials conducted, the recommendations on native vitamin D supplementation in CHD were very imprecise and sparse, limited to suggesting correction of any state of vitamin D insufficiency or deficiency.
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4.
[The different modalities of isonatric hemodialysis].
Petitclerc, T, Gaillard, F
Nephrologie & therapeutique. 2019;(1):22-28
Abstract
Setting dialysate sodium allows to adequately adjust sodium balance and plasma sodium at the end of dialysis session. In accordance with the set-point theory based on the concept of restoring cellular hydration, an adequate target for plasma sodium at the end of the session could be the value of predialysis plasma sodium concentration (isonatric hemodialysis). Some recently available dialysis monitors provide an on-line value of plasma-water conductivity usually converted in on-line natremia. There are different modalities of isonatric hemodialysis depending on whether the online value of natremia is used or not. By reviewing the few studies concerning the isonatric hemodialysis, it seems logical to set a target of postdialysis on-line natremia (or plasma-water conductivity) slightly lower than its predialysis value. However this strategy requires specifically designed software not yet available in clinical routine.
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5.
Malnutrition-Wasting Conditions in Older Dialysis Patients: An Individualized Approach.
Hanafusa, N, Tsuchiya, K, Nitta, K
Contributions to nephrology. 2019;:12-20
Abstract
BACKGROUND The dialysis population is growing and aging worldwide. The aging dialysis population exhibits specific conditions, including sarcopenia, protein-energy wasting, and frailty, that are associated with worse outcomes. Thus, strategies to address these conditions are indispensable to improving prognosis, quality of life, and ability to perform activities of daily living in older patients. SUMMARY Several strategies have been employed to manage these conditions. The two major approaches are nutritional therapy and exercise training. These correlate strongly with each other and each is necessary to maintain the health of patients. Ensuring adequate protein and energy intake is the mainstay of nutritional therapy. However, older dialysis patients often have reduced appetite, and appropriate nutritional therapy can enhance appetite. Conversely, nutritional therapy without an appropriate exercise training system will fail to enhance physical function. Thus, the focus of attention has been on exercise training both during dialysis treatment and while at home. The Japanese Society of Renal Rehabilitation has issued a guideline for exercise training in patients with kidney disease. It encourages using the time during dialysis treatment for performing both nutritional intake measures and exercise training. Nutritional care in dialysis patients has previously focused on restriction of dietary intake. However, patients with these malnutrition-wasting conditions should be encouraged to improve their dietary intake and physical activity. Older dialysis patients have heterogenic characteristics in terms of frailty, so their nutritional and exercise plans should be individualized. Key Messages: Individualized management should be used in the heterogeneous older dialysis population, with special considerations for malnutrition-wasting conditions.
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6.
Individualized Hemodialysis Treatment: A Perspective on Residual Kidney Function and Precision Medicine in Nephrology.
Hur, I, Lee, YK, Kalantar-Zadeh, K, Obi, Y
Cardiorenal medicine. 2019;(2):69-82
Abstract
BACKGROUND Residual kidney function (RKF) is often expected to inevitably and rapidly decline among hemodialysis patients and, hence, has been inadvertently ignored in clinical practice. The importance of RKF has been revisited in some recent studies. Given that patients with end-stage renal disease now tend to initiate maintenance hemodialysis therapy with higher RKF levels, there seem to be important opportunities for incremental hemo-dialysis by individualizing the dose and frequency according to their RKF levels. This approach is realigned with precision medicine and patient-centeredness. SUMMARY In this article, we first review the available methods to estimate RKF among hemodialysis patients. We then discuss the importance of maintaining and monitoring RKF levels based on a variety of clinical aspects, including volume overload, blood pressure control, mineral and bone metabolism, nutrition, and patient survival. We also review several potential measures to protect RKF: the use of high-flux and biocompatible membranes, the use of ultrapure dialysate, the incorporation of hemodiafiltration, incremental hemodialysis, and a low-protein diet, as well as general care such as avoiding nephrotoxic events, maintaining appropriate blood pressure, and better control of mineral and bone disorder parameters. Key Message: Individualized hemodialysis regimens may maintain RKF, lead to a better quality of life without compromising long-term survival, and ensure precision medicine and patient-centeredness in nephrology practice.
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Ethical Issues in Pragmatic Cluster-Randomized Trials in Dialysis Facilities.
Goldstein, CE, Weijer, C, Taljaard, M, Al-Jaishi, AA, Basile, E, Brehaut, J, Cook, CL, Grimshaw, JM, Lacson, E, Lindsay, C, et al
American journal of kidney diseases : the official journal of the National Kidney Foundation. 2019;(5):659-666
Abstract
A pragmatic cluster-randomized trial (CRT) is a research design that may be used to efficiently test promising interventions that directly inform dialysis care. While the Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials provides general ethical guidance for CRTs, the dialysis setting raises additional considerations. In this article, we outline ethical issues raised by pragmatic CRTs in dialysis facilities. These issues may be divided into 7 key domains: justifying the use of cluster randomization, adopting randomly allocated individual-level interventions as a facility standard of care, conducting benefit-harm analyses, gatekeepers and their responsibilities, obtaining informed consent from research participants, patient notification, and including vulnerable participants. We describe existing guidelines relevant to each domain, illustrate how they were considered in the Time to Reduce Mortality in End-Stage Renal Disease (TiME) trial (a prototypical pragmatic hemodialysis CRT), and highlight remaining areas of uncertainty. The following is the first step in an interdisciplinary mixed-methods research project to guide the design and conduct of pragmatic CRTs in dialysis facilities. Subsequent work will expand on these concepts and when possible, argue for a preferred solution.
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8.
Renal Complications Following Lung Transplantation and Heart Transplantation.
Puttarajappa, CM, Bernardo, JF, Kellum, JA
Critical care clinics. 2019;(1):61-73
Abstract
Renal complications are common following heart and/or lung transplantation and lead to increased morbidity and mortality. Renal dysfunction is also associated with increased mortality for patients on the transplant wait list. Dialysis dependence is a relative contraindication for heart or lung transplantation at most centers, and such patients are often listed for a simultaneous kidney transplant. Several factors contribute to the impaired renal function in patients undergoing heart and/or lung transplantation, including the interplay between cardiopulmonary and renal hemodynamics, complex perioperative issues, and exposure to nephrotoxic medications, mainly calcineurin inhibitors.
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Symptomatic Hyperglycemia in a Patient with Dialysis Ascites.
Vigil, D, Kien, C, Gibb, J, Glew, RH, Tzamaloukas, AH
The American journal of the medical sciences. 2019;(6):512-516
Abstract
An anuric woman with ascites rapidly developed extreme hyperglycemia and seizures after hemodialysis. During development of hyperglycemia, the decrease in serum sodium concentration (Δ[Na]) was nearly twice the value predicted by a formula accounting for the degree of hyperglycemia and the intracellular-to-extracellular volume ratio. The prediction assumed that ascitic fluid is part of the extracellular volume. Potential contributors to the development of seizures include the rapid development of severe hypertonicity, a remote history of seizure disorder and development of dialysis disequilibrium syndrome. Observations in peritoneal dialysis suggest that fluid with sodium concentration lower than in the ascitic fluid is transferred from the abdominal cavity into the blood during rapid development of hyperglycemia. In this case, Δ[Na], which determines the tonicity level expected after correction of hyperglycemia, resulted from exit of both intracellular and ascitic fluid into the extracellular compartment and, therefore, ascitic fluid functions as an extension of the intracellular fluid.
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10.
Ocular dialysis disequilibrium-Management of intraocular pressure during hemodialysis of open angle glaucoma: A case report and review of the literature.
Lippold, CL, Kalarn, SP, Swamy, RN, Patel, AM
Hemodialysis international. International Symposium on Home Hemodialysis. 2019;(3):E72-E77
Abstract
It has been shown that patients with end-stage renal disease (ESRD) have an increased risk for changes in intraocular pressure during hemodialysis, or ocular dialysis disequilibrium which can cause pain or discomfort during treatment and lead to decreased vision over time. This is a case of an elderly male with ESRD who was having headaches, nausea, and eye pain during hemodialysis due to increased intraocular pressures. Using a higher sodium prescription resolved his symptoms and normalized his intraocular pressures. This case illustrates that modification in dialysate tonicity can decrease changes in intraocular pressures while patients are on hemodialysis, a vision saving consideration for patients.