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Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach.
Piccoli, GB, Lippi, F, Fois, A, Gendrot, L, Nielsen, L, Vigreux, J, Chatrenet, A, D'Alessandro, C, Cabiddu, G, Cupisti, A
Nutrients. 2020;(3)
Abstract
Dialysis and nutrition are two sides of the same coin-dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.
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2.
SGLT2 inhibitors and the kidney: Effects and mechanisms.
Tsimihodimos, V, Filippatos, TD, Elisaf, MS
Diabetes & metabolic syndrome. 2018;(6):1117-1123
Abstract
AIMS: Numerous clinical trials have shown that sodium glucose cotransporter 2 (SGLT2) inhibitors exert a favorable effect on the indices of renal function (albuminuria, glomerular filtration rate decline over time) and the incidence of hard renal endpoints such as renal death or time to initiation of renal replacement therapy. MATERIALS AND METHODS In this review, we describe in detail the evidence regarding the nephroprotective mechanisms of SGLT2 inhibitors and describe the risk factors that may predispose to the development of acute kidney injury in patients receiving these drugs. RESULTS Although the impact of these drugs on renal hemodynamics seems to represent the most important renoprotective mechanism of action, many other effects of these compounds, including beneficial effects on metabolism and blood pressure, have been proposed to contribute to the observed clinical benefit. CONCLUSIONS SGLT2 inhibitors clearly act beneficially in terms of kidney function with many proposed mechanisms.
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3.
Novel therapeutic agents and strategies for the management of chronic kidney disease mineral and bone disorder.
Connor, A
Postgraduate medical journal. 2009;(1003):274-9
Abstract
Abnormalities in the serum concentrations of calcium, phosphate, parathyroid hormone and vitamin D develop with declining renal function, leading in turn to renal osteodystrophy. Observational data now suggest that these disturbances in bone and mineral metabolism play an important role in the development of vascular calcification and subsequent cardiovascular disease, contributing to the high burden of cardiovascular disease within this population. A new nomenclature-"chronic kidney disease mineral and bone disorder"-has been introduced to describe this broader clinical syndrome and reflect the new emphasis that has been placed upon its management. This article describes the current therapeutic options for this condition, focusing particularly on the novel medications and strategies that have recently been introduced, and highlighting promising therapeutic possibilities for the future.
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4.
Dyslipidaemia and cardiorenal disease: mechanisms, therapeutic opportunities and clinical trials.
Chan, DT, Irish, AB, Dogra, GK, Watts, GF
Atherosclerosis. 2008;(2):823-34
Abstract
Dyslipidaemia is an important risk factor for the development of chronic kidney disease (CKD) and cardiovascular disease (CVD). CKD generates an atherogenic lipid profile, characterised by high triglycerides, low high-density lipoprotein (HDL) cholesterol and accumulation of small dense low-density lipoprotein (LDL) particles, comparable to that in the metabolic syndrome. These changes are due specifically to the effects of CKD on key enzymes, transfer proteins and receptors involved in lipid metabolism. Dyslipidaemia is further compounded by dialysis, immunosuppressive drugs, and concomitant diseases such as diabetes mellitus. Post hoc analyses from large intervention trials suggest the benefit of statins in patients with early CKD, but prospective clinical trials in haemodialysis (HD) and renal transplant recipients have not conclusively shown improvements in hard cardiovascular end-points. The lack of efficacy of statins in late-stage CKD could be a consequence of other disease processes, such as calcific arteriopathy and insulin resistance, which are not modified by lipid-lowering agents. Despite uncertainty and pending the results of ongoing statin trials such as Study of Heart and Renal Protection (SHARP) and AURORA (A study to evaluate the Use of Rosuvastatin in subjects On Regular haemodialysis: an Assessment of survival and cardiovascular events), major international guidelines continue to support statin therapy in CKD and renal transplant patients to reduce cardiovascular risk burden. Because of increased risk of toxicity, particularly myopathy, statins and other lipid-regulating agents should be used cautiously in CKD and renal transplant recipients.
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5.
[Chronic renal disease as cardiovascular risk factor].
Hermans, MM, Kooman, JP, Stehouwer, CD
Nederlands tijdschrift voor geneeskunde. 2008;(29):1614-8
Abstract
A lowering of the glomerular filtration rate (GFR) and/or the presence of albuminuria are signs of chronic renal disease. Both variables are for the most part independently associated with an increased risk of cardiovascular morbidity and mortality. Albuminuria is a marker of endothelial dysfunction. A decrease of the GFR is associated with non-traditional risk factors, e.g. renal anaemia, uraemic toxins due to a decrease of the renal clearance, hyperhomocysteinaemia caused by a diminished homocysteine metabolism, excessive activation of the sympathetic nervous system which is related to sleep apnoea syndrome, oxidative stress and dyslipidaemia associated with the formation of vasotoxic, oxidised LDL cholesterol. These non-traditional risk factors may, alone or in combination with traditional atherogenic risk factors (e.g. age, male gender, smoking, hypercholesterolaemia, hypertension, obesity, positive family history and diabetes mellitus), partially via endothelial dysfunction, result in harmful effects on arterial function, increasing cardiovascular morbidity and mortality. Different stages of chronic kidney disease are associated with specific risk factors, making a specific therapeutic approach essential.
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6.
[Education of diabetic patients with chronic kidney disease and after transplantation].
Jirkovská, A
Vnitrni lekarstvi. 2008;(5):530-4
Abstract
Despite recent advances in the management of diabetes, diabetic nephropathy is the most frequent cause ofend-stage renal disease. Even when diabetic nephropathy is established, patient's care should be optimized to delay progression of nephropathy or other diabetic complications. Evidence exists for the effectiveness of diet intervention, blood pressure and diabetes control and treatment of metabolic syndrome. We emphasize the need for closer co-operation not only between diabetologists, primary care physicians and nephrologists, but with educated diabetic patients, too. At referral to nephrologist, many patients' care is suboptimal and referral is too late. The most important education information for patients is to stick to diet and keep adequate blood pressure and diabetes control with self-monitoring. Effectiveness of each of these recommendations is critically assessed. Patients after kidney or combined kidney and pancreas transplantation have to be educated mainly in symptoms of rejection and diabetic foot care. They are recommended to take regularly the prescribed medicines, to distinguish the adverse events of immunosuppression and keep all doctor's appointments.
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7.
[Vitamin D deficiency in CKD patients].
Hamano, T
Clinical calcium. 2007;(5):718-24
Abstract
It is well known that vitamin D deficiency and associated elevation of parathyroid hormone (PTH) are common in general population. This fact also applies to chronic kidney disease (CKD) patients. The risk factors for 25-hydroxyvitamin D [25 (OH) D] deficiency are malnutrition, nephrotic syndrome, and low sunlight exposure. Low serum 25 (OH) D leads to low calcitriol level in CKD patients, because compensative elevation in PTH cannot activate 1-alpha hydroxylase in proximal tubules efficiently due to reduced viable nephron numbers and elevated fibroblast growth factor-23 (FGF-23) . Given that vitamin D is associated with renin-angiotensin-aldosterone system and insulin resistance, intervention on vitamin D metabolism in CKD patients may have impact on clinical outcomes besides bone metabolism.
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8.
Calcium channel blockers and renal protection: insights from the latest clinical trials.
Segura, J, García-Donaire, JA, Ruilope, LM
Journal of the American Society of Nephrology : JASN. 2005;:S64-6
Abstract
Calcium channel blockers have been widely used in clinical practice because of their antihypertensive capacity. Prevention of renal damage is a very important aim of antihypertensive therapy. This is particularly so taking into account the high prevalence of chronic kidney disease (CKD) in the general population. Recent data have shown that CKD is related to the absence of adequate BP control and also to the clustering of other cardiovascular risk factors seen in the metabolic syndrome. The knowledge of the capacities of the different antihypertensive drugs or their combinations to simultaneously control BP while protecting the kidney and avoiding the facilitation of metabolic alterations is warranted. Recent data from the Intervention as a Goal in Hypertension Treatment trial, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, and African American Study of Kidney Disease and Hypertension (AASK) allow the conclusion that in hypertensive patients with preserved renal function or with CKD, calcium channel blockers are effective antihypertensive drugs to be considered alone or in combination with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker.
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9.
[Clinical dialysis: new problems and new prospects].
Locatelli, F, Manzoni, C, Pozzoni, P, Pontoriero, G, Di Filippo, L
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia. 2004;(2):156-64
Abstract
The main problem nephrologists have to face today is the very high patient morbidity and mortality. A number of traditional and non-traditional risk factors have a role; among these anaemia, hypertension, dislipidemia, abnormalities in calcium-phosphate metabolism, hyperhomocysteinemia and endothelial dysfunction. An important innovation in the field of hemodialysis has been the availability of high-permeable and high-flux membranes, characterized by a high biocompatibility and ultrafiltration coefficient. The development of automatic systems to control ultrafiltration has enabled the utilisation of these membranes in the clinical setting (high-flux hemodialysis, hemofiltration, hemodiafiltration). It is common opinion that high-flux membranes can positively influence cardiovascular instability, but this has not been confirmed by clinical trials. Although preliminary data indicated a favorable effect on the correction of anemia in patients treated with high-permeable membranes, randomized trials have not shown a significant effect. Better control of anemia could be possible by means of on-line treatments, given their higher removal of medium- and large molecules and reduced microbiological and pyrogenic contamination of the dialysate. A number of analyses showed a lower incidence of bone cysts and/or carpal tunnel syndrome in patients treated with high-flux membranes compared to low-flux ones. High-flux treatments could reduce morbidity and mortality in hemodialysis patients. However, despite its large sample size, the HEMO Study has not been capable of showing a statistically significant effect of higher dialysis dose and high-flux membranes on survival and morbidity. The MPO study has been expressively designed to do a prospective evaluation of the long-term effect of membrane permeability on clinical outcomes. These results are greatly awaited.
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10.
[The calciphylaxis syndrome as a complication of chronic kidney failure. 6 case reports and literature review].
Válek, M, Sulková, S, Schestauberová, E, Svára, F, Mann, H, Polakovic, V
Casopis lekaru ceskych. 2002;(11):355-8
Abstract
Calciphylaxis is a rate complication of unknown pathogenesis in patients with end stage renal disease. It is characterized by calcification of tunica media of small arteries associated with intimal fibrosis and thrombus formation which leads to the development of skin and subcutaneous tissue necrosis. Superinfection of skin lesions is a common consequence of this syndrome which may lead to the sepsis. The prognosis of this condition in serious. We performed a retrospective study of 6 subjects (4 men and 2 women) in the age of 35 to 59 years. We followed the parameters of calcium-phosphate metabolism, presence of calciphylaxis risk factors and the effect of parathyreoidectomy. Five patients were on hemodialysis, one had a kidney transplant. Skin and subcutaneous tissue necrosis were present in all subjects. The serum levels of parathormone were either high, normal or low, levels of calcium were normal or slightly elevated and phosphate levels were high or normal. Calcium was substituted before calciphylaxis development in 5 patients, calcitriole in 3 of therm. Five patients underwent parathyroidectomy. Three patients died (all of sepsis), one patient had the lower into amputation for infected lesions and the remaining two achieved regression. Our findings do support the hypothesis that calcium and calcitriole administration participates in development of calciphylaxis. Fatal prognosis of the once infections skin lesions was also proved.