Clinical Kidney Journal最新文献

Indications for peritoneal dialysis (PD) have undergone a paradigm shift in recent years. Medical barriers previously viewed as contraindications for PD such as anuria, autosomal dominant polycystic kidney disease, cardiovascular diseases or advanced age are increasingly re-examined. We learned that establishing a safe, functional and durable catheter access can be established even in patients with a variety of co-morbidities. Moreover, conditions that predispose to catheter-related infections and peritonitis are not as obvious as we thought. In this case-based review we present patients who have been performing PD for a long time and in whom PD might still be viewed unfeasible. The aim of the paper is to underline the importance of PD as a kidney replacement therapy with fewer medical limits than previously thought. It is also a plaidoyer for interdisciplinary and interprofessional collaboration. This 'Mission PD-possible' should be accompanied by a coordinated approach aligning policy, organizational structures and financial resources.

Background: Non-anaemic iron deficiency is highly prevalent in people living with chronic kidney disease (CKD) but is underdiagnosed and undertreated, especially in earlier stages of CKD. A multicentre trial assessing the effect of intravenous iron supplementation in iron-deficiency but not anaemic people with CKD included a qualitative sub-study that aimed to explore the patient experience and psychosocial impact of living with CKD and iron deficiency, and the experience of the therapeutic intervention (intravenous iron and exercise).

Methods: Semi-structured interviews were conducted with 23 trial participants blinded to treatment. Topics explored included experiences of living with CKD and iron deficiency, symptoms, social and leisure activities, quality of life, and participants' views and experiences of receiving the therapeutic intervention. Thematic analysis was used to identify and report themes.

Results: Six overarching themes were identified: lack of awareness of iron deficiency; overwhelming feelings of tiredness; feeling limited; balancing emotions; perceptions and experiences of therapeutic treatment received; and impact of trial participation on life participation. Trial participation, specifically the exercise training, was perceived to be beneficial, with improvements in life participation and psychological wellbeing experienced. However, there were no clear differences between treatment groups, with mixed perceptions about which therapeutic treatment was received.

Conclusions: The impact of tiredness on individuals with CKD is profound and can result in reduced vitality, impaired ability to engage in life activities and emotional conflict. Improved communication and support about psychosocial impact and management of symptoms, particularly fatigue, for people with CKD may be required, alongside effective therapeutic interventions, to improve symptom management and quality of life.

Acute kidney injury (AKI) is a common complication in critically ill and perioperative patients and is associated with mortality, morbidity, medical costs, and progression to chronic kidney function. Unfortunately, despite numerous research efforts, until recently, there was no AKI preventive therapy supported by level 1 evidence. Among the several factors that contribute to renal damage, two of the major triggers of AKI development are renal hypoperfusion and renal medullary hypoxia. The intravenous administration of a mixture of amino acids promotes the prevention of AKI through multiple mechanisms: the recruitment of renal functional reserve, increased renal blood flow, and improvements in renal oxygenation. Such mechanisms of action led to increased glomerular filtration rate and urine output in preclinical and pilot clinical studies. To test if these benefits on physiological parameters could be translated into clinically meaningful outcomes, a multicenter, randomized, placebo-controlled, trial was conducted in the cardiac surgery setting. Among 3511 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass, intravenous amino acid administration, compared to placebo, significantly reduced the occurrence of AKI, providing the first level 1 evidence of an effective treatment for AKI prevention. In this review, we provide the epidemiology and pathophysiology of cardiac surgery-associated AKI and the concept of renal functional reserve. Then, we summarize the underlying mechanisms of intravenous amino acid infusion as a renoprotective strategy and its preclinical and clinical evidence. Finally, we discuss the existing evidence gaps and future directions of this promising intervention.

Background: Few contemporary studies have investigated the changes in quality of life across dialysis modalities. Our aim was to compare longitudinal changes in health-related physical and mental quality of life between patients on institutional hemodialysis (IHD), peritoneal dialysis (PD) and home hemodialysis (HHD).

Methods: Patients on dialysis with registered Research and Development 36 (RAND-36) questionnaires between 2017-2021 in the Swedish Renal Registry (SRR) were eligible for inclusion. Information on dialysis, patient characteristics and medication were collected from SRR and other registries. Patients were followed up to 39 months. Changes in physical (PCS) and mental (MCS) component summary scores were analyzed in adjusted linear mixed models and joint models.

Results: We included 930 patients (IHD 714, PD 128, HHD 88) with a median follow-up of 1.8 years (interquartile range 1.0-2.1). At baseline, the mean unadjusted PCS was lower in IHD (30.7; 95% CI 29.9, 31.4) compared with HHD (35.3; 95% CI 33.0, 37.5) and PD (33.2; 95% CI 31.3, 35.1). PCS declined over time in all modalities, but faster for PD compared with IHD (-1.2; 95% CI -2.1, -0.3 per year) and HHD (-1.5, 95% CI -2.9, -0.04). MCS was similar at baseline. HHD had improving MCS trajectory compared to IHD (-1.5, 95% CI -2.8, 0.2) and PD (-2.3, 95% CI -3.9, 0.7), largely resulting from improvement in role limitations caused by mental health (6.2, 95% CI 0.9, 11.5).

Conclusion: Insights about the variation in quality-of-life trajectories for different dialysis modalities are important for patients to make informed choices.

Background: The burden of chronic kidney disease is increasing, driven by population aging and the increase in risk factors. In-centre haemodialysis (HD), which accounts for most of the environmental impact of kidney replacement therapy, is a power-hungry, water-hungry and a waste-generating intervention.

Methods: Here we characterize the environmental impact of 20 HD centres over 5 years and its modulation by operational changes (centre size, opening days, geographic location, type of water treatment plant and disinfection, dialysis modalities such as HD versus haemodiafiltration, seasonal variations and the impact of various corrective actions throughout time).

Results: Average water and energy consumption per session were lower in larger centres compared with smaller ones, as well as in centres that operated daily compared with those that opened three times a week (both P < .05). Seasonality, which depends on the geographic region, had a marked influence (P < .001) on water and energy consumption, as does the choice of water treatment plant (P < .001). Actions taken in certain centres significantly reduced energy consumption up to 30%, plastic waste up to 65% and hazardous waste up to 63%.

Conclusion: Annual monitoring must be performed to detect variations and plans must be designed to reduce the environmental impact. As it is not possible to reduce HD water and energy consumption to zero, implementing targeted actions offers a promising strategy for reducing the environmental burden.

We report a case of acute interstitial nephritis (AIN) in a 68-year-old male with squamous cell carcinoma (SCC) and relapsed/refractory multiple myeloma (RRMM) who developed acute kidney injury (AKI) shortly after starting teclistamab for RRMM. Despite stable renal function on immune checkpoint inhibitor (ICI) therapy for SCC, proton pump inhibitors and trimethoprim-sulfamethoxazole for 3 years, AKI only occurred post-teclistamab initiation. Biopsy-confirmed AIN with serum creatinine improved only after pulse-dose steroids. This case highlights a potential synergistic nephrotoxic effect of teclistamab and ICIs, warranting further investigation into teclistamab's renal safety.

Background: Cancer is a leading cause of death among patients on hemodialysis; however, the data on its diagnosis, treatment and prognosis are limited. Here we analyzed the surgical practice patterns and outcomes of patients on hemodialysis with cancer and compared them with those of general cancer patients from the National Cancer Center database.

Methods: This nationwide registry enrolled hemodialysis patients who were subsequently diagnosed with primary cancers of the kidney, colorectum, stomach, lung, liver, bladder, pancreas and breast in 20 hospitals in Japan between 2010 and 2012. The primary endpoint was the overall 3-year survival rate. We also examined the association of factors with mortality using Cox regression analysis.

Results: Of the 502 patients, 370 (74%) underwent surgery. More than half of the patients (57%) were asymptomatic at diagnosis and diagnosed with cancer through screening. Among the patients who underwent surgery, most (99%) had resectable cancers; while among those who did not undergo surgery, more than half (52%) had metastatic cancers. The 3-year overall survival in the surgery and non-surgery groups was 83% and 32%, respectively. Non-cancer-related deaths were dominant (80%) in the surgery group, whereas cancer-related deaths were dominant in the non-surgery group (70%). Pancreatic cancer and anemia were associated with a poor prognosis in the surgery group. Surgery and 3-year overall survival rates were comparable between the patients on hemodialysis and the general cancer patients.

Conclusion: Prognosis in hemodialysis cancer patients might be equivalent to that of general cancer patients.

Background: Intradialytic hypertension (IDH) is associated with an increase in hospitalization and mortality. Several studies have shown that spironolactone reduces pre-dialysis blood pressure. However, none evaluated its effect on IDH. This study aims to evaluate the effects of spironolactone on IDH.

Methods: A 24-week, two-treatment, four-period, multicentre, double-blind, randomized, crossover study was conducted in stable maintenance haemodialysis (HD) patients who experienced IDH in >30% of their sessions during the past 3 months. Each participant was randomly assigned to one of four treatment sequences. In each intervention period, patients received a single dose of 50 mg spironolactone or a placebo 30 minutes before undergoing HD for 4 weeks according to their preassigned sequence, separated by a 2-week washout period. The primary outcome was an incidence of IDH.

Results: A total of 49 eligible patients were recruited with a total of 1211 dialysis sessions. The mean age was 54 ± 14 years and the mean systolic and diastolic blood pressures (SBP and DBP) were 145 ± 15 and 75 ± 10 mmHg, respectively. All patients had hypertension. The average number of antihypertensive drugs was 3.5 ± 1.4. Spironolactone reduced the incidence of IDH compared with placebo (57% versus 69%, P for treatment effect < .001). Patients receiving spironolactone had lower peak intradialytic SBP (161 ± 14 versus 165 ± 13 mmHg, P = .003), mean intradialytic SBP (149 ± 13 versus 152 ± 12 mmHg, P = .01) and post-dialysis SBP (152 ± 15 versus 157 ± 14 mmHg, P < .001) than placebo.

Conclusion: In maintenance HD patients who had frequent IDH, a pre-dialysis 50-mg spironolactone administration significantly decreased the incidence of IDH.

Trial registration: Thai Clinical Trial Registry, reference number TCTR20200604013.