Contributions to nephrology最新文献

Peritoneal dialysis (PD) has undergone several improvements over the years. Among the numerous advances, we may recall the improvement in the quality of fluids, safety of catheters and connections, knowledge of the peritoneal membrane in the process of mass transfer separation typical of PD. In parallel with these achievements, PD techniques have also displayed significant improvements mainly due to the evolution of machines and cyclers. Originally, bottles or containers were used to deliver and drain fluid to and from the peritoneal cavity by gravity using manual techniques. Subsequently, the development of semiautomatic or automatic machines have permitted to deliver an adequate treatment during night-time without the need of patient or care giver intervention. These advances solved the problem of treatment delivery, but other aspects including complications and adherence to prescription could only be managed using magnetic cards containing data from different treatments and brought by the patient at the following routinely planned hospital consultation. Today these limitations have been overcome by the new cycler "HOMECHOICE CLARIA" equipped with SHARESOURCE software featuring a bidirectional communication protocol that allows a full remote patient management (RPM). RPM has demonstrated significant advantages including higher technique survival, reduced rate of complications, and reduced costs in patients undergoing long-term PD.

Remote patient management (RPM) has the potential to improve patient outcomes in home dialysis patients. Achieving this requires an operational plan that addresses data collection, RPM adoption, and plans for therapeutic interventions on abnormal results. The objective of this chapter is to discuss the key factors to be considered when setting up a RPM program, and in particular how a RPM program can be beneficial in the management of home dialysis patients. RPM is already being utilized in many other disease states to a greater extent than the home dialysis population (heart failure, COPD, diabetes) to improve clinical outcomes. The key components needed to set up a RPM program will be discussed in this chapter. Furthermore, literature regarding the potential benefits to the home dialysis population will be reviewed along with barriers to the adoption of technology.

The results of previous large clinical trials have revealed that low hemoglobin (Hb) levels are significantly associated with adverse events (cardiovascular disease, infection, hospitalization, and mortality) in patients with chronic kidney disease (CKD). However, in the general population, the mean Hb levels differ by sex and age. Furthermore, the comorbidities and activities of daily living of elderly patients are markedly different from those of nonelderly patients. CKD in elderly patients is accompanied by not only chronic inflammation, which is more severe than that in nonelderly patients, but also changes in the secretion of sex hormones with aging and decreases in erythropoiesis in the bone marrow. Thus, it is presumed that compared with nonelderly CKD patients, elderly CKD patients are hyporesponsive to erythropoiesis-stimulating agents (ESAs) and show the dysutilization of iron for erythropoiesis. However, in these patients, the target Hb levels and the appropriate doses of ESA and iron preparations are not indicated clearly. Recent clinical trials have reported that higher Hb levels, the same as those in nonelderly CKD patients, might not necessarily improve the quality of life or survival of elderly CKD patients. We have also revealed that hyporesponsiveness to ESAs and higher doses of intravenous iron affect the adverse events occurring in elderly patients undergoing maintenance hemodialysis compared with nonelderly CKD patients. Therefore, before the administration of ESAs and iron preparations to elderly CKD patients, the pathophysiological characteristics of these patients should be considered.

Background: The Japanese Society for Dialysis Therapy established 14 clinical practice guidelines (CPGs) for various fields of renal replacement therapy. About 10 years have passed since the previous peritoneal dialysis (PD) guidelines were established. We commenced the establishment of new PD guidelines in 2016. Recently, the methods for development of CPGs have changed dramatically.

Summary: The previous guidelines were described in a textbook-like format. However, these kinds of guidelines no longer meet the definition of CPGs as defined by the National Academy of Medicine in the USA, according to which "CPGs are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options." Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a systematic approach to rating the certainty of evidence in systematic reviews and other evidence syntheses. We have commenced the creation of new guidelines based on the same policy. The new guidelines are presented in 2 parts. Part 1 is described in a textbook-style format and includes 7 chapters, namely, Initiation of PD, Adequacy of PD, Adequate nutrition in PD patients, Evaluation of peritoneal membrane function, Discontinuation of PD for prevention of encapsulating peritoneal sclerosis, Management of peritonitis, and Management of the PD catheter and exit site. Part 2 comprises systematic reviews and recommendations on clinical questions (CQs) according to the GRADE system. Six CQs are included in Part 2: CQ1. Are renin-angiotensin inhibitors useful in the management of PD? CQ2. Is combination of icodextrin solution with glucose-based solution useful or not in the management of PD? CQ3. Is mupirocin or gentamicin ointment useful in the prevention of exit site infection? CQ4. Which method is more useful for the insertion of the PD catheter - open or laparoscopic surgery? CQ5. Intravenous or intraperitoneal administration, which route is more effective in the treatment of patients with PD-related peritonitis? CQ6. Which therapy is preferable for the management of diabetic end-stage renal failure, PD or HD? Key Messages: The new PD guidelines are under construction and will be completed by the beginning of 2019.

The SHARESOURCE platform was designed to transform how clinicians approach dialysis by empowering them to focus on improving clinical decision making for their patients. Sharesource supports remote patient management through secure communication with Baxter's AMIA, HOMECHOICE CLARIA and KAGUYA peritoneal dialysis cyclers. Sharesource organizes and presents the treatment data to the clinician in a timely manner for assessment, allowing the clinician to review the treatment results, assess the therapy, and evaluate patient status and compliance. If the clinician determines that a change to the patient's therapy is required, Sharesource provides the clinician the ability to act on that assessment by updating the patient's device settings that can be communicated to the cycler in time for the patient's next treatment.

The burden of chronic kidney disease is increasing globally. Novel methods for the management of end-stage kidney disease at home have been available for several years, however uptake of home peritoneal dialysis (PD) has been suboptimal for a variety of reasons. Non-adherence is an important factor that determines the outcomes of PD; patients on home dialysis are subject to feeling isolated and are anxious to lack of routine clinical oversight. When patients feel disconnected from their health care professionals, their compliance to medical advice drops and their confidence in self-care comes down. Remote patient management (RPM) has the potential to improve outcomes in PD through telehealth platforms that facilitate virtual clinical presence, enable patient-generated clinical documentation and feedback mechanism, and promote self-monitoring. Bi-directional communications between patients and clinicians provide an enabling environment for autonomy while being clinically monitored through a co-presence, resulting in collaborative care that could alleviate the anxiety of the patients about not being under the direct care of a physician. RPM enables the clinicians to closely monitor and detect early issues, provide feedback in real-time, and initiate early interventions such as prescription modifications and contextual clinical decision support. As the computational capabilities improve and clinical data are collated, machine learning and artificial intelligence algorithms would help detect patterns and predict impending complications such as fluid overload, heart failure or peritonitis, thereby allowing early detection and interventions to avoid hospitalizations. The technical framework and essential features for a RPM system in PD is outlined in this chapter.

Telehealth describes the use of information and communication technologies to deliver healthcare remotely. Given the twin healthcare pressures of demographic change, where increased numbers of people suffer long-term conditions and there is requirement to deliver care ever more cost effectively, there is a considerable need to make the best use of these technologies in the redesign of clinical services. The opportunity for telehealth in peritoneal dialysis (PD) is to strengthen an already enabled population of resilient individuals who undertake their treatment in the community while at the same time providing the opportunity for more people to have their treatment at home. Relevant to this discussion are the challenges that characterize PD. In many parts of the world, uptake is low, technique survival is disappointing, and access to the therapy is impacted by a range of factors such as socioeconomic status, ethnic minority status, and social isolation. There are barriers to learning the technique that may be physical, educational or cognitive, and support by a family member or paid carer may be required. Can remote monitoring impact these factors - and would its widespread use build confidence in patient perceptions that would enable more people to benefit from home dialysis? For that to happen, a clear sighted goal is required for the development of high quality evidence that examines the opportunities and challenges around its use, and understands the needs of all stakeholders. This is key for appropriate and patient-centered implementation that benefits healthcare outcomes, which matter to patients and to those who provide healthcare. This will not happen by accident and must be carefully built into the plan for the roll out and evaluation of these technologies.

Background: Uric acid (UA) stones are responsible for 5-10% of the formation of all kidney stones. Recently, an association between UA stones and insulin resistance, diabetes mellitus, and obesity has been demonstrated and so the incidence has increased. The development of UA stones is dependent on several risk factors, including genetic predisposition, geographical location, dietary indiscretion, and various metabolic characteristics.

Summary: UA nephrolithiasis can arise from diverse etiologies, all with distinct underlying defects converging to one or more of 3 defects of hyperuricosuria, acidic urine pH, and low urinary volume. Low urinary pH is the commonest and by far the most important factor in UA nephrolithiasis, but the reason for this defect is unknown. Patients with UA nephrolithiasis have normal acid-base parameters assessed according to conventional clinical tests. Studies have revealed that there could be an insufficient production of urinary ammonium buffer. Many transport proteins are candidate participants in urate handling, with URAT1 and GLUT9 being the best characterized to date. Because low urine pH is the most important pathogenic factor of UA stone formation, urine alkalinization is an effective intervention to reduce UA crystallization and dissolve UA stones. Key Messages: Epidemiological and metabolic studies have indicated an association between UA nephrolithiasis and insulin resistance. Some potential mechanisms include impaired ammoniagenesis caused by resistance to insulin action in the renal proximal tubule or due to substrate competition by free fatty acids. The identification of novel complementary DNA has provided an interesting insight into the renal handling of UA, including one genetic cause of renal UA wasting.

Hyperuricemia is common in subjects with obesity, metabolic syndrome, and type 2 diabetes. For many years, hyperuricemia was attributed to the effects of insulin resistance to reduce urinary excretion of uric acid, and it was believed that uric acid may not have any causal role in the metabolic syndrome. However, in recent years, hyperuricemia has been found to independently predict the development of diabetes. Experimental studies have also shown that hyperuricemia may mediate insulin resistance, fatty liver, and dyslipidemia in both fructose-dependent and fructose-independent models of metabolic syndrome. The mechanism for uric acid-induced insulin resistance appears to be mediated by the development of mitochondrial oxidative stress and impairment of insulin-dependent stimulation of nitric oxide in endothelial cells. Pilot studies in humans have reported a potential benefit of lowering serum uric acid on insulin resistance. Large clinical trials are recommended. If uric acid is shown to be a mediator of incident type 2 diabetes in humans, then lowering serum uric acid would represent a simple and inexpensive way to help prevent the development of diabetes and to slow the epidemic.