Contributions to nephrology最新文献

Background: With the growth in the global economy, the number of patients worldwide undergoing renal replacement therapy such as hemodialysis is increasing by 6-7% annually. Accordingly, medical costs for the treatment of chronic kidney disease (CKD) progressing to end-stage renal disease (ESRD) as well as for renal replacement therapy have become a major issue.

Summary: It has been reported that in the United States, the annual medical cost for a patient with CKD is approximately USD 20,000, and that the total medical cost for a CKD patient is higher than that of an ESRD patient [1]. In the present study, we found that the medical costs for renal replacement therapy (RRT) in Japan are reasonable compared to those in the United States and Europe. Key Messages: The medical costs for RRT in Japan are reasonable and are not a major issue in Japan.

Peritoneal dialysis (PD) has many advantages compared to in-center hemodialysis, which include technical simplicity, and being a home therapy it allows patients significant autonomy for all their daily activities. Nephrologists require trustworthy information from patients for the appropriate management of PD, that is, a careful record of adherence to the prescribed schedule, effective time of dialysis, and a detailed volume of ultrafiltration (UF) is required. All these tasks demand time and commitment from patients, resulting frequently in incomplete or inconsistent information. Development and incorporation of remote monitoring devices to machines for automated PD makes data recovery easy and safe, and provides the medical team the opportunity to be more proactive, and prevent complications due to under dialysis, catheter dysfunction or chronic and acute changes in UF. Remote monitoring devices/machines may be a useful tool in the early diagnosis of peritoneal damage and even in the initial manifestation of peritonitis.

Remote patient management (RPM) has been increasingly implemented in the care of chronic patients in the last decades with significant positive impact on clinical outcomes. Home-based dialysis therapies constitute an attractive alternative to in-center hemodialysis as they offer patients more flexibility and empowerment. Nonetheless, their remote nature and intrinsic problematic visibility to therapy-related issues occurring at home contribute to holding back both patients and nephrologists from adopting them. RPM has recently become available in automated peritoneal dialysis (APD) by means of a new cloud-based platform with a 2-way communication system (Sharesource), offering accurate daily monitoring of the therapy as well as ability to remotely alter the prescription. Its main documented advantage is the early identification of clinically relevant issues such as catheter dysfunction and non-adherence to prescribed PD therapy; its contribution to recognition of an imminent peritonitis has still to be evaluated. RPM is also of particular interest for patients with social, geographical or physical limitations in terms of travel reduction. Moreover, permanent access to data for PD teams may provide reassurance and alleviate anxiety generated by the remote nature of the method for both patients and nephrologists. Finally, RPM offers further advantages such as a more personalized APD prescription, tailored to patients' needs, as well as improved clinical follow-up and a more proactive care. Long-term impacts of RPM in PD on patients' outcomes, healthcare costs, and its potential influence on a greater take-up of the technique, notably through reinforced confidence for both patients and nephrologists through better visibility of the progress of the therapy, have still to be evaluated. Given the positive impact of PD on the preservation of residual renal function and association of the latter with better survival, any tool that may contribute to its broader use is most valuable.

Background: The purpose of this study was to determine the correlation between aortic calcification and demographic and biochemical parameters in hemodialysis patients.

Summary: Calcification scores of the aortic arch and abdominal aorta were determined from multi-slice computed tomography scans and evaluated according to the Agatston score. The associations between demographic and biochemical parameters and aortic calcification score were determined. In total, 190 patients were included in the study. There was a significant positive correlation between aortic calcification scores and age, duration of hemodialysis, cardiothoracic ratio, normalized protein catabolic rate, brachial-ankle pulse wave velocity (baPWV), serum markers of mineral metabolism, and inflammation. A significant negative correlation was found between aortic calcification scores and platelet count. Multivariate analysis showed that age, duration of hemodialysis, baPWV, phosphate, calcium and phosphate (Ca×P) product, parathyroid hormone, and C-reactive protein levels were independent risk factors for calcification of the aortic arch, while baPWV and Ca×P product were independent risk factors for calcification of the abdominal aorta. Key Messages: Aortic calcification scores correlate with age, duration of hemodialysis, and several biochemical parameters of inflammation and mineral metabolism.

Two and a half centuries have passed since the therapeutic use of peritoneal cavity for the treatment of ascites by peritoneal lavage was reported. George Ganter was the first to describe the use of peritoneal dialysis (PD) in humans. This chapter will describe the various milestones in the field of PD achieved over the years. These include the understanding of solute and water transport across the peritoneal membrane, developments in PD technique and technology, progress in the prevention and treatment of infections, and other important milestones.

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.

Background: Vascular calcification (VC) is common in patients with chronic kidney disease (CKD) including end-stage renal disease (ESRD). The pathogenesis of VC is complex, resulting in increased arterial stiffening, which is associated with cardiovascular mortality. In addition to traditional cardiovascular risk factors, CKD patients also have a number of non-traditional cardiovascular risk factors that may play an important role in the pathogenesis of VC.

Summary: Management of CKD-mineral bone disorder using conventional therapeutic approaches, which include restricting dietary phosphate, administering phosphate binders, and using active vitamin D and calcimimetics, may inhibit the progression of VC, but these approaches remain controversial because recommended biochemical targets are difficult to achieve. Current treatment strategies focus on correcting abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels in ESRD patients. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in randomized controlled trials. This review summarizes current treatment strategies and therapeutic targets for the management of VC in patients with ESRD. Key Messages: A better understanding of the potential therapeutic approaches to VC may lead to improved mortality rates among patients with CKD including those on dialysis. Fetuin-A inhibits VC by binding to the nanoparticles of calcium and phosphate, preventing mineral accretion. These particles are known as calciprotein particles and may provide an important pathway for mineral transport and clearance. This review article summarizes the current management of VC in patients with ESRD.

Remote patient management and telemedicine have great potential to improve the care of patients with end-stage kidney disease undergoing peritoneal dialysis (PD). Since PD is performed by patients and their families, typically in the home setting away from expert clinical support, remote monitoring of treatments may detect early problems, ensure compliance, and give both providers and patients a sense of reassurance that complications can be minimized and detected. These advantages may translate into improved outcomes and increased uptake of home dialysis therapies. Estimates of the financial impact of these potential improvements in care can be performed and are discussed in this chapter. These economic impacts are potentially significant and further the case for carefully designed clinical trials to assess the impact of these new technologies.