Contributions to nephrology最新文献

Background: An arteriovenous fistula (AVF) is considered the gold standard modality of vascular access (VA) for maintenance hemodialysis (HD) because of its superior patency, few complications, provision of high quality of life, and low risk of patient mortality. The rapid growth of the aging population and the high prevalence of comorbidities, particularly diabetes mellitus and peripheral vascular disease, in patients requiring HD inevitably deteriorate the ability to construct and maintain a conventional AVF because of these patients' insufficient vascular adaptability. Furthermore, a substantial proportion of patients undergoing HD encounter non-maturation AVF failure and mis-cannulation-related complications, resulting in the need for a temporary VA procedure. Superficialization of the AVF is an alternative form of VA that facilitates the construction of an autologous fistula by maximizing the availability of a deeply located vein. Superficialization is also utilized in VA revision to improve the cannulability of an arterialized vein.

Summary: Superficialization involves various approaches, including tunnel transposition, elevation, lipectomy, and liposuction. Tunnel transposition and elevation are prerequisites for construction of an alternative autologous AVF, especially a one- or two-stage transposed brachial-basilic AVF, which is widely recognized as preferential to an arteriovenous graft in patients who cannot undergo conventional AVF installation. Elevation, lipectomy, and liposuction are also employed as revisional interventions for approximating the depth of the arterialized vein and ensuring a sufficient cannulable segment in the forearm and upper arm area. More recently, modified minimally invasive techniques for each superficialization procedure have been introduced to avoid postoperative complications. Amid the growing methodological diversity of superficialization, increasingly more studies have been performed in an attempt to clarify its feasibility and outcomes. On the whole, most superficialization procedures have acceptable patency and safety profiles. However, the preferable superficialization approach varies in accordance with both the influence of the anatomic location and the inherent advantages and limitations of each procedure. Key Messages: Both careful assessment of a patient's vascular adaptability and adequate comprehension of the various superficialization modalities that are available will enable optimal establishment of an autologous AVF in individual patients. This could lead to better outcomes and more successful management of HD.

Background: Hypoxia-inducible factor (HIF) stabilizers, also known as inhibitors of HIF prolyl hydroxylase domain (PHD) inhibitors enzymes, are novel small-molecule agents to treat renal anemia. They increase endogenous erythropoietin (EPO) production by stabilizing HIF. This review focuses on the mechanisms by which PHD inhibitors ameliorate anemia in chronic kidney disease (CKD) and summarizes the current clinical experience with and prospects for these drugs.

Summary: Anemia is a serious complication of CKD and is an independent risk factor for congestive heart failure. Appropriate treatment of anemia is important in the management of advanced stage CKD, as it might help to extend life expectancy and improve the physical function of patients with CKD. However, at present, adverse effects of treatment, such as thromboembolic events, as well as high therapeutic cost have a negative impact on society. PHD inhibitors stabilize the transcription factor HIF, increasing the expression of downstream target genes, including EPO and enzymes involved in iron metabolism, resulting in increased EPO production and improved iron utilization. Key Messages: The potential advantages of PHD inhibitors over conventional EPO-based therapies include a more physiologic response to renal anemia, noninvasive oral administration, and lower cost. Phase III trials of more than 5 PHD inhibitors are ongoing, with overall demonstration of success in increasing hemoglobin levels. In this review, we focus on the mechanisms of PHD inhibitors in improving renal anemia in CKD and summarize the current clinical findings regarding these drugs.

Background: Carnitine deficiency is a common condition in hemodialysis patients. Therefore, abnormalities in fatty acid metabolism and organic acid metabolism are also common in dialysis patients. Tandem mass spectrometry is a standard technique in pediatric and neonatal medicine. However, it could be a new powerful tool in other fields for estimating the state of intracellular fatty acid metabolism.

Summary: Tandem mass spectrometry has recently revealed the relationships between carnitine profile and dialysis patients' anemia, reduced physical function, and survival rate. Fatty acid and organic acid metabolism, which could previously only be evaluated qualitatively, can now be quantitatively assessed. Key Message: The applications of tandem mass spectrometry are expected to expand not only in the field of dialysis but also in clinical medicine in general.

Background: From a global perspective, diabetic kidney disease (DKD) is the leading cause of not only chronic kidney disease and end-stage renal disease but also cardiovascular disease (CVD).

Summary: In the early stages of diabetes, patients have a high risk of developing microvascular complications, loss of kidney function, CVD, infection, and death. Hyperglycemia, free fatty acids, and insulin resistance induce metabolic imbalance and DKD initiation. Inflammation is recognized to play a role in DKD pathogenesis. Our recent study indicated that angiopoietin-like protein 2, which is a circulating proinflammatory protein, might be a strong mediator for the development of DKD and a good predictive biomarker of its progression. The need for effective and safe treatment options for complications such as DKD or CVD becomes ever more urgent. Key Messages: Inflammatory mediators have emerged as potential biomarkers and therapeutic targets for DKD.

Background: Recent technical and experimental advances in extracorporeal blood purification therapy (eBPT) can be applied in paediatric patients, including neonates. However, there are several specific issues in performing eBPT in paediatric patients in regard to the safety and effectiveness of treatments. The aim of this review is to explore the technical aspects of acute paediatric eBPT, especially regarding renal replacement therapy and the present situation in Japan.

Summary: In children requiring eBPT, especially small children and neonates, it is difficult to secure sufficient blood flow to obtain optimal treatment effects for various diseases and critical illnesses. In such conditions, it should be considered which modalities of eBPT and anticoagulants are used and how optimal blood flow and replacement fluid/dialysate flow rate should be chosen for the safety and effectiveness of treatments. Key Messages: In paediatric patients requiring eBPT, frequent complications are observed; therefore, we should apply optimal eBPT depending on the pathophysiological conditions of paediatric patients, develop a deep understanding about paediatric eBPT, and collect evidence on treatment outcomes. In addition, the eBPT systems and devices specifically for small children are expected to be developed in Japan to improve the safety and efficacy of eBPT.

Remote patient management (RPM) for patients receiving peritoneal dialysis (PD) is an emerging technology whereby a patients' biometric information (including weight, blood pressure, and other parameters) can be remotely monitored by providers along with important PD treatment information. As part of an evolving field of telemedicine, RPM has the potential to improve clinical outcomes for patients receiving PD, reduce resource utilization, and improve PD uptake, and positively impact a patients' experience with PD. Preliminary reports of RPM are encouraging, however, research in the field is limited to small, single center studies, and remains largely observational; interventions have been heterogenous in terms of what clinical and treatment parameters are being remotely monitored and what outcomes are under evaluation. In the present review, we will describe the evolving field of RPM in PD, discuss potential benefits of the technology while highlighting existing and important future areas for research.

Remote patient management (RPM) via 2-way connectivity addresses many challenges that the peritoneal dialysis (PD) renal care team faces when treating home dialysis patients. It addresses psychological barriers and social determinants of health by permitting self-care, increased independence, and enabling patients to remain in their community. RPM lends opportunities for patient's empowerment in self-care and treatment decisions. AMIA cycler with remote monitoring, step-by-step voice guidance, and graphic interface all contribute to patient engagement and empowerment in the Canadian home dialysis setting.

Objectives: To describe a series of unique patient cases in the realm of PD and how adopting new technology has enabled patients and clinicians to rise above challenging circumstances to optimize home dialysis, especially in patients living in remote communities.

Methods: With the introduction of RPM at Seven Oaks Hospital in Winnipeg, MB, nurses have tracked and documented examples of success on home dialysis. Despite obstacles, patients embraced self-care in the home setting with increased confidence.

Results: Included are patients who were provided support to perform reliable home dialysis with AMIA cycler with Sharesource that offers voice guidance, graphic interface, and 2-way connectivity. Patients overcame the challenges of self-care in a remote setting with physical impairments, as well as enhanced acceptance of home dialysis. The utilization of RPM by the care team promoted patient independence and confidence in performing therapy at home.

Conclusions: Our experience with this technology demonstrates an increase in patient confidence in training and RPM of home dialysis. We have provided specific case examples of patient engagement and empowerment leading to improved self-care. New technology can address psychological barriers and social determinants of health in home dialysis patients.

In June 2015, Sharesource, a cloud-based, bi-directional connectivity platform, was launched by Baxter Healthcare in the UK. With this came the ability to use remote patient management (RPM) with peritoneal dialysis (PD) patients in an easy, standardized manner across dialysis units. Improved nursing efficiency and patient outcomes, achieved utilizing RPM include individualized PD patient prescriptions, early detection and prevention of potential PD complications, reduced planned and unplanned hospital attendance, reduced drop off, and increased healthcare professional and patient/carer confidence in self-care. These are illustrated with Case Studies. The potential to reduce glucose exposure is explored and for PD units yet to use RPM, lessons learned during the implementation of Sharesource are shared.

Chronic diseases are a global concern and a leading cause of death and disability. These conditions require intensive and ongoing medical assistance to maximize outcomes and avoid the risk of frequent flare-ups and hospitalizations, which increase the cost of healthcare. Remote patient management (RPM) is a strategy that allows for accurate home monitoring of chronic patients, enabling the team to improve care through prevention and early identification of problems, with consequent timely interventions. Peritoneal dialysis (PD) is a home-based therapy representing an ideal model for testing the ability of RPM to improve clinical outcomes by allowing the 2-way link between health providers and patients. The literature and our own results confirm that RPM applied to automated peritoneal dialysis (APD) allows an efficient use of healthcare resources, helping to improve tailoring of APD prescription and to intervene early with troubleshooting, reducing the frequency of in-person visits for emergency problems. RPM-APD is today made possible by a cloud-based software providing bidirectional communication between patient's home and the hospital care team (Cycler HOMECHOICE CLARIA with SHARESOURCE platform). This approach can be useful in promptly identifying patients with higher risk of complications: a knowledge-based management permits the reduction of urgent events, and the prevention of clinical complications improving patient outcomes. In our experience, matured over 2 years in a cohort of prevalent patients, we observed a significant reduction of patient drop-out and technique failure, the number of scheduled and unscheduled hospital visits, the number of episodes of overhydration, rate of hospitalization, episodes of non-compliance to prescription, patient and hospital team time spent in travelling and management of therapy, healthcare costs and patient's expenditure, miles travelled by patients from home to hospital and vice versa. The cost/benefit analysis is strongly in favor of the RPM-APD modality versus the traditional periodic hospital visit regime.

Peritoneal dialysis is the ideal field where remote patient management (RPM) techniques can be experimented and implemented for a better care. Real-time feedback on patients and machine signals allow for rapid and effective correction of prescription and troubleshooting. Recent results have spurred new interest in this area, where new technology and new options appear to open interesting scenarios for the future. The acronym G.R.E.E.N. describes the initials of the disciplines that are likely to characterize the future of this area of care and research. G for genetics: patient genotyping will allow in the future to expand the application of precision medicine solutions in response to remote monitoring signals. R for robotics: the mechanical actuation of operations normally carried out by a care giver will permit to take maximum advantage of bidirectional interactions between remote signals and remote feedback on dialysis equipment. E for E-health and Information communication technology. Remote monitoring will provide the basis for specific algorithms that can be further implemented and improved by artificial intelligence networks. This will provide support in the decision-making process and will even provide the basis for automated feedback operations. E for eco-compatibility: home therapies with remote monitoring will contribute to save fuel consumption and will provide environment-friendly solutions. N for nanosciences: this interesting area of research will offer a new spectrum of biomaterials and will enable possible uses of nanofluids. The application of advanced RPM with a G.R.E.E.N. approach is likely to provide significant benefits for the future with cost reduction, early detection and resolution of problems, improved treatment compliance, reduction of patient's access to hospital center for technical and clinical complications, increased confidence of patients treated at home with higher incidence and prevalence of home therapies, and consequent improvement in patient's quality of life.