Seminars in Dialysis最新文献

Background: People receiving dialysis treatment are at higher risk of sarcopenia. This review aimed to determine the global prevalence of sarcopenia in people on peritoneal dialysis and hemodialysis. We investigated whether the prevalence of sarcopenia differs based on assessment criteria, timing of assessment, and measurement tools used and explored the risk factors for sarcopenia in people on dialysis.

Methods: This review followed JBI and PRISMA guidelines and included studies assessing sarcopenia in adults aged 18 and older with chronic kidney disease undergoing dialysis. Five databases were searched from inception to November 2022. The JBI SUMARI software was used to perform the meta-analysis. Publication bias and risk factor analysis were performed using STATA (Version 18).

Results: A meta-analysis of 62 studies (15,382 participants) found the global prevalence of sarcopenia to be 30.1% (95% CI: 25.6%-39.9%) for hemodialysis and 20.5% (95% CI: 15.1%-26.4%) for peritoneal dialysis. Sarcopenia prevalence ranged between 23.1% and 30.3% in HD and between 6.1% and 26.9% in PD, based on the assessment criteria. Post-dialysis sarcopenia prevalence was higher (33%) than pre-dialysis (24.2%) in hemodialysis patients. Measuring muscle mass after dialysis using dual-energy X-ray assessment yielded a lower prevalence of sarcopenia (22.5%) than bioimpedance analysis or spectroscopy (33%). Risk factors in the HD population included age, sex, diabetes, inflammation markers, nutritional indices, and dialysis vintage, although heterogeneity between studies was high.

Conclusion: This study showed a high prevalence of sarcopenia among the dialysis population and identified many risk factors, emphasizing the need for early identification and intervention and standardized assessments.

Background: Anemia is a common occurrence in people with chronic kidney disease and end-stage kidney disease. Intravenous administration of iron is standard treatment for people undergoing maintenance hemodialysis. However, until the recent PIVOTAL randomized control trial, there was uncertainty around clinically effective regimens. This study found that among incident, people receiving hemodialysis in the first year, a proactive high-dose intravenous iron regimen was superior to reactive low-dose regimen, leading to reduced mortality and cardiac events. Our study investigated whether the research and guidelines have been successfully implemented into clinical care across the United Kingdom, identified barriers experienced, and explored our local hemodialysis population's awareness of the treatment they are receiving.

Methods: We conducted a cross-sectional survey using a convenient sample of UK-based kidney physicians working in the NHS and local people receiving hemodialysis. Two preconceived, standardized questionnaires were designed.

Results: Forty physicians responded. Of these, 40% had implemented a proactive iron protocol, whereas 37.5% had not. Respondents acknowledged concerns about doses of iron and the need for local protocols. Thirty-seven patients responded to the patient questionnaire within our own hemodialysis unit. Fifty-one percent of patients reported to be receiving iron supplementation, of which 84% stated it was intravenous through their dialysis machine.

Conclusions: We have not observed a paradigm shift in clinical practice and identified poor patient understanding of their treatment. Strategies to overcome barriers are necessary to introduce treatments that offer both clinical advantages and cost savings. Eliminating futile practice is challenging due to departmental prioritization and economic considerations. Traditionally, efforts to improve care are targeted towards newer therapies; however, there is an opportunity to improve implementation of current evidence.

Here we describe six kinetic modeling programs that allow quantification of removal of urea, creatinine, phosphate, and beta-2-microglobulin. They can be used with asymmetric dialysis treatment schedules ranging from one to seven times per week. Once downloaded, the programs can be run locally from a personal computer without requiring connection to the internet. They have been designed to analyze solute removal in a single patient or in thousands of patients. Each program is contained in a single JavaScript-HTML text file, and all of the assumptions and equations used are easily accessible in uncompressed text format and are accompanied by comments and annotations. Inputs are in the form of comma-delimited files which can be imported from spreadsheets. Outputs appear in the form of web pages or as comma-delimited files that can be exported into spreadsheets for graphing and further analysis. This perspective focuses on describing the potential utility of these programs (two pertaining to urea, two to creatinine, one to phosphate, and one to beta-2-microglobulin) as well as two helper calculators, one that computes dialyzer mass transfer area coefficient for urea (K0A) from dialyzer specification chart urea clearance data, and another that can be used to calculate the phosphate binder equivalent dose.

Peritoneal dialysis (PD) outcomes analysis presents challenges due to heterogeneous outcomes. Our study aims to evaluate mortality, transition to hemodialysis (HD), and kidney transplant (KT) rates and investigate potential baseline patient characteristics influencing these outcomes. We conducted an observational retrospective registry-based single-center cohort study involving 722 incident adult PD patients admitted between 1985 and 2022. Follow-up duration extended from PD initiation to the first occurrence of death (n = 143), transfer to HD (n = 313), or KT (n = 202). Utilizing competitive risks analysis, we calculated cumulative incidence (CI) functions and applied a Fine and Gray model to baseline variables to understand their impact. The majority of patients were female (n = 401; 55.54%), with an average age of 49.64 ± 15.80 years. Transfer to HD had the highest probability (CI of 0.38 at 60 months), followed by KT (CI of 0.27 at 60 months) and death (CI of 0.19 at 60 months). Diabetes correlated solely with death (HR 1.71 (0.18); p = 0.004). PD-first was associated with a lower risk of HD transfer (HR 0.76 (0.13); p = 0.036) and positively influenced KT (HR 1.73 (0.16); p < 0.01). Vascular access as the reason for PD selection was associated with death (HR 2.16 (0.19); p < 0.001). The main risk for PD patients is transitioning to HD, unaffected by baseline patient characteristics. PD-first option positively influences KT access, and mortality rates remain low and unaffected by this option, ensuring the safety of the technique. Vascular access-related PD initiations correlate with increased mortality, potentially due to comorbidities.

Acquired reactive proliferating collagen (ARPC), usually associated with systemic diseases, is a rare skin disease characterized by the elimination of altered dermal collagen through the epidermis. Here, we report two cases of ARPC in maintenance hemodialysis patients, one of which is combined with type 2 diabetes, chronic renal failure, and hypertension and the other is combined with chronic renal failure and hypothyroidism. Two patients were treated with oral thalidomide and ebastine, local application of fluticasone propionate cream, and enhanced dialysis. After treatment, the itching and the rash significantly improved. We report for the first time that ARPC in patients with hemodialysis could be improved by oral thalidomide and antihistamines and local application of steroid. This report provides reference for guiding the understanding of ARPC and the new treatment of ARPC in hemodialysis patients.

Objective: The aim of this study is to investigate the impact of the causes of arteriovenous fistula (AVF) stenosis on the 1-year primary patency rate of AVF following percutaneous transluminal angioplasty (PTA) and to identify the independent risk factors that affect vascular access patency post-PTA.

Methods: In this investigation, we analyzed the clinical data of 78 patients who underwent successful PTA for dysfunctional autologous AVF in the Nephrology Department of our hospital between January 2020 and September 2022. The primary focus of this study was to observe the postoperative patency rate of AVF in these patients. Subsequently, the patients were categorized based on primary diseases, Charlson comorbidity index (CCI), AVF typing, and causes of AVF stenosis. The postoperative patency rates of AVF were then compared among the respective groups. To further analyze the relevant risk factors influencing vascular access patency following PTA, the Cox proportional hazard model was employed.

Results: A total of 78 eligible patients who underwent PTA were included in this study revealing patency rates of 93%, 85%, 80%, and 72% at 3, 6, 9, and 12 months postoperatively, respectively. Analysis using the Kaplan-Meier curve indicated no significant association between the presence of diabetic nephropathy (p = 0.313) and AVF stenosis typing (p = 0.195) with post-PTA patency of AVF. However, the 1-year patency rate demonstrated notable differences, with higher rates observed in the CCI < 7 group compared with the CCI ≥ 7 group and similarly in the simple AVF stenosis group compared with the intimal hyperplasia group (p < 0.001). Furthermore, based on multivariate survival analysis (Cox regression model), the causes of AVF stenosis and CCI index were identified as independent risk factors influencing AVF patency following PTA (p < 0.05).

Conclusion: Patients with intimal hyperplasia were found to have a higher likelihood of AVF restenosis compared with those with simple stenosis. Similarly, individuals with a high CCI were more prone to AVF restenosis than those with low CCI. The causes of AVF stenosis and CCI were identified as independent risk factors influencing vascular access patency following PTA.

The objective of India's One Nation One Dialysis (ONOD) program is to remove the barriers that end-stage kidney disease patients face in accessing consistent, quality dialysis services across the nation. A unified and standardized dialysis care approach is what ONOD aims to achieve at a national level. The objective of ONOD is to improve access to, affordability of, and quality in dialysis services for economically weaker segments of society and those living in remote areas of the country by providing dialysis services through public-private partnerships. The ONOD program places a lot of emphasis on the infrastructure development, funding support, skill development, regulatory reforms, and technological integration of dialysis services. By implementing ONOD, India can improve patient outcomes, close the supply-demand gaps for end-stage kidney disease kidney replacement therapy, and create a more balanced and sustainable kidney healthcare ecosystem.

Expanded hemodialysis (HDx) represents a transformative innovation in renal replacement therapy, addressing the limitations of conventional hemodialysis and high-flux modalities. By employing medium cut-off (MCO) membranes, HDx ensures efficient clearance of middle- and large-molecular-weight uremic toxins, such as β₂-microglobulin and cytokines, while selectively retaining vital proteins like albumin. This comprehensive review examines the clinical efficacy, safety, and broader implications of HDx, highlighting its potential to improve outcomes for patients with chronic kidney disease (CKD). The review synthesizes findings from comparative studies, emphasizing HDx's superior toxin removal capabilities, particularly for solutes implicated in systemic inflammation and cardiovascular complications. Key mechanisms, including the internal filtration-backfiltration process, contribute to hemodynamic stability and enhanced toxin clearance. HDx demonstrates significant reductions in inflammatory biomarkers, improved arterial compliance, and better cardiovascular outcomes compared with traditional methods. Patient-reported outcomes further underscore HDx's benefits, with shorter recovery times, enhanced quality of life, and reduced intradialytic complications. While albumin loss remains a consideration, studies confirm its clinical acceptability and minimal impact on nutritional status. HDx's economic viability, reduced infrastructure requirements, and compatibility with existing systems position it as a cost-effective alternative, especially in resource-limited settings. Despite promising evidence, the review identifies gaps in long-term data, particularly regarding mortality and sustained quality-of-life improvements. Future directions include refining membrane technologies and incorporating personalized medicine approaches to optimize HDx protocols. By bridging these gaps, HDx has the potential to redefine renal replacement therapy, offering a safer, more effective, and scalable solution for CKD management.

Background: This study compares the outcomes of tunneled catheters (TCs) and non-tunneled catheters (NTCs) in incident hemodialysis patients undergoing early arteriovenous fistula (AVF) creation.

Methods: Adult incident ESKD patients were randomized in two catheter groups (TC and NTC) for hemodialysis initiation and were followed for 12 weeks from March 2021 in a 3-year study period. Catheter salvage was attempted in both the groups until AVF maturation in cases of catheter-related bloodstream infection (CRBSI) or mechanical dysfunction. Catheter insertion and removal dates, infection episodes, and mechanical dysfunction events were recorded. CRBSI rates, dysfunction rates, and catheter survival were compared.

Results: A total of 133 patients were randomized into TC (65) and NTC (68) groups. Seventy-six patients developed symptoms of CRBSI, of whom eight patients required catheter removal (TC: 2, NTC: 6). CRBSI episodes per 1000 catheter days were 15.14 for TCs and 16.85 for NTCs, but mechanical dysfunction rates were 0.96 and 1.68, respectively. By 6 weeks, one catheter was removed in the TC group (AVF maturation), and eight in the NTC group were removed (four due to AVF maturation, three due to CRBSI, and one due to mechanical dysfunction). Kaplan-Meier analysis showed significantly longer catheter survival for TCs compared to NTCs (66.9 vs. 57.9 days, p = 0.001).

Conclusion: CRBSI rates and catheter patency were comparable between TCs and NTCs at 6 weeks, but TCs demonstrated better survival beyond this period. When early AVF creation is ensured, NTCs may serve as a viable short-term vascular access option, particularly in resource-limited settings.

Tunneled dialysis catheter is the alternative for dialysis patients who cannot benefit from an arteriovenous fistula. The insertion of such catheters is usually ultrasound-guided to prevent complications. A 36-year old patient had an unexpected complication following the insertion of a right femoral tunneled dialysis catheter: Although the blood collected from the catheter was venous after insertion, the blood turned arterial few minutes after initiating a continuous renal replacement therapy (CRRT). It became venous again after stopping the therapy. The first, yet unlikely hypothesis, was an arterial location of the catheter. In fact, it turned out not to be. We describe the management of such a case.