Seminars in Dialysis最新文献

Introduction: The purity of water and dialysis fluids is of utmost importance in ensuring the safe and effective administration of hemodialysis treatment to patients with chronic kidney disease. It is crucial to enforce compliance with international standards for dialysis water and fluids, as this is mandatory in reducing chemical hazards, mitigating the adverse effects of bioincompatibility resulting from contaminated water and ultimately enhancing long-term patient outcomes.

Standards and risks: Within this comprehensive review, we highlight the presence of water contaminants and thoroughly assess the existing international standards for dialysis water and fluids, spanning from pure to ultrapure. Additionally, we delve into the fundamental components of water purification and present a comprehensive range of water treatment options, encompassing pre-treatment, primary treatment (reverse osmosis), and tertiary water treatment. Furthermore, we outline recommended monitoring and maintenance procedures, ensuring the consistent delivery of high-quality water and dialysis fluids at the point of care. WATER PURIFICATION AND MONITORING SUSTAINABILITY AND FUTURE CHALLENGES: Importantly, we raise concerns regarding the sustainability and conservation of water resources in hemodialysis treatment. It is imperative that these concerns be addressed in the future to avert the potential shortage of this essential resource.

Conclusion: In conclusion, the contemporary landscape of hemodialysis conditions has engendered an urgent necessity for advanced water treatment systems and optimized delivery of dialysis fluids. This review serves as a comprehensive update on the latest technological advancements aimed at meeting these critical demands. Dialysis water and fluids must adhere to increasingly stringent purity constraints, encompassing both biochemical and microbiological perspectives.

This review article describes the evolution of dialysis technologies spanning the past few decades and discusses the current advancements in hemodialysis devices. These advancements aim to meet the growing global demand for hemodialysis through improved engineering and patient-centered developments that enhance treatment accessibility, automation and sustainability. This article aims to bring together hemodialysis hardware, its clinical utility and the philosophy underpinning it-aiming to improve outcomes, user experience and restore independence for patients with end-stage kidney failure undergoing dialysis care.

The key goals for dialysis treatments are to prevent the progressive accumulation of waste products of metabolism and volume overload. Traditionally uremic solutes have been classified according to molecular weight and termed small, middle sized, and large solutes. Solute clearance during dialysis sessions will potentially be by diffusion, convection and adsorption. Dialyzer membranes act as a semi-permeable membrane restricting solute removal predominantly by size. Small molecules move faster than large molecules, so small solutes are readily removed by diffusion. Increasing the size of the pores in the membrane will potentially allow middle and larger sized solutes to pass through the dialyzer membrane, although in practice there is a limit to increasing pore sizes to prevent the loss of albumin and other important proteins. Differences in membrane surface and charge will influence protein absorption. The removal of fluid during dialysis depends in part on the hydraulic permeability of the membrane. Combining higher hydraulic permeability and larger sized pores increases convective clearance with solutes moving across the membrane with the water movement. Depending upon dialyzer design, higher hydrostatic pressure as blood enters the dialyzer leads to a variable amount of internal diafiltration, so improving the clearance of middle sized solutes. Although the dialyzer membrane plays a key role in solute clearance, the design of the casing and header also play a role in directing the countercurrent blood and dialysate flows to maximize the surface area available for diffusive and convective clearances.

Interest in the use of sorbents in chronic dialysis treatment has undergone a revival in the last decades, for which two major factors are responsible. The first is the potential of sorbents as adjunct therapy for the removal of substances that are difficult to remove by conventional dialysis therapies. The second is their use in regeneration of dialysate, which is of pivotal importance in the design of portable or even wearable treatments, next to the potential for reducing water use during conventional dialysis treatment. Sorbent-enhanced dialysis with synthetic polymers was associated with a reduction in inflammatory parameters as compared to hemodialysis and even associated with improved survival in smaller studies, although this needs to be confirmed in large randomized trials. Incorporation of sorbents within a dialysis membrane (mixed matrix membrane) appears a promising way forward to reduce the complexity and costs of a dual therapy but needs to be tested in vivo. For regeneration of dialysate, at present, a combination of urease, zirconium-based sorbents, and activated charcoal is used. Next to sodium release by the sorbent in exchange for ammonium and the CO₂ release by the hydrolysis of urea has been a bottleneck in the design of wearable devices, although short-term trials have been performed. Still, for widespread and flexible application of sorbent-assisted portable or wearable devices, a direct urea sorbent would be a major asset. In the near future, it will likely become apparent whether sorbent-assisted dialysis techniques are feasible for routine implementation in clinical practice.

Vascular access dysfunction is associated with reduced delivery of dialysis, unplanned admissions, patient symptoms, and loss of access, making assessment of vascular access a fundamental part of routine care in dialysis. Clinical trials to predict the risk of access thrombosis based on accepted reference methods of access performance have been disappointing. Reference methods are time-consuming, affect the delivery of dialysis, and therefore cannot repeatedly be used with every dialysis session. There is now a new focus on data continuously and regularly collected with every dialysis treatment, directly or indirectly associated with access function, and without interrupting or affecting the delivered dose of dialysis. This narrative review will focus on techniques that can be used continuously or intermittently during dialysis, taking advantage of methods integrated into the dialysis machine and which do not affect the delivery of dialysis. Examples include extracorporeal blood flow, dynamic line pressures, effective clearance, dose of delivered dialysis, and recirculation which are all routinely measured on most modern dialysis machines. Integrated information collected throughout every dialysis session and analyzed by expert systems and machine learning has the potential to improve the identification of accesses at risk of thrombosis.

Background: Dialyzer reprocessing for dialyzer reuse in the same patient has been developed since the early time in hemodialysis history to save cost and time related to reassembling the new dialyzer during that time. The procedure can reduce the first-use and allergic reactions from using incompatible cellulosic dialyzer membrane by altering some manufacturing chemicals.

Methods: All of established literatures regarding recent dialyzer reprocessing methods and considerations were extensively reviewed and summarized.

Results: Dialyzer reprocessing can be performed by multiple protocols but involves common steps including bedside rinsing after use, cleaning, dialyzer testing to prevent excessive drop in dialyzer clearance and membrane integrity, high-level disinfection or sterilization either by chemicals or heat, storage, and preparation for subsequent dialysis session by adequate rinsing to reduce the residual reprocessing chemical to the safe level. Compared with the single-use strategy, evidence is conflicting for the mortality advantages or disadvantages of dialyzer reuse, with some showing increased mortality in patients receiving peracetic acid sterilization. Keys for the effective and safe dialyzer reuse involve strict adherence to specific manufacturer's protocol, adequate dialysis water quality complied with the Association for the Advancement of Medical Instrumentation standard, measurement of the total cell volume to prevent inadequate hemodialysis, and infectious control consideration. In the present era, single-use strategy is increasingly adopted due to the decreased cost for dialyzer manufacturing. Environmental concerns of higher solid waste from dialyzer disposal in single-use dialysis should be compared with the liquid waste from reprocessing chemicals along with plastic waste and cardboard in reuse dialysis.

Conclusion: Dialyzer reprocessing with adequate regulation is considered as an acceptable option for cost-effective hemodialysis, compared with the single-use strategy.

Background: Patients with end-stage renal disease undergoing dialysis suffer from muscle cramps, a prevalent and burdensome symptom for which there is a paucity of efficient and safe treatments.

Aim: What is the efficacy and safety of pharmacological interventions for the treatment of dialysis-related muscle cramps?

Design: A systematic review was conducted in OVID, CINAHL, PubMed, Web of Science, and Central Cochrane databases up to August 25, 2023.

Data sources: Experimental studies reporting on a pharmacological intervention for the treatment of dialysis-related muscle cramps were included. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, and the studies quality was assessed with the RoB2 tool.

Results: A total of 4660 studies were retrieved, and 13 articles were included. The studies reported on nine interventions: vitamin C, vitamin E, vitamin K2, vitamin B7, dextrose solutions, gabapentin, sodium chloride, creatine monohydrate, and L-carnitine. The studies testing L-carnitine and creatine monohydrate were the only ones deemed to have a low risk of bias. Side effects were reported in only two trials, consisting primarily of gastrointestinal discomfort and hyperglycemia. Vitamins C and E are the two most studied interventions that showed positive results in reducing the frequency, severity, and duration of dialysis-related muscle cramps. L-carnitine is a promising intervention that warrants further investigation.

Conclusion: Our review consolidates the existing evidence, elucidating the range of treatments along with their potential benefits and limitations. Future studies should uphold high-quality standards, incorporate patient-reported outcomes, and utilize well-defined, robust samples to improve patient care.

Gastric-acid suppressants (GASs) are commonly prescribed to patients undergoing peritoneal dialysis for various gastrointestinal disorders. However, long-term GAS use has been linked with the risk of enteric peritonitis in this patient population. To assess the association between the enteric peritonitis risk and GAS use in patients undergoing peritoneal dialysis for end-stage renal disease, we conducted a systematic search for relevant articles published until December 2023 in PubMed, Embase, and the Cochrane Library databases. We included 11 articles on the association between GAS use and enteric peritonitis risk in patients undergoing peritoneal dialysis. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) using fixed and random-effects models to obtain overall effect estimates. We also explored potential sources of heterogeneity through subgroup analyses. We qualitatively analyzed data from 11 studies (n = 1993 participants), out of which, nine studies were included in meta-analysis. The overall results revealed a significant association between the enteric peritonitis risk and the use of GASs (OR, 1.61; 95% CI, 1.26-2.05; p < 0.00001). The analysis of study design subgroups showed a significant association in retrospective cohort studies (OR, 1.70; 95% CI, 1.42-2.03; p < 0.00001) but not in case-control studies. Histamine-2 receptor antagonist (H2RA) use was significantly associated with enteric peritonitis (OR, 1.49; 95% CI, 1.05-2.11, p = 0.03), whereas proton pump inhibitor use was not (OR, 1.13; 95% CI, 0.72-1.77, p = 0.28). Our findings suggest a significant association between the development of enteric peritonitis and GAS use in patients undergoing peritoneal dialysis. However, the observed heterogeneity in study characteristics warrants caution in interpreting the results.

Background: Bacterial peritonitis is a common complication of peritoneal dialysis. In the absence of systemic signs of infection, adult guidelines recommend treatment with intraperitoneal vancomycin either as empiric coverage of gram-positive organisms or as targeted therapy. However, there is no guidance on how to administer vancomycin in children on automated peritoneal dialysis.

Case report: We report vancomycin pharmacokinetics upon intraperitoneal administration for the treatment of a Staphylococcus hominis peritonitis in an 11-year-old patient on automated nocturnal intermittent peritoneal dialysis. While the patient was hospitalized, vancomycin was administered intraperitoneally as a continuous treatment. After hospital discharge, the nocturnal peritoneal dialysis was resumed. In the absence of treatment guidelines, intraperitoneal vancomycin was initially administered empirically only during the nocturnal dialysis exchanges which led to repetitive subtherapeutic vancomycin plasma concentrations and the persistence of S. hominis in dialysate cultures. Based on studies in adults, the dosing strategy was subsequently modified to administer vancomycin at a dosage of 15 mg kg^-1 in the dialysate with a 6-h dwell period prior to the nocturnal dialysis thereby allowing to reach optimal peak concentrations. The dosing interval was subsequently individualized using therapeutic drug monitoring to ensure residual vancomycin concentrations > 10 mg L^-1 thereby leading to clinical and microbiological recovery.

Conclusions: This case presents a dosing strategy based on a comprehensive review of the literature and highlights that a sufficient dwell period is critical when treating pediatric patients on automated peritoneal dialysis in order to allow vancomycin distribution and equilibration between the dialysate and the plasma.