Pub Date : 2024-01-01DOI: 10.1016/j.semnephrol.2024.151501
Kaitlyn E. Order MD, Nancy M. Rodig MD
Children with end-stage kidney disease (ESKD) face a lifetime of complex medical care, alternating between maintenance chronic dialysis and kidney transplantation. Kidney transplantation has emerged as the optimal treatment of ESKD for children and provides important quality of life and survival advantages. Although transplantation is the preferred therapy, lifetime exposure to immunosuppression among children with ESKD is associated with increased morbidity, including an increased risk of cancer. Following pediatric kidney transplantation, cancer events occurring during childhood or young adulthood can be divided into two broad categories: post-transplant lymphoproliferative disorders and non-lymphoproliferative solid tumors. This review provides an overview of cancer incidence, types, outcomes, and preventive strategies in this population.
{"title":"Pediatric Kidney Transplantation: Cancer and Cancer Risk","authors":"Kaitlyn E. Order MD, Nancy M. Rodig MD","doi":"10.1016/j.semnephrol.2024.151501","DOIUrl":"10.1016/j.semnephrol.2024.151501","url":null,"abstract":"<div><p>Children with end-stage kidney disease (ESKD) face a lifetime of complex medical care, alternating between maintenance chronic dialysis and kidney transplantation. Kidney transplantation has emerged as the optimal treatment of ESKD for children and provides important quality of life and survival advantages. Although transplantation is the preferred therapy, lifetime exposure to immunosuppression among children with ESKD is associated with increased morbidity, including an increased risk of cancer. Following pediatric kidney transplantation, cancer events occurring during childhood or young adulthood can be divided into two broad categories: post-transplant lymphoproliferative disorders and non-lymphoproliferative solid tumors. This review provides an overview of cancer incidence, types, outcomes, and preventive strategies in this population.</p></div>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":2.8,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140788705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-28DOI: 10.1016/j.semnephrol.2023.151466
Anthony Batte, Lubaba Shahrin, Rolando Claure-Del Granado, Valerie A. Luyckx, Andrea L. Conroy
Globally, there are an estimated 13.3 million cases of acute kidney injury (AKI) annually. Although infections are a common cause of AKI globally, most infection-associated AKI occurs in low- and lower-middle-income countries. There are marked differences in the etiology of infection-associated AKI across age groups, populations at risk, and geographic location. This article provides a global overview of different infections that are associated commonly with AKI, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), human immunodeficiency virus, malaria, dengue, leptospirosis, tick-borne illnesses, and viral hemorrhagic fevers. Further discussion focuses on infectious conditions associated with AKI including sepsis, diarrheal diseases and pregnancy, peripartum and neonatal AKI. This article also discusses the future of infection-associated AKI in the framework of climate change. It explores how increased investment in achieving the sustainable development goals may contribute to the International Society of Nephrology's 0 by 25 objective to curtail avoidable AKI-related fatalities by 2025.
据估计,全球每年有 1330 万例急性肾损伤(AKI)病例。虽然感染是全球 AKI 的常见病因,但大多数感染相关性 AKI 发生在低收入和中低收入国家。感染相关性 AKI 的病因在不同年龄组、高危人群和地理位置之间存在明显差异。本文概述了常见的与 AKI 相关的各种感染,包括严重急性呼吸系统综合征冠状病毒 2(SARS-CoV-2)、人类免疫缺陷病毒、疟疾、登革热、钩端螺旋体病、蜱媒疾病和病毒性出血热。文章还重点讨论了与 AKI 相关的感染性疾病,包括败血症、腹泻疾病以及妊娠、围产期和新生儿 AKI。本文还讨论了气候变化框架下与感染相关的 AKI 的未来。文章探讨了在实现可持续发展目标方面增加投资如何有助于实现国际肾脏病学会的 "0 by 25 "目标,即到 2025 年减少可避免的 AKI 相关死亡。
{"title":"Infections and Acute Kidney Injury: A Global Perspective","authors":"Anthony Batte, Lubaba Shahrin, Rolando Claure-Del Granado, Valerie A. Luyckx, Andrea L. Conroy","doi":"10.1016/j.semnephrol.2023.151466","DOIUrl":"https://doi.org/10.1016/j.semnephrol.2023.151466","url":null,"abstract":"<p>Globally, there are an estimated 13.3 million cases of acute kidney injury<span><span><span> (AKI) annually. Although infections are a common cause of AKI globally, most infection-associated AKI occurs in low- and lower-middle-income countries. There are marked differences in the etiology of infection-associated AKI across age groups, populations at risk, and geographic location. This article provides a global overview of different infections that are associated commonly with AKI, including severe acute respiratory syndrome coronavirus 2<span> (SARS-CoV-2), human immunodeficiency virus, malaria, dengue, </span></span>leptospirosis, tick-borne illnesses, and </span>viral hemorrhagic fevers<span>. Further discussion focuses on infectious conditions associated with AKI including sepsis, diarrheal diseases and pregnancy, peripartum and neonatal AKI. This article also discusses the future of infection-associated AKI in the framework of climate change. It explores how increased investment in achieving the sustainable development goals may contribute to the International Society of Nephrology's 0 by 25 objective to curtail avoidable AKI-related fatalities by 2025.</span></span></p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-12-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139068524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-18DOI: 10.1016/j.semnephrol.2023.151464
Saraladevi Naicker, Chih-Wei Yang, Vivekanand Jha
Abstract not available
无摘要
{"title":"Introduction: ISN Frontiers Meeting on “Infections and the Kidney”","authors":"Saraladevi Naicker, Chih-Wei Yang, Vivekanand Jha","doi":"10.1016/j.semnephrol.2023.151464","DOIUrl":"https://doi.org/10.1016/j.semnephrol.2023.151464","url":null,"abstract":"Abstract not available","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138742675","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-13DOI: 10.1016/j.semnephrol.2023.151483
Florine V Janssens, Björn Meijers, Karlien François
Heparin is the most widely used anticoagulant for maintaining patency of the extracorporeal blood circuit during intermittent hemodialysis. Inadvertently, this leads to systemic heparinization of the patient. Repeated intermittent heparinization during hemodialysis has been associated with increased bleeding risks and metabolic and immunologic effects. Alternative strategies for minimizing systemic anticoagulation encompass dilution methods, regional citrate anticoagulation, priming of the extracorporeal circuit, and modifications to dialyzer membranes and dialysate composition. The effectiveness of these alternatives in maintaining patency of the extracorporeal circuit varies substantially. Although most studies have focused on particular changes in the hemodialysis setup, several combined interventions for adapting the hemodialysis setup are now being studied. This narrative review aims to present an overview of the current landscape of hemodialysis setup strategies aimed at limiting or avoiding systemic anticoagulation during treatment. Additionally, this review intends to shed light on the underlying pathophysiological mechanisms that contribute to variations observed in reported outcomes.
{"title":"Avoiding Systemic Heparinization During Hemodialysis: How the Dialysis Setup Might Help.","authors":"Florine V Janssens, Björn Meijers, Karlien François","doi":"10.1016/j.semnephrol.2023.151483","DOIUrl":"10.1016/j.semnephrol.2023.151483","url":null,"abstract":"<p><p>Heparin is the most widely used anticoagulant for maintaining patency of the extracorporeal blood circuit during intermittent hemodialysis. Inadvertently, this leads to systemic heparinization of the patient. Repeated intermittent heparinization during hemodialysis has been associated with increased bleeding risks and metabolic and immunologic effects. Alternative strategies for minimizing systemic anticoagulation encompass dilution methods, regional citrate anticoagulation, priming of the extracorporeal circuit, and modifications to dialyzer membranes and dialysate composition. The effectiveness of these alternatives in maintaining patency of the extracorporeal circuit varies substantially. Although most studies have focused on particular changes in the hemodialysis setup, several combined interventions for adapting the hemodialysis setup are now being studied. This narrative review aims to present an overview of the current landscape of hemodialysis setup strategies aimed at limiting or avoiding systemic anticoagulation during treatment. Additionally, this review intends to shed light on the underlying pathophysiological mechanisms that contribute to variations observed in reported outcomes.</p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":2.8,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139466992","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-09DOI: 10.1016/j.semnephrol.2023.151480
Bernd Stegmayr, Li Zuo, Ward Zadora
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly prescribed anticoagulants for chronic hemodialysis (HD). The dialysis population comprises a unique group that receives heparin three times per week for a long period, with potential long-term cumulative metabolic effects such as osteoporosis and worsening lipid profile. HD patients have approximately half the number of lipases as healthy individuals, and their lipid metabolism is limited because of this decrease as well as partially inhibited function. Administration of UFH or LMWHs for anticoagulation can lead to metabolic starvation despite high triglyceride levels at the end of HD. In vitro studies indicate that UFH and LMWHs inhibit osteoblasts and promote osteoclasts. In patients on HD, long-term use of UFH or LMWHs did not worsen chronic kidney disease-mineral bone disease. Further investigation is needed to elucidate the underlining mechanisms of UFH and LMWHs and their possible influences on maintenance HD patients.
非减量肝素(UFH)和低分子量肝素(LMWH)是慢性血液透析(HD)的常用抗凝剂。透析人群是一个独特的群体,他们每周三次长期服用肝素,可能会产生长期累积的代谢影响,如骨质疏松症和血脂状况恶化。血液透析患者的脂肪酶数量约为健康人的一半,由于脂肪酶数量减少以及部分功能受到抑制,他们的脂质代谢受到限制。尽管在 HD 结束时甘油三酯水平较高,但为抗凝而服用 UFH 或 LMWHs 可能会导致代谢饥饿。体外研究表明,UFH 和 LMWHs 可抑制成骨细胞,促进破骨细胞。在接受 HD 的患者中,长期使用 UFH 或 LMWHs 不会加重慢性肾病-矿物质骨病。要阐明 UFH 和 LMWHs 的基本机制及其对维持性 HD 患者可能产生的影响,还需要进一步的研究。
{"title":"Lipid and Bone Effects of Heparin Use During Hemodialysis.","authors":"Bernd Stegmayr, Li Zuo, Ward Zadora","doi":"10.1016/j.semnephrol.2023.151480","DOIUrl":"10.1016/j.semnephrol.2023.151480","url":null,"abstract":"<p><p>Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly prescribed anticoagulants for chronic hemodialysis (HD). The dialysis population comprises a unique group that receives heparin three times per week for a long period, with potential long-term cumulative metabolic effects such as osteoporosis and worsening lipid profile. HD patients have approximately half the number of lipases as healthy individuals, and their lipid metabolism is limited because of this decrease as well as partially inhibited function. Administration of UFH or LMWHs for anticoagulation can lead to metabolic starvation despite high triglyceride levels at the end of HD. In vitro studies indicate that UFH and LMWHs inhibit osteoblasts and promote osteoclasts. In patients on HD, long-term use of UFH or LMWHs did not worsen chronic kidney disease-mineral bone disease. Further investigation is needed to elucidate the underlining mechanisms of UFH and LMWHs and their possible influences on maintenance HD patients.</p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139404283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-23DOI: 10.1016/j.semnephrol.2023.151482
Hideki Kawanishi, Masahide Koremoto, Casper F M Franssen, Marco van Londen
The development of biocompatible membranes, aiming to limit the inflammatory response, oxidative stress, and coagulability during hemodialysis, has been an important step in reducing dialysis-related adverse outcomes. This includes a reduction in the risk of clotting of the extracorporeal circuit, thus enabling hemodialysis with a reduced dose or even without systemic anticoagulant drugs in patients with an increased bleeding risk. In this article, we summarize the in vitro research and clinical evidence on the antithrombotic properties of vitamin E- and heparin-coated membranes.
生物相容性膜的开发旨在限制血液透析过程中的炎症反应、氧化应激和凝固性,是减少透析相关不良后果的重要一步。这包括降低体外循环的凝血风险,从而使出血风险增加的患者能够减少血液透析的剂量,甚至不使用全身抗凝药物。在本文中,我们总结了有关维生素 E 和肝素涂层膜抗血栓特性的体外研究和临床证据。
{"title":"Clotting Propensity of Surface-Treated Membranes in a Hemodialysis Set-up That Avoids Systemic Anticoagulation.","authors":"Hideki Kawanishi, Masahide Koremoto, Casper F M Franssen, Marco van Londen","doi":"10.1016/j.semnephrol.2023.151482","DOIUrl":"10.1016/j.semnephrol.2023.151482","url":null,"abstract":"<p><p>The development of biocompatible membranes, aiming to limit the inflammatory response, oxidative stress, and coagulability during hemodialysis, has been an important step in reducing dialysis-related adverse outcomes. This includes a reduction in the risk of clotting of the extracorporeal circuit, thus enabling hemodialysis with a reduced dose or even without systemic anticoagulant drugs in patients with an increased bleeding risk. In this article, we summarize the in vitro research and clinical evidence on the antithrombotic properties of vitamin E- and heparin-coated membranes.</p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139542911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-10DOI: 10.1016/j.semnephrol.2023.151485
Karlien François, Björn Meijers
{"title":"Anticoagulation for Hemodialysis: A Hidden Quest to Ensure Safe Dialysis.","authors":"Karlien François, Björn Meijers","doi":"10.1016/j.semnephrol.2023.151485","DOIUrl":"10.1016/j.semnephrol.2023.151485","url":null,"abstract":"","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139417992","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-24DOI: 10.1016/j.semnephrol.2023.151484
Matthew Ades, Camille Simard, Thomas Vanassche, Peter Verhamme, John Eikelboom, Thomas A Mavrakanas
Patients with end-stage kidney disease (ESKD) experience a high thrombotic risk but are also at increased risk of bleeding. There is an unmet need for safer antithrombotic therapy in patients with ESKD on hemodialysis. Factor XI (FXI) represents an attractive therapeutic target for anticoagulation because of the potential to mitigate the bleeding risks associated with currently approved anticoagulants, especially in patients at high risk of bleeding. FXI inhibition is also an attractive option in settings where coagulation is activated by exposure of the blood to artificial surfaces, including the extracorporeal circuit during hemodialysis. Therapies targeting FXI that are in the most advanced stages of clinical development include antisense oligonucleotides, monoclonal antibodies, and synthetic small molecules, which serve either to lower FXI levels or block its physiological effects. This review article presents the most recent pharmacological data with FXI inhibitors, briefly describes phase 2 and 3 clinical trials with these agents, and critically examines the potential future use of FXI inhibitors for extracorporeal circuit anticoagulation in patients with ESKD. In addition, laboratory monitoring and reversal of FXI inhibitors are briefly discussed.
{"title":"Factor XI Inhibitors: Potential Role in End-Stage Kidney Disease.","authors":"Matthew Ades, Camille Simard, Thomas Vanassche, Peter Verhamme, John Eikelboom, Thomas A Mavrakanas","doi":"10.1016/j.semnephrol.2023.151484","DOIUrl":"10.1016/j.semnephrol.2023.151484","url":null,"abstract":"<p><p>Patients with end-stage kidney disease (ESKD) experience a high thrombotic risk but are also at increased risk of bleeding. There is an unmet need for safer antithrombotic therapy in patients with ESKD on hemodialysis. Factor XI (FXI) represents an attractive therapeutic target for anticoagulation because of the potential to mitigate the bleeding risks associated with currently approved anticoagulants, especially in patients at high risk of bleeding. FXI inhibition is also an attractive option in settings where coagulation is activated by exposure of the blood to artificial surfaces, including the extracorporeal circuit during hemodialysis. Therapies targeting FXI that are in the most advanced stages of clinical development include antisense oligonucleotides, monoclonal antibodies, and synthetic small molecules, which serve either to lower FXI levels or block its physiological effects. This review article presents the most recent pharmacological data with FXI inhibitors, briefly describes phase 2 and 3 clinical trials with these agents, and critically examines the potential future use of FXI inhibitors for extracorporeal circuit anticoagulation in patients with ESKD. In addition, laboratory monitoring and reversal of FXI inhibitors are briefly discussed.</p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139565007","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-17DOI: 10.1016/j.semnephrol.2023.151475
Chandana Guha, Daniel Gallego, Amanda Grandinetti, Madeleine Warren, Allison Jaure
Clotting of the extracorporeal circuit is a complication in the process of hemodialysis that can result in missed or shortened dialysis sessions, higher nursing workload, and elevated cost of treatment. Repercussions of inadequate dialysis may include patient blood loss, fluid overload, build-up of minerals, higher hospitalization rates, and poor quality of life, contributing to increased patient distress. Preventing clotting through anticoagulation therapy is the key to maintaining patency of the dialysis circuit and supporting dialysis adequacy. Despite the severe consequences of clotting in the extracorporeal circuit patients encounter, their perspectives on decision-making regarding anticoagulation therapy are not well known. In this article, we discuss patients' perspectives and priorities around clotting and anticoagulation therapy and outline ways to support their treatment through shared decision-making. Insights into patients' perspectives on addressing thrombotic complications of the extracorporeal circuit can inform strategies to improve care and outcomes for patients receiving hemodialysis.
{"title":"Patient Perspectives on Clotting in the Extracorporeal Circuit and Decision-Making Regarding Anticoagulation Therapy.","authors":"Chandana Guha, Daniel Gallego, Amanda Grandinetti, Madeleine Warren, Allison Jaure","doi":"10.1016/j.semnephrol.2023.151475","DOIUrl":"10.1016/j.semnephrol.2023.151475","url":null,"abstract":"<p><p>Clotting of the extracorporeal circuit is a complication in the process of hemodialysis that can result in missed or shortened dialysis sessions, higher nursing workload, and elevated cost of treatment. Repercussions of inadequate dialysis may include patient blood loss, fluid overload, build-up of minerals, higher hospitalization rates, and poor quality of life, contributing to increased patient distress. Preventing clotting through anticoagulation therapy is the key to maintaining patency of the dialysis circuit and supporting dialysis adequacy. Despite the severe consequences of clotting in the extracorporeal circuit patients encounter, their perspectives on decision-making regarding anticoagulation therapy are not well known. In this article, we discuss patients' perspectives and priorities around clotting and anticoagulation therapy and outline ways to support their treatment through shared decision-making. Insights into patients' perspectives on addressing thrombotic complications of the extracorporeal circuit can inform strategies to improve care and outcomes for patients receiving hemodialysis.</p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":2.8,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139486355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01Epub Date: 2024-01-08DOI: 10.1016/j.semnephrol.2023.151479
Theodore E Warkentin
Intermittent hemodialysis (HD) is almost invariably performed with heparin, and thus HD patients are at risk of developing the immune-mediated adverse effect heparin-induced thrombocytopenia (HIT), caused by anti-platelet factor 4/heparin IgG, which strongly activates platelets. HIT patients develop hypercoagulability with greatly increased risk of thrombosis, both venous and arterial. Certain HIT-associated complications are more likely to develop among HD patients, including hemofilter thrombosis despite heparin, intravascular catheter and/or arteriovenous fistula-associated thrombosis, post-heparin bolus anaphylactoid/anaphylactic reactions, and thrombotic stroke and acute limb artery thrombosis (reflecting the high frequency of underlying arteriopathy in many patients with renal failure). Management of HIT in HD usually requires use of an alternative (non-heparin) anticoagulant; for example, danaparoid sodium (outside the USA) or argatroban (USA and elsewhere). Whether heparin-grafted hemodialyzers (without systemic heparin) can be used safely in acute HIT is unknown. The HIT immune response is remarkably transient and usually not retriggered by subsequent heparin administration. Accordingly, since renal failure patients often require long-term HD, there may be the opportunity-following seroreversion (loss of platelet-activating HIT antibodies)-to restart heparin for HD, a practice that appears to have a low likelihood of retriggering HIT.
间歇性血液透析(HD)几乎无一例外地使用肝素,因此,HD 患者有可能患上肝素诱导的血小板减少症(HIT),这种免疫介导的不良反应是由抗血小板因子 4/肝素 IgG 引起的,它会强烈激活血小板。HIT 患者会出现高凝状态,大大增加静脉和动脉血栓形成的风险。血液透析患者更容易出现某些与 HIT 相关的并发症,包括使用肝素后仍出现的血液滤器血栓形成、血管内导管和/或动静脉瘘相关血栓形成、肝素栓剂注射后过敏性反应、血栓性中风和急性肢体动脉血栓形成(反映出许多肾功能衰竭患者存在高频率的潜在动脉病变)。处理 HD 中的 HIT 通常需要使用替代(非肝素)抗凝剂,例如达那帕罗钠(美国以外)或阿加曲班(美国和其他国家)。肝素移植血液透析器(无全身肝素)能否安全用于急性 HIT 尚不清楚。HIT 免疫反应具有明显的短暂性,通常不会因后续肝素给药而再次触发。因此,由于肾衰竭患者通常需要长期进行血液透析,因此在血清转换(血小板激活型 HIT 抗体消失)后可能有机会重新开始使用肝素进行血液透析,而这种做法再次引发 HIT 的可能性似乎很低。
{"title":"Immunologic Effects of Heparin Associated With Hemodialysis: Focus on Heparin-Induced Thrombocytopenia.","authors":"Theodore E Warkentin","doi":"10.1016/j.semnephrol.2023.151479","DOIUrl":"10.1016/j.semnephrol.2023.151479","url":null,"abstract":"<p><p>Intermittent hemodialysis (HD) is almost invariably performed with heparin, and thus HD patients are at risk of developing the immune-mediated adverse effect heparin-induced thrombocytopenia (HIT), caused by anti-platelet factor 4/heparin IgG, which strongly activates platelets. HIT patients develop hypercoagulability with greatly increased risk of thrombosis, both venous and arterial. Certain HIT-associated complications are more likely to develop among HD patients, including hemofilter thrombosis despite heparin, intravascular catheter and/or arteriovenous fistula-associated thrombosis, post-heparin bolus anaphylactoid/anaphylactic reactions, and thrombotic stroke and acute limb artery thrombosis (reflecting the high frequency of underlying arteriopathy in many patients with renal failure). Management of HIT in HD usually requires use of an alternative (non-heparin) anticoagulant; for example, danaparoid sodium (outside the USA) or argatroban (USA and elsewhere). Whether heparin-grafted hemodialyzers (without systemic heparin) can be used safely in acute HIT is unknown. The HIT immune response is remarkably transient and usually not retriggered by subsequent heparin administration. Accordingly, since renal failure patients often require long-term HD, there may be the opportunity-following seroreversion (loss of platelet-activating HIT antibodies)-to restart heparin for HD, a practice that appears to have a low likelihood of retriggering HIT.</p>","PeriodicalId":21756,"journal":{"name":"Seminars in nephrology","volume":null,"pages":null},"PeriodicalIF":3.3,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139404282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}