Dialysis & Transplantation最新文献

On June 24 the U.S. Food and Drug Administration (FDA) made a major modification to the erythropoiesis stimulating agent (ESA) label, recommending fundamental changes to how ESAs are used to manage chronic kidney disease (CKD) anemia (Table I).1 The FDA emphasized there should be a paradigm shift from aiming for a hemoglobin (Hgb) target range of 10 to 12 g/dL to using the lowest possible dose of ESA to prevent a blood transfusion. Treatment of CKD anemia with ESA therapy should be individualized and, the FDA pointed out, no Hgb target level or ESA dosing strategy should be considered without adverse risk. The FDA has gone further than many would have predicted, but the important issue is how clinicians are going to respond to these label changes in altering their clinical practice. In this article, I will evaluate how these guidelines can be applied to clinical case scenarios that are common in clinical practice. A more detailed discussion of the evidence is published elsewhere.2, 3

CMS's proposed rules for accountable care organizations have some members of the renal community concerned, while others see potential for improved care for kidney patients

A new acronym is swimming in the healthcare alphabet soup: ACO, which stands for accountable care organization. And just as HMO and PPO have made it into the popular lexicon, ACO is rapidly moving from the world of policy wonks onto the radar of concerned patients, clinicians, and other care providers. That's because one of the provisions of the Patient Protection and Affordable Care Act passed last year will allow ACOs to start contracting with Medicare in January 2012 as part of the Medicare Shared Savings Program. Response to this development from members of the renal community has ranged from cautious optimism to concern that kidney patients may get the short shrift.

Despite the continued growth of diverse populations on dialysis, no prior studies have comprehensively compared the barriers to kidney transplantation among different racial and ethnic groups. This brief review summarizes key findings from a recent study that examined specific determinants of diminished access to, or delayed completion of, deceased-donor kidney transplantation among major racial-ethnic groups in the United States. In particular, we focus on the relative influence on transplantation rates of clinical factors, such as histocompatibility, residential geography, health insurance coverage, poverty, and other socioeconomic factors according to patient race or ethnicity. Dial. Transplant. © 2011 Wiley Periodicals, Inc.

In August 1998, my family doctor scheduled me for a complete physical after noticing that my blood pressure readings had been elevated the last two visits.When I returned for my follow-up, he advised me that my creatinine and protein numbers were alarming, and he referred me to a nephrologist.

My nephrologistdiagnosed me with end-stage renal disease so advanced that I only had 10% kidney function remaining.After I got past the initial shock, we discussed dialysis options.

My first thoughts were purely cosmetic.As a middle school physical education teacher, my arms and legs are often exposed at work.I wanted to avoid the enlarged veins of hemodialysis if I could.With peritoneal dialysis (PD), the catheter would be hidden under my clothing.The thought of having the somewhat expanded stomach due to the peritoneal fluid did not bother me much.

I read that PDmight provide better clearances, possibly providing me with more energy.Since my job required me to be outside often and could be physically demanding, I wanted the mode of dialysis that would allowme to drink more fluids and give me the best chance at increased energy levels.

During those first days, there seemed to be a basic feeling within the community of patients and healthcare providersthat every dialysis patientends up quitting their jobs, even patients like me with careers and good benefits.I reflected on my brother's experience.Jonathan was on PD during college.In addition to the usual rigors of the college curriculum, he worked with the university band and was a member of a fraternity.Like him, I believed that PD treatment would give me the betterlevel of wellness so I could continue working.

I strongly considered what most people regard as the major drawback to PD—that I would have to do PD nightly and be responsible for lugging heavy boxes or bags of fluids at home.Iknew it would be a pain sometimes, lugging all the supplies.I knew that I would have to regularly miss activities whenever I would have to “hook-up.” Essentially, I would have to resign myself to becoming room-bound at night.Still, the pros outweighed the cons and I decided that PD would be the best mode of dialysis for me.

When I initiated PD in 1999, I was a little nervous about having to be so meticulous with the self care. The only complication I had was a case of peritonitis that was resolved without too much difficulty. Before long, I felt the benefits. PDgave me the most flexibility to be free on weekends so that I could travel. My mode of treatment was the continuous cycler-assisted dialysis, but I performed manual exchanges whenever I traveled by air. I estimate that between 2000 and 2004, I took 40 flights around the country, performing manual PD each trip.

In February 2006, the doctors removed my catheter following a successful kidney transplant. This catheter had been my lifeline for seven years! My success with PD can be attributed to extensive patient training, pers

Hemodialysis today has evolved into a highly technical treatment in which knowledge of the physics and chemistry of the dialysis treatment system as well as knowledge of individual patient's pathology allows for a better understanding of how the treatment is best performed and individually modified. The “treatment prescription” is a set of specific treatment parameters that includes the treatment duration and frequency, the choice of dialyzer, and the specifics of the dialysate composition. It is imperative that the nephrologist understand how to deliver the most optimal treatment that is additionally the most cost effective.

In short, hemodialysis is the process by which a patient's blood can be chemically modified by driving it through a device (dialyzer) that allows for the removal of substances (blood solutes) as well as the gain of substances (dialysate solutes) with the additional option of the simultaneous removal of plasma water. It has evolved for almost a century but remains dependent on the chemical properties of a semipermeable membrane that is selective to the movement of solute and resistive to the movement of solvent. The primary purpose of dialysis is to eliminate uremic poisons in patients with end-stage renal disease and to modify serum electrolytes so as to mimic the appropriate serum composition of healthy individuals.

A dialyzer can be classified based on properties of the chemical composition of its membrane or based on its properties of solute removal (most commonly urea removal) and solvent permeability (most commonly water, termed hydraulic permeability) under specific operating conditions (blood flow rate [QB in mL/min] and dialysate flow rate [QD in mL/min]). Some dialyzers are more efficient at solute removal and are termed high-efficiency, whereas other dialyzers have lesser resistance to water movement and are termed high-flux. Dialyzer membrane properties have been recently reviewed.1

in which the dialyzer's ability to remove a solute K is proportional to the product of the mass transfer coefficient of that dialyzer's membrane (Ko) and the membrane surface area (A). KoA is specific to a particular solute (such as urea) and is independent of QB and QD (assumption of the model). The KoA of a particular dialyzer is provided by the manufacturer, is determined in vitro in aqueous solutions, and usually overestimates by about 20% when compared with in vivo blood-based solutions containing proteins and red blood cells.

It is difficult to fully appreciate the relationships among KoA, QB, and QD. Figure 1 presents these relationships graphically, depicting urea clearance K as a function of QB for a dialyzer KoA of 1,000 and three separate QDs of 1,000, 500, and 400 mL/min (from the top curve down).

At lower QBs, the clearance (K) is linear with QD, but as QB increases closer to QD, there is a diminishing benefit of increasing QB further (as QD becomes clearan

There are many obstacles to leap across on the road to successful rehabilitation for someone diagnosed with end-stage renal disease (ESRD). Yet, there is likely no obstacle perceived by the professional that is larger than the obstacles perceived by the patient. Life Options Rehabilitation Advisory Council (LORAC) provided the opportunity for a paradigm shift in rehabilitation thinking in the mid-1990 s.

The moments of our first encounter with patients are important. At different stages of chronic kidney disease (CKD), we may feel the need to communicate a great deal medically. If the patient can see the reflection of hope in the people they are working with, their hope endures and increases during the time(s) of crisis. With hope, we can conquer much more than without it.

In terms of employment, research has shown that it is easier to help someone stay employed than to have an interruption in employment and help them to prepare for and seek re-employment. However, whether the patient is working as they prepare for transplant or if they are on dialysis and haven't worked for some time as they prepare for transplant, planning for return to work begins prior to transplant.

If the “game plan” is not communicated to the dialysis team, the chances of executing the “play” are not good. Looking for a win-win in an ideal world, if a patient has stopped working, he or she could engage with their state rehabilitation agency to consider part-time work that would keep a resume active and build self-esteem, consider skill building while awaiting transplant, or consider volunteer work. With the transplant waiting list hovering at 90,000 for kidneys, we want to help the patient plan realistically if they do not have a living donor.

Working with state vocational rehabilitation counselors (VRC) is not without barriers. Helping VRC understand the opportunities available to them in working with patients who have kidney failure can increase the likelihood of success. Therefore, continuous education as well as building partnerships increases potential for patients and successful outcomes. A valuable resource is the 27th Institute on Rehabilitation Issues.3 This resource was developed to help vocational counselors understand the unique opportunities available to them as they work with people who have kidney failure.

Let's examine how we help patients to see that yes, it may be a difficult time when initiating dialysis; yes, there may be bumps in the road as they go through treatment. However, keeping life as much the same as it was before dialysis or transplant will help the patient feel as if chronic kidney disease is a part of their life, not all of their life.

The Medical Education Insitute's “Renal Rehabilitation: Bridging the Barriers” provided a formal definition of rehabilitation created by a multidisciplinary team of experts assembled by LORAC: “The ideal proce

As our awareness of chronic kidney disease (CKD) rolls over into a new era of bundling, improved treatment options, and medicinal choices, so our knowledge of nutrition and its impact on disease management also evolves. For decades, vegetarianism and kidney disease has been seen as an oil-and-water amalgamation. Dietitians have been challenged to align diet recommendations with vegetarian-type diets. Dietitians may struggle with concerns that more plant-based diets would be lacking in protein or would be high potassium and phosphorus. However, just as we have advanced in our understanding of so many aspects of kidney disease, we can now appreciate that a plant-based diet can work to our patient's advantage and, by learning these advantages, feel more comfortable with working these foods into patient meal planning.

Although studies are small, several support the idea that plant-based diets can delay the progression of CKD, provide endothelial protection, control high blood pressure, and decrease proteinuria.1-10 These days, our dialysis patients seldom die secondary to high potassium or uremia. Many of our patients now face the same diseases as the general population: heart disease, cancer, and strokes.11 A plant-based diet provides nutrients that not only assist in kidney disease management but also can provide an edge of protection against costly, debilitating complications.8

In a poll conducted by the Vegetarian Resource Group in 2009, it was found that 3% of American adults did not eat red meat, fish, or poultry, and a third of those did not eat dairy, eggs, or honey. The same survey found that 8% of American adults did not eat red meat. As a result, the chances of having a patient who chooses to eat vegetarian based on preference may be low, and a dietician may choose to encourage plant-based options for beneficial health reasons. This includes preventing the co-morbid conditions associated with kidney disease, kidney disease progression, or possibly kidney disease itself.

Hydroxocobalamin was approved by the Food and Drug Administration in 2006 to treat known or suspected cyanide toxicity.1 Cyanide is a potent toxin that inhibits numerous metal-containing enzymes, including cytochrome oxidases, which leads to cellular hypoxia, cardiovascular collapse, and frequently death.2 Hydroxocobalamin is the naturally occurring form of vitamin B₁₂, and its therapeutic effects are believed to be from chelation of cyanide by the central cobalt atom and the subsequent formation of cyanocobalamin, which is then renally eliminated.3 It has been shown to be well tolerated in animal and human studies, with minimal adverse effects.4 One of the few known adverse effects from hydroxocobalamin is a dark red discoloration of skin and body fluids, which can lead to interference with several colorometric laboratory tests.5-8 There is one prior case report in the literature describing the inability to perform intermittent hemodialysis after administration of hydroxocobalamin due to the red pigment triggering the blood leak detector on the hemodialysis machine.9 In this article, we describe the first reported case of using continuous renal replacement therapy (CRRT) to overcome the hydroxocobalamin-related interference with hemodialysis.

A 33-year-old man was transported to the emergency department by paramedics after he was found unresponsive in a parking lot. The patient was unable to provide any history; however, there was no obvious sign of trauma. Upon arrival, the patient was placed on 100% oxygen by non-rebreather facemask and had the following vital signs: pulse 120 beats/min, blood pressure 189/95 mmHg, respiratory rate 35/min, and temperature 96.6°F. Physical examination revealed a depressed level of consciousness, rapid and deep respirations, normal-sized reactive pupils, absence of any external signs of trauma, and withdrawal to painful stimuli in all extremities. Finger stick glucose was 147 mg/dL. For airway protection the patient was endotracheally intubated by rapid sequence induction. An initial blood gas, ordered and reported as venous, but later determined to be arterial, revealed a pH of 6.92, pCO₂ of 41 mmHg, pO₂ of 198 mmHg, and carboxyhemoglobin of 0.5%.

Further lab tests revealed: sodium 139 mmol/L, potassium 5.0 mmol/L, chloride 100 mmol/L, bicarbonate 8 mmol/L, creatinine 1.31 mg/dL, blood urea nitrogen (BUN) 18 mg/dL, calcium 8.4 mg/dL, lactate 58.8 mg/dL (normal range 4.5–19.8 mg/dL), measured serum osmolarity 306 mOsm/kg, and calculated serum osmolarity 292 mOsm/kg (osmolar gap = 14). Liver enzymes were normal. Serum concentrations of acetaminophen, salicylate, and ethanol were not detectable. Microscopic analysis of the initial urine revealed hippuric acid crystals in a low amount. The toxicology service was consulted and recommended the immediate administration

We report the case of kidney graft dysfunction secondary to ureteral obstruction caused by an inguinal hernia. A 52-year-old renal transplant recipient was admitted to our transplantation unit for abdominal pain and acute rise in serum creatinine level. Radiological work-up showed that the distal transplant ureter was trapped in a left inguinal hernia. After placement of a temporary percutaneous nephrostomy tube and hernia repair by the Shouldice technique, the graft function improved and has remained stable at 1 year of follow-up. Although infrequent, inguinal hernia can be a cause of obstructive uropathy and graft failure in a transplanted kidney, and the Shouldice technique is appropriate for cure of hernia in this setting. Dial. Transplant. © 2011 Wiley Periodicals, Inc.