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Obi Y, Raimann JG, Kalantar-Zadeh K, Murea M. Residual Kidney Function in Hemodialysis: Its Importance and Contribution to Improved Patient Outcomes. Toxins (Basel) 2024; 16:298. [PMID: 39057938 PMCID: PMC11281084 DOI: 10.3390/toxins16070298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 07/28/2024] Open
Abstract
Individuals afflicted with advanced kidney dysfunction who require dialysis for medical management exhibit different degrees of native kidney function, called residual kidney function (RKF), ranging from nil to appreciable levels. The primary focus of this manuscript is to delve into the concept of RKF, a pivotal yet under-represented topic in nephrology. To begin, we unpack the definition and intrinsic nature of RKF. We then juxtapose the efficiency of RKF against that of hemodialysis in preserving homeostatic equilibrium and facilitating physiological functions. Given the complex interplay of RKF and overall patient health, we shed light on the extent of its influence on patient outcomes, particularly in those living with advanced kidney dysfunction and on dialysis. This manuscript subsequently presents methodologies and measures to assess RKF, concluding with the potential benefits of targeted interventions aimed at preserving RKF.
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Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, The University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Jochen G. Raimann
- Renal Research Institute, New York, NY 10065, USA;
- Katz School of Science and Health, Yeshiva University, New York, NY 10033, USA
| | - Kamyar Kalantar-Zadeh
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA;
- The Lundquist Institute at Harbor, UCLA Medical Center, Torrance, CA 90502, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
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Dopierała M, Schwermer K, Hoppe K, Kupczyk M, Pawlaczyk K. Benefits of Preserving Residual Urine Output in Patients Undergoing Maintenance Haemodialysis. Int J Nephrol Renovasc Dis 2023; 16:231-240. [PMID: 37868106 PMCID: PMC10590073 DOI: 10.2147/ijnrd.s421533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/01/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Chronic kidney disease is a widespread medical problem that leads to higher morbidity, mortality, and a decrease in the overall well-being of the general population. This is especially expressed in patients with end-stage renal disease (ESRD) undergoing maintenance haemodialysis. Several variables could be used to evaluate those patients' well-being and mortality risk. One of them is the presence of residual urine output. Materials and Methods The study was conducted on 485 patients treated with maintenance haemodialysis. After enrollment in the study, which consisted of medical history, physical examination, hydration assessment, and blood sampling, each patient was followed up for 24 months. We used residual urine output (RUO) as a measure of residual renal function (RRF). The entire cohort was divided into 4 subgroups based on the daily urinary output (<=100mL per day, >100mL to <=500mL, >500mL to <=1000mL and >1000mL). Results The data show that the mortality rate was significantly higher in groups with lower RUO, which was caused mainly by cardiovascular events. Also, patients with higher RUO achieved better sodium, potassium, calcium, and phosphate balance. They were also less prone to overhydration and had a better nutritional status. Preserved RRF also had a positive impact on markers of cardiovascular damage, such as NT-proBNP as well as TnT. Conclusion In conclusion, preserving residual urine output in ESRD patients undergoing maintenance haemodialysis is invaluable in reducing their morbidity and mortality rates and enhancing other favourable parameters of those patients.
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Affiliation(s)
- Mikołaj Dopierała
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Schwermer
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Hoppe
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Małgorzata Kupczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Pawlaczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Matsuoka D, Hirabayashi K, Murase T, Saito S, Nakazawa Y. Comment on: Assessment of kidney function using inulin-based and estimated glomerular filtration rates before and after allogeneic hematopoietic stem cell transplantation in pediatric patients. Pediatr Blood Cancer 2022; 69:e29634. [PMID: 35234332 DOI: 10.1002/pbc.29634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Daisuke Matsuoka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichi Hirabayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsubasa Murase
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shoji Saito
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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Human Umbilical Cord Mesenchymal Stem Cell-Derived Small Extracellular Vesicles Ameliorated Insulin Resistance in Type 2 Diabetes Mellitus Rats. Pharmaceutics 2022; 14:pharmaceutics14030649. [PMID: 35336023 PMCID: PMC8948940 DOI: 10.3390/pharmaceutics14030649] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022] Open
Abstract
Human umbilical cord mesenchymal stem cell-derived small extracellular vesicle (hUC-MSCs-sEVs) therapy has shown promising results to treat diabetes mellitus in preclinical studies. However, the dosage of MSCs-sEVs in animal studies, up to 10 mg/kg, was considered high and may be impractical for future clinical application. This study aims to investigate the efficacy of low-dose hUC-MSCs-sEVs treatment on human skeletal muscle cells (HSkMCs) and type 2 diabetes mellitus (T2DM) rats. Treatment with hUC-MSCs-sEVs up to 100 μg/mL for 48 h showed no significant cytotoxicity. Interestingly, 20 μg/mL of hUC-MSCs-sEVs-treated HSkMCs increased glucose uptake by 80–90% compared to untreated cells. The hUC-MSCs-sEVs treatment at 1 mg/kg improved glucose tolerance in T2DM rats and showed a protective effect on complete blood count. Moreover, an improvement in serum HbA1c was observed in diabetic rats treated with 0.5 and 1 mg/kg of hUC-MSCs-sEVs, and hUC-MSCs. The biochemical tests of hUC-MSCs-sEVs treatment groups showed no significant creatinine changes, elevated alanine aminotransferase (ALT) and alkaline phosphatase (ALP) levels compared to the normal group. Histological analysis revealed that hUC-MSCs-sEVs relieved the structural damage to the pancreas, kidney and liver. The findings suggest that hUC-MSCs-sEVs could ameliorate insulin resistance and exert protective effects on T2DM rats. Therefore, hUC-MSCs-sEVs could serve as a potential therapy for diabetes mellitus.
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Okuda Y, Hamada R, Uemura O, Sakai T, Sawai T, Harada R, Hamasaki Y, Ishikura K, Hataya H, Honda M. Mean of creatinine clearance and urea clearance examined over 1 h estimates glomerular filtration rate accurately and precisely in children. Nephrology (Carlton) 2021; 26:763-771. [PMID: 34091977 DOI: 10.1111/nep.13911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 05/25/2021] [Accepted: 05/30/2021] [Indexed: 11/27/2022]
Abstract
AIM Accurate and precise estimation of glomerular filtration rate (GFR) is essential in kidney disease. We evaluated the usefulness of the mean of creatinine clearance (CCr ) and urea clearance (CUN ) examined over a 1-h urine collection period (1-h (CCr + CUN )/2) in a retrospective, cross-sectional study across two centres, as a relatively simple method for estimating GFR in children. METHODS Children aged ≤18 years who underwent inulin clearance (CIn ) tests were eligible. Two clearance values were obtained during a 2-h test consisting of two periods of 1 h each. The mean clearance in two periods was defined as 1-h clearance. 1-h (CCr + CUN )/2, 1-h CCr , 1-h CUN and GFR estimated by Cr-based and cystatin C (CysC)-based formulas for Japanese children were compared with CIn . Bland-Altman plots were used to evaluate correlations. The primary outcome measure was the correlation between 1-h (CCr + CUN )/2 and CIn . RESULTS Fifty-three children were analysed. Their median age was 10.9 (interquartile range [IQR] 5.3-14.2) years, and median CIn and 1-h (CCr + CUN )/2 were 77.0 (IQR: 51.5-95.1) and 81.0 (IQR: 64.1-97.7) ml/min/1.73 m2 , respectively. Percentage difference of CIn and 1-h (CCr + CUN )/2 in the Bland-Altman plot was -11.2% (95% confidence interval - 15.3% - -7.1%), with 95% lower and upper limits of agreement of -40.3% and 18.0%, respectively. Thus, 1-h (CCr + CUN )/2 was 1.12 times CIn . CONCLUSION 1 h (CCr + CUN )/2 was almost concordant with CIn . 1-h (CCr + CUN )/2 can estimate GFR accurately and precisely, making it a simple and speedy test for use in clinical practice.
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Affiliation(s)
- Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan.,Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan.,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Uemura
- Department of Pediatrics, Ichinomiya Medical Treatment & Habilitation Center, Aichi, Japan
| | - Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan
| | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan
| | - Ryoko Harada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan.,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Liu KD, Forni LG, Heung M, Wu VC, Kellum JA, Mehta RL, Ronco C, Kashani K, Rosner MH, Haase M, Koyner JL. Quality of Care for Acute Kidney Disease: Current Knowledge Gaps and Future Directions. Kidney Int Rep 2020; 5:1634-1642. [PMID: 33102955 PMCID: PMC7569680 DOI: 10.1016/j.ekir.2020.07.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) and acute kidney disease (AKD) are common complications in hospitalized patients and are associated with adverse outcomes. Although consensus guidelines have improved the care of patients with AKI and AKD, guidance regarding quality metrics in the care of patients after an episode of AKI or AKD is limited. For example, few patients receive follow-up laboratory testing of kidney function or post-AKI or AKD care through nephrology or other providers. Recently, the Acute Disease Quality Initiative developed a consensus statement regarding quality improvement goals for patients with AKI or AKD specifically highlighting efforts regarding quality and safety of care after hospital discharge after an episode of AKI or AKD. The goal is to use these measures to identify opportunities for improvement that will positively affect outcomes. We recommend that health care systems quantitate the proportion of patients who need and actually receive follow-up care after the index AKI or AKD hospitalization. The intensity and appropriateness of follow-up care should depend on patient characteristics, severity, duration, and course of AKI of AKD, and should evolve as evidence-based guidelines emerge. Quality indicators for discharged patients with dialysis requiring AKI or AKD should be distinct from end-stage renal disease measures. Besides, there should be specific quality indicators for those still requiring dialysis in the outpatient setting after AKI or AKD. Given the limited preexisting data guiding the care of patients after an episode of AKI or AKD, there is ample opportunity to establish quality measures and potentially improve patient care and outcomes. This review will provide specific evidence-based and expert opinion–based guidance for the care of patients with AKI or AKD after hospital discharge.
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Affiliation(s)
- Kathleen D Liu
- Division of Nephrology, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
- Division of Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego Medical Center, San Diego, San Diego, California, USA
| | - Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, and International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University Magdeburg and Diaverum MVZ, Potsdam, Germany
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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Johnson DW, Mudge DW, Sturtevant JM, Hawley CM, Campbell SB, Isbel NM, Hollett P. Predictors of Decline of Residual Renal Function in New Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080302300311] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
♦ Objective The aim of this study was to prospectively evaluate the risk factors for decline of residual renal function (RRF) in an incident peritoneal dialysis (PD) population. ♦ Design Prospective observational study of an incident PD cohort at a single center. ♦ Setting Tertiary-care institutional dialysis center. ♦ Participants The study included 146 consecutive patients commencing PD at the Princess Alexandra Hospital between 1 August 1995 and 1 July 2001 (mean age 54.8 ± 1.4 years, 42% male, 34% diabetic). Patients with failed renal transplants ( n = 26) were excluded. ♦ Main Measurements Timed urine collections ( n = 642) were performed initially and at 6-month intervals thereafter to measure RRF. The development of anuria was also prospectively recorded. ♦ Results The mean (±SD) follow-up period was 20.5 ± 14.8 months. The median slope of RRF decline was –0.05 mL/minute/month/1.73 m2. Using binary logistic regression, it was shown that the 50% of patients with more rapid RRF loss (< –0.05 mL/min/month/1.73 m2) were more likely to have had a higher initial RRF at commencement of PD [adjusted odds ratio (AOR) 1.83, 95% confidence interval (CI) 1.39 – 2.40] and a higher baseline dialysate/plasma creatinine ratio at 4 hours (D/P creat; AOR 44.6, 95% CI 1.05 – 1900). On multivariate Cox proportional hazards model analysis, time from commencement of PD to development of anuria was independently predicted by baseline RRF [adjusted hazard ratio (HR) 0.81, 95% CI 0.60 – 0.81], D/P creat (HR 2.87, 95% CI 2.06 – 82.3), body surface area (HR 6.23, 95% CI 1.53 – 25.5), dietary protein intake (HR 2.87, 95% CI 1.06 – 7.78), and diabetes mellitus (HR 1.65, 95% CI 1.00 – 2.72). Decline of RRF was independent of age, gender, dialysis modality, urgency of initiation of dialysis, smoking, vascular disease, blood pressure, medications (including angiotensin-converting enzyme inhibitors), duration of follow-up, and peritonitis rate. ♦ Conclusions The results of this study suggest that high baseline RRF and high D/P creat ratio are risk factors for rapid loss of RRF. Moreover, a shorter time to the onset of anuria is independently predicted by low baseline RRF, increased body surface area, high dietary protein intake, and diabetes mellitus. Such at-risk patients should be closely monitored for early signs of inadequate dialysis.
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Affiliation(s)
- David W. Johnson
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - David W. Mudge
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Joanna M. Sturtevant
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Carmel M. Hawley
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Scott B. Campbell
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nicole M. Isbel
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter Hollett
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Holley JL, Aslam N, Bernardini J, Fried L, Piraino B. The Influence of Demographic Factors and Modality on Loss of Residual Renal Function in Incident Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080102100312] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo determine whether gender, race, diabetes, peritoneal dialysis (PD) modality, and comorbid conditions influence loss of residual renal function (RRF).DesignRetrospective study of incident PD patients, using database of prospectively collected demographic, laboratory, and clearance data.SettingPeritoneal Dialysis Registry of the University of Pittsburgh Medical Center.PatientsThe study included 184 continuous ambulatory PD and automated PD patients who had at least two 24-hour urine collections for glomerular filtration rate (GRF) between April 1991 and March 2000. 836 urine collections were analyzed.Outcome MeasuresLoss of RRF was defined as the slope of the decline in GFR as measured by the average of creatinine and urea clearances in 24-hour urine collections. Stepwise forward regression was used to identify demographic and laboratory factors associated with loss of GFR. Spearman correlations were used to assess the significance of associations.ResultsThe median rate of decline of renal function was –0.17 mL/minute/month. Gender, race, diabetes, automated PD, peritoneal equilibration test, protein equivalent of nonprotein nitrogen appearance normalized to body surface area, and serum albumin did not predict loss of RRF. Cardiac disease was the only variable affecting decline of RRF ( p = 0.045).ConclusionModality of PD and patient demographic factors do not contribute to the rate at which RRF is lost in incident PD patients. Additional study of the factors contributing to the decline and maintenance of RRF is needed.
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Affiliation(s)
- Jean L. Holley
- University of Rochester Medical Center, Rochester, New York
| | - Nabeel Aslam
- the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Judith Bernardini
- the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Linda Fried
- the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Beth Piraino
- the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Hiroshige K, Yuu K, Soejima M, Takasugi M, Kuroiwa A. Rapid Decline of Residual Renal Function in Patients on Automated Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686089601600313] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To determine the effect of peritoneal dialysis modalities such as nightly intermittent peritoneal dialysis (NIPD), continuous cyclic peritoneal dialysis (CCPD), and continuous ambulatory peritoneal dialysis (CAPD) on residual renal function. Design A six-month prospective, nonrandomized comparison study. Setting Outpatient CAPD unit of a university hospital. Participants Eighteen end-stage renal disease patients treated by peritoneal dialysis (8 by NIPD, 5 by CCPD, and 5 by CAPD). Interventions Samples from the total dialysate, blood, and 24hour urine collection were obtained monthly. Measurements Urea, creatinine, and beta2-microglobulin concentrations were measured. Renal and peritoneal clearances of each substance and KT/V urea were calculated. Residual renal function (RRF) was estimated by renal creatinine clearance (RCcr). Results No significant differences in age, sex, and primary renal disease among the three groups were noted. In all groups, anemic and hypertensive states were controlled identically, and mean weekly total (renal + peritoneal) KT/V urea (over 2.1/wk) and total creatinine clearance (over 60 L/wk/1.73 m2) were maintained during the whole experimental period. Starting mean RCcr was near 4.0 mL/min/1.73 m2 in all groups. Thereafter, a rapid and significant decline in RRF was demonstrated on NIPD and CCPD. The declining rates of RCcr values at 6 months after starting NIPD and CCPD were -0.29 and -0.34 mL/min/month, respectively, which were much greater than those of CAPD (+0.01 mL/min/month). Conclusion Because of a possibly characteristic progressive loss of RRF in automated peritoneal dialysis (APD), strict regular assessment of RRF should be performed from the start of APD.
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Affiliation(s)
- Kinya Hiroshige
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Kougi Yuu
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Masasuke Soejima
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Masayuki Takasugi
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Akio Kuroiwa
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu City, Japan
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Lameire N, Van Biesen W. The Impact of Residual Renal Function on the Adequacy of Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686089701702s20] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Norbert Lameire
- Renal Division, Department of Internal Medicine, University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Department of Internal Medicine, University Hospital, Ghent, Belgium
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Shemin D, Bostom AG, Lambert C, Hill C, Kitsen J, Kliger AS. Residual Renal Function in a Large Cohort of Peritoneal Dialysis Patients: Change over Time, Impact on Mortality and Nutrition. Perit Dial Int 2020. [DOI: 10.1177/089686080002000411] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ObjectiveResidual renal function contributes importantly to total solute clearance in peritoneal dialysis (PD) patients. This study was designed to examine the progression of residual renal function over time and its impact on nutrition and mortality in PD patients in the six New England states (ME, NH, VT, CT, MA, RI) comprising End Stage Renal Disease (ESRD) Network 1.DesignAs part of the ESRD Clinical Indicators Project, data on 990 PD patients in Network 1 were abstracted from data supplied by dialysis units in the fourth quarter of 1997. This included demographic information; dose of PD in L/day; weekly renal, dialysis, and total Kt/V urea; weekly renal, dialysis, and total creatinine clearance (CCr); serum albumin level; and mortality and transplantation information. Data collection was repeated in the second and fourth quarters of 1998 and in the second quarter of 1999.Patients990 PD patients in Network 1.Outcome MeasuresThe change in total and renal solute clearances over time, the relationship between renal clearance and mortality, and the relationship between renal clearance and nutritional status, as represented by serum albumin.ResultsOver the 2-year period, mean weekly renal Kt/V urea and weekly renal CCr dropped significantly. To examine the effect of residual renal function on mortality, patients were divided into high and low (above and below the median) weekly renal Kt/V urea and weekly renal CCr groups. Patients above the median levels of both weekly renal Kt/V urea and weekly renal CCr had a significantly decreased risk of dying during the observation period, after controlling for age, gender, serum albumin level, and diabetic status [OR for high vs low renal Kt/V urea 0.54 (CI 0.34 – 0.84), OR for high vs low renal CCr 0.61 (CI 0.40 – 0.94)]. The mean weekly renal Kt/V urea was significantly and directly correlated with the mean serum albumin level by Spearman rank correlation ( R = 0.133, p < 0.001), as was the mean weekly renal CCr ( R = 0.115, p < 0.001).ConclusionsResidual renal function is an important contributor to total solute clearance in PD patients. Even at low levels it is linked to decreased mortality and better nutritional status.
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Affiliation(s)
- Douglas Shemin
- Division of Renal Diseases, Rhode Island/Brown University School of Medicine, Providence, Rhode Island
- End Stage Renal Disease Network of New England New Haven, Connecticut, U.S.A
| | - Andrew G. Bostom
- Division of Renal Diseases, Rhode Island/Brown University School of Medicine, Providence, Rhode Island
| | - Cynthia Lambert
- End Stage Renal Disease Network of New England New Haven, Connecticut, U.S.A
| | - Connie Hill
- End Stage Renal Disease Network of New England New Haven, Connecticut, U.S.A
| | - Jenny Kitsen
- End Stage Renal Disease Network of New England New Haven, Connecticut, U.S.A
| | - Alan S. Kliger
- End Stage Renal Disease Network of New England New Haven, Connecticut, U.S.A
- Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Chen CH, Perl J, Teitelbaum I. Prescribing high-quality peritoneal dialysis: The role of preserving residual kidney function. Perit Dial Int 2020; 40:274-281. [DOI: 10.1177/0896860819893821] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Maintenance of residual kidney function (RKF) is independently associated with increased survival in patients with end-stage renal disease. Presence of RKF is also associated with improved volume status, better nutritional status, reduced erythropoietin requirement, and decreased rate of peritonitis in patients on peritoneal dialysis (PD). Thus, the preservation of RKF is an important therapeutic end point in the management of patients on PD. Measurement of RKF in PD patients should be based on the mean of 24-h urinary creatinine and urea clearances, and ideally, this should be done quarterly. Compared to those started on hemodialysis, patients initiated on PD appear to have slower decline in RKF. The choice of PD modality should be based on patient preference, as there is no clear evidence to date showing one modality is superior than the other in preserving RKF. Peritoneal dialysates with neutral pH and low glucose degradation products seem to have a favorable effect on RKF. An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker should be used whenever possible to preserve RKF and reduce cardiac mortality. Both loop diuretics and icodextrin can be utilized to maintain fluid balance in PD patients. However, caution should be taken to avoid volume depletion which could accelerate RKF decline. Short-term use of aminoglycosides does not have a detrimental impact on RKF, but prolonged use (>3 weeks) should be avoided to minimize the risk of ototoxicity. Lastly, potential nephrotoxic agents such as intravenous contrast should be used judiciously.
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Affiliation(s)
- Chang Huei Chen
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeff Perl
- Department of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Isaac Teitelbaum
- Department of Medicine, University of Colorado Health Sciences Center, Aurora, CO, USA
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14
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Murea M, Moossavi S, Garneata L, Kalantar-Zadeh K. Narrative Review of Incremental Hemodialysis. Kidney Int Rep 2019; 5:135-148. [PMID: 32043027 PMCID: PMC7000841 DOI: 10.1016/j.ekir.2019.11.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023] Open
Abstract
The prescription of hemodialysis (HD) in patients with incident end-stage kidney disease (ESKD) is fundamentally empirical. The abrupt transition from nondialysis chronic kidney disease (CKD) to thrice-weekly in-center HD of much the same dialysis intensity as in those with prevalent ESKD underappreciates the progressive nature of kidney disease whereby the decline in renal function has been gradual and ongoing-including at the time of HD initiation. Adjuvant pharmacologic treatment (i.e., diuretics, acid buffers, potassium binders), coupled with residual kidney function (RKF), can complement an initial HD regimen of lower intensity. Barriers to less intensive HD in incident ESKD include risk of inadequate clearance of uremic toxins due to variable and unexpected loss of RKF, lack of patient adherence to assessments of RKF or adjustment of HD intensity, increased burden for all stakeholders in the dialysis units, and negative financial repercussions. A stepped dialysis regimen with scheduled transition from time-delineated twice-weekly HD to thrice-weekly HD could represent an effective and safe strategy to standardize incremental HD in patients with CKD transitioning to early-stage ESKD. Patients' adherence and survival as well as other clinical outcomes should be rigorously evaluated in clinical trials before large-scale implementation of different incremental schedules of HD. This review discusses potential benefits of and barriers to alternative dialysis regimens in patients with incident ESKD, with emphasis on twice-weekly HD with pharmacologic therapy, and summarizes in-progress clinical trials of incremental HD schedules.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Liliana Garneata
- Department of Internal Medicine, Section on Nephrology, "Dr Carol Davila" University Hospital of Nephrology, Bucharest, Romania
| | - Kamyar Kalantar-Zadeh
- Department of Internal Medicine, Section on Nephrology, University of California Irvine School of Medicine, Orange, California, USA
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15
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Predicting Residual Function in Hemodialysis and Hemodiafiltration-A Population Kinetic, Decision Analytic Approach. J Clin Med 2019; 8:jcm8122080. [PMID: 31795401 PMCID: PMC6947429 DOI: 10.3390/jcm8122080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 01/16/2023] Open
Abstract
In this study, we introduce a novel framework for the estimation of residual renal function (RRF), based on the population compartmental kinetic behavior of beta 2 microglobulin (B2M) and its dialytic removal. Using this model, we simulated a large cohort of patients with various levels of RRF receiving either conventional high-flux hemodialysis or on-line hemodiafiltration. These simulations were used to estimate a novel population kinetic (PK) equation for RRF (PK-RRF) that was validated in an external public dataset of real patients. We assessed the performance of the resulting equation(s) against their ability to estimate urea clearance using cross-validation. Our equations were derived entirely from computer simulations and advanced statistical modeling and had extremely high discrimination (Area Under the Curve, AUC 0.888–0.909) when applied to a human dataset of measurements of RRF. A clearance-based equation that utilized predialysis and postdialysis B2M measurements, patient weight, treatment duration and ultrafiltration had higher discrimination than an equation previously derived in humans. Furthermore, the derived equations appeared to have higher clinical usefulness as assessed by Decision Curve Analysis, potentially supporting decisions for individualizing dialysis prescriptions in patients with preserved RRF.
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16
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Steubl D, Inker LA. How best to estimate glomerular filtration rate? Novel filtration markers and their application. Curr Opin Nephrol Hypertens 2019; 27:398-405. [PMID: 30063487 DOI: 10.1097/mnh.0000000000000444] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease is an increasing health burden. Estimating equations using serum concentrations of creatinine and cystatin C facilitate the assessment of kidney function as reflected in estimated glomerular filtration rate (eGFR). Reduced eGFR is associated with increased risk for numerous adverse outcomes and is an important aspect in many clinical situations. However, current equations are suboptimal in some clinical settings. The review focuses on approaches to improve the estimation of GFR and aims to familiarize the reader with the underlying methodological hypotheses how new markers could contribute to improve the overall performance of estimating equations. RECENT FINDINGS Low molecular weight proteins such as β-trace-protein and β-2-microglobulin, as well as newly discovered metabolites, show promise as new filtration markers, as they might be beneficial in populations in which creatinine or cystatin C are inaccurate. We propose that the combination of multiple novel markers, alone or in combination with creatinine, cystatin C or demographics, can potentially improve GFR estimation. For special populations such as dialysis patients, separate equations have been developed to estimate residual kidney function. SUMMARY Current GFR estimating equations are an essential part of routine clinical practice but have limitations. The use of multiple markers combined in a single equation appears to be the most promising approach. Future research is required to validate proposed equations in diverse populations.
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Affiliation(s)
- Dominik Steubl
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA.,Abteilung für Nephrologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
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17
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Kong J, Davies M, Mount P. The importance of residual kidney function in haemodialysis patients. Nephrology (Carlton) 2018; 23:1073-1080. [DOI: 10.1111/nep.13427] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Jessica Kong
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
| | - Matthew Davies
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
| | - Peter Mount
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
- Department of Medicine (Austin Health), Faculty of Medicine, Dentistry and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Institute of Breathing and Sleep (Kidney Laboratory); Austin Health; Melbourne Victoria Australia
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18
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Djukanović LD, Mimić-Oka JI, Potić JB. The Effects of Hemodialysis with Different Membranes on Middle Molecules and Uremic Neuropathy. Int J Artif Organs 2018. [DOI: 10.1177/039139888901200102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Twenty-four hemodialysis patients, 14 with uremic neuropathy and 10 symptom-free, were studied over 12 months. Cuprophan and AN 69 membrane dialyzers were used in their treatment in order to investigate the influence of different membranes on plasma levels of middle molecular weight substances (MMS) and uremic neuropathy. Hemodialysis with the cuprophan membrane caused no significant changes in plasma MMS levels or in the neurological condition of patients. The effect of dialysis with AN 69 membrane depended on initial plasma MMS levels. Initially high plasma MMS levels decreased significantly and significant improvement of neuropathy was achieved. In neuropathic patients with plasma MMS levels similar to those of symptom-free patients, hemodialysis with AN 69 membrane had no effect. These results suggest that hemodialysis with MMS high-permeability membranes may be recommended for neuropathic patients with high plasma MMS levels.
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Affiliation(s)
- L.J. D. Djukanović
- Zvezdara Clinical Hospital Centre, Institute for Kidney Diseases and Metabolic Disorders and Department of Neuropsychiatry
| | - J. I. Mimić-Oka
- Institute of Biochemistry, School of Medicine, Beograd - Yugoslavia
| | - J. B. Potić
- Zvezdara Clinical Hospital Centre, Institute for Kidney Diseases and Metabolic Disorders and Department of Neuropsychiatry
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19
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Iest C, Vanholder R, Ringoir S. Loss of Residual Renal Function in Patients on Regular Haemodialysis. Int J Artif Organs 2018. [DOI: 10.1177/039139888901200305] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The literature offers scant data on loss of residual renal function in chronic haemodialysis patients. The present study was undertaken in 34 patients, to evaluate residual creatinine clearances (CCr) before the start of haemodialysis and after 3, 12 and 24 months. CCr progressively declined from 6.15± 2.61 (before) to 1.40± 1.29 ml.min–1 (after 24 months: p<0.01). The decrease was largest during the first three months of dialysis therapy (slope - 0.99± 1.01 ml.min–1. month-–1 for the first three months vs. – 0.23± 0.12 ml.min–1. month–1 for the entire 24-month period: p<0.01). The decline in Ccr during the first three months was significantly more pronounced in glomerular disease than in tubulo-interstitial disease (p<0.05). This could not be attributed to differences in blood pressure, body weight or hypotensive medications. Age and sex also had no influence. Our data indicate that there is a characteristic progressive loss of renal function in haemodialyzed patients and that the early decline is most pronounced in patients with glomerular disease. Regular assessment of residual renal function at least every three months is indicated in patients starting chronic haemodialysis treatment.
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Affiliation(s)
- C.G. Iest
- Nephrology Department, University Hospital, Ghent - Belgium
| | - R.C. Vanholder
- Nephrology Department, University Hospital, Ghent - Belgium
| | - S.M. Ringoir
- Nephrology Department, University Hospital, Ghent - Belgium
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20
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Davenport A. Measuring residual renal function for hemodialysis adequacy: Is there an easier option? Hemodial Int 2018; 21 Suppl 2:S41-S46. [PMID: 29064172 DOI: 10.1111/hdi.12592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/01/2017] [Indexed: 02/04/2023]
Abstract
Most patients starting hemodialysis (HD) have residual renal function. As such, there has been increased interest in starting patients with less frequent and shorter dialysis session times. However, for this incremental approach to be successful, patients require regular monitoring of residual renal function, so that as residual renal function declines, the amount of HD is appropriately increased. Currently most dialysis centers rely on interdialytic urine collections. However, many patients find these inconvenient and there may be marked intrapatient variability due to compliance issues. Thus, alternative markers of residual renal function are required for routine clinical practice. Currently three middle sized molecules; cystatin C, β2 microglobulin, and βtrace protein have been investigated as potential endogenous markers of glomerular filtration. Although none is ideal, combinations of these markers have been proposed to provide a more accurate estimation of glomerular clearance, and in particular cut offs for minimal residual renal function. However, in patients with low levels of residual renal function it remains unclear as to whether the benefits of residual renal function equally apply to glomerular filtration or tubular function.
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Affiliation(s)
- Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, Rowland Hill Street, London, NW3 2PF
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21
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Seegmiller JC, Eckfeldt JH, Lieske JC. Challenges in Measuring Glomerular Filtration Rate: A Clinical Laboratory Perspective. Adv Chronic Kidney Dis 2018; 25:84-92. [PMID: 29499892 DOI: 10.1053/j.ackd.2017.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 10/12/2017] [Accepted: 10/16/2017] [Indexed: 11/11/2022]
Abstract
The assessment of kidney function is a cornerstone in the clinical management and health of the patient. Although the kidneys perform many physiologic functions and are essential for maintaining homeostasis, kidney function is typically evaluated, quantitated, and understood using the glomerular filtration rate (GFR). Although GFR can be directly measured using a variety of externally administered glomerular filtration markers, in general practice, the GFR is usually estimated (eGFR) using endogenous markers that are cleared primarily by kidney filtration. Common situations exist where the GFR needs to be measured (mGFR) in order to proceed with care. This manuscript will review laboratory challenges in the assessment of GFR. Key points to consider when implementing a mGFR testing protocol are the following: marker selection, clearance methodology (urinary vs solely plasma measurements of filtration marker), sample collection, number of samples to collect, staff required, and analytical measurement technology for the filtration marker selected. We suggest those wanting to implement mGFR testing examine site-specific institutional resources along with patient population and proceed with the approaches best suited for their clinical needs and laboratory resources available.
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22
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Shafi T, Levey AS. Measurement and Estimation of Residual Kidney Function in Patients on Dialysis. Adv Chronic Kidney Dis 2018; 25:93-104. [PMID: 29499893 PMCID: PMC5841591 DOI: 10.1053/j.ackd.2017.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/11/2017] [Indexed: 12/17/2022]
Abstract
Residual kidney function (RKF) in patients on dialysis is strongly associated with survival and better quality of life. Assessment of kidney function underlies the management of patients with chronic kidney disease before dialysis initiation. However, methods to assess RKF after dialysis initiation are just now being refined. In this review, we discuss the definition of RKF and methods for measurement and estimation of RKF, highlighting the unique aspects of dialysis that impact these assessments.
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Affiliation(s)
- Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA.
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
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23
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Silver SA, Adu D, Agarwal S, Gupta K, Lewington AJ, Pannu N, Bagga A, Chakravarthi R, Mehta RL. Strategies to Enhance Rehabilitation After Acute Kidney Injury in the Developing World. Kidney Int Rep 2017. [PMCID: PMC5678669 DOI: 10.1016/j.ekir.2017.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) is independently associated with new-onset chronic kidney disease (CKD), end-stage kidney disease, cardiovascular disease, and all-cause mortality. However, only a minority of patients receive follow-up care after an episode of AKI in the developing world, and the optimal strategies to promote rehabilitation after AKI are ill-defined. On this background, a working group of the 18th Acute Dialysis Quality Initiative applied the consensus-building process informed by a PubMed review of English-language articles to address questions related to rehabilitation after AKI. The consensus statements propose that all patients should be offered follow-up within 3 months of an AKI episode, with more intense follow-up (e.g., <1 month) considered based on patient risk factors, characteristics of the AKI event, and the degree of kidney recovery. Patients should be monitored for renal and nonrenal events post-AKI, and we suggest that the minimum level of monitoring consist of an assessment of kidney function and proteinuria within 3 months of the AKI episode. Care should be individualized for higher risk patients, particularly patients who are still dialysis dependent, to promote renal recovery. Although evidence-based treatments for survivors of AKI are lacking and some outcomes may not be modifiable, we recommend simple interventions such as lifestyle changes, medication reconciliation, blood pressure control, and education, including the documentation of AKI in the patient’s medical record. In conclusion, survivors of AKI represent a high-risk population, and these consensus statements should provide clinicians with guidance on the care of patients after an episode of AKI.
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24
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Shafi T, Mullangi S, Toth-Manikowski SM, Hwang S, Michels WM. Residual Kidney Function: Implications in the Era of Personalized Medicine. Semin Dial 2017; 30:241-245. [PMID: 28264139 DOI: 10.1111/sdi.12587] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The association of residual kidney function (RKF) with improved outcomes in peritoneal dialysis and hemodialysis patients is now widely recognized. RKF provides substantial volume and solute clearance even after dialysis initiation. In particular, RKF provides clearance of nonurea solutes, many of which are potential uremic toxins and not effectively removed by conventional hemodialysis. The presence of RKF provides a distinct advantage to incident dialysis patients and is an opportunity for nephrologists to individualize dialysis treatments tailored to their patients' unique solute, volume, and quality of life needs. The benefits of RKF present the opportunity to personalize the management of uremia.
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Affiliation(s)
- Tariq Shafi
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Surekha Mullangi
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | | | - Seungyoung Hwang
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Wieneke M Michels
- Division of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands
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25
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Eriguchi R, Obi Y, Rhee CM, Chou JA, Tortorici AR, Mathew AT, Kim T, Soohoo M, Streja E, Kovesdy CP, Kalantar-Zadeh K. Changes in urine volume and serum albumin in incident hemodialysis patients. Hemodial Int 2016; 21:507-518. [PMID: 27885815 DOI: 10.1111/hdi.12517] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hypoalbuminemia is a predictor of poor outcomes in dialysis patients. Among hemodialysis patients, there has not been prior study of whether residual kidney function or decline over time impacts serum albumin levels. We hypothesized that a decline in residual kidney function is associated with an increase in serum albumin levels among incident hemodialysis patients. METHODS In a large national cohort of 38,504 patients who initiated hemodialysis during 1/2007-12/2011, we examined the association of residual kidney function, ascertained by urine volume and renal urea clearance, with changes in serum albumin over five years across strata of baseline residual kidney function, race, and diabetes using case-mix adjusted linear mixed effects models. FINDINGS Serum albumin levels increased over time. At baseline, patients with greater urine volume had higher serum albumin levels: 3.44 ± 0.48, 3.50 ± 0.46, 3.57 ± 0.44, 3.59 ± 0.45, and 3.65 ± 0.46 g/dL for urine volume groups of <300, 300-<600, 600-<900, 900-<1,200, and ≥1,200 mL/day, respectively (Ptrend < 0.001). Over time, urine volume and renal urea clearance declined and serum albumin levels rose, while the baseline differences in serum albumin persisted across groups of urinary volume. In addition, the rate of decline in residual kidney function was not associated with the rate of change in albumin. DISCUSSION Hypoalbuminemia in hemodialysis patients is associated with lower residual kidney function. Among incident hemodialysis patients, there is a gradual rise in serum albumin that is independent of the rate of decline in residual kidney function, suggesting that preservation of residual kidney function does not have a deleterious impact on serum albumin levels.
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Affiliation(s)
- Rieko Eriguchi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Jason A Chou
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Amanda R Tortorici
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Anna T Mathew
- Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Great Neck, New York, USA
| | - Taehee Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA.,Division of Nephrology, Inje University, Busan, Korea
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA.,Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA.,Department Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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26
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Wong J, Kaja Kamal RM, Vilar E, Farrington K. Measuring Residual Renal Function in Hemodialysis Patients without Urine Collection. Semin Dial 2016; 30:39-49. [DOI: 10.1111/sdi.12557] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jonathan Wong
- Lister Renal Unit; Hertfordshire United Kingdom
- University of Hertfordshire; United Kingdom
| | | | - Enric Vilar
- Lister Renal Unit; Hertfordshire United Kingdom
- University of Hertfordshire; United Kingdom
| | - Ken Farrington
- Lister Renal Unit; Hertfordshire United Kingdom
- University of Hertfordshire; United Kingdom
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27
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Wang AYM. Preserving Residual Kidney Function in Hemodialysis Patients-Back in the Spotlight. J Am Soc Nephrol 2016; 27:3504-3507. [PMID: 27493256 DOI: 10.1681/asn.2016060693] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
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28
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Sjolund J, Garcia Anton D, Bayes LY, Hoekstra T, Dekker FW, Munoz Mendoza J. Diuretics, Limited Ultrafiltration, and Residual Renal Function in Incident Hemodialysis Patients: A Case Series. Semin Dial 2016; 29:410-5. [PMID: 27150124 DOI: 10.1111/sdi.12508] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effect of diuretics on residual renal function expressed as residual GFR (rGFR) and urine volume (rUV) using 24-hour urine collections has not been well examined in hemodialysis (HD) patients. We present a small (seven patient) but provocative case series describing a strikingly low rate of decline in rUV and rGFR (average of creatinine and urea clearances, 24-hour urine collections) in patients treated with increasing doses of furosemide (up to 360 mg/day) during the first 2 years after initiation of HD. Between 6 and 12 months, the mean rUV fell by 1 ml/month, whereas rGFR declined by 0.03 ml/min/1.73 m(2) /month. The mean rate of decline from 12 to 24 months for rUV (33 ml/month) and rGFR (0.02 ml/min/1.73 m(2) /month) were also low. While data are clearly limited and the observation retrospective, they are consistent with the better documented benefit of diuretics observed in end-stage renal disease patients treated with peritoneal dialysis.
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Affiliation(s)
- Jessica Sjolund
- The Sahlgrenska Academy School of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Desiree Garcia Anton
- Division of Nephrology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, Florida
| | - Liz Y Bayes
- Department of Pediatrics, University of Miami, Miller School of Medicine, Miami, Florida
| | - Tiny Hoekstra
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jair Munoz Mendoza
- Division of Nephrology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, Florida.
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29
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Chen HC, Chou CY, Jheng JS, Chen IR, Liang CC, Wang SM, Liu JH, Lin SY, Kuo HL, Wang IK, Chang CT, Huang CC. Loss of Residual Renal Function is Associated With Vascular Calcification in Hemodialysis Patients. Ther Apher Dial 2015; 20:27-30. [PMID: 26637989 DOI: 10.1111/1744-9987.12376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/25/2015] [Accepted: 08/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Hung-Chih Chen
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Che-Yi Chou
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Jyun-Shan Jheng
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - I-Ru Chen
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Chih-Chia Liang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
| | - Shu-Ming Wang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Jiung-Hsiun Liu
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Shih-Yi Lin
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Huey-Liang Kuo
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - I-Kuan Wang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Chiz-Tzung Chang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
| | - Chiu-Ching Huang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine; China Medical University Hospital; Taichung Taiwan
- College of Medicine; China Medical University; Taichung Taiwan
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Seegmiller JC, Burns BE, Schinstock CA, Lieske JC, Larson TS. Discordance Between Iothalamate and Iohexol Urinary Clearances. Am J Kidney Dis 2015; 67:49-55. [PMID: 26454686 DOI: 10.1053/j.ajkd.2015.08.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 08/04/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Iothalamate and iohexol are contrast agents that have supplanted inulin for the measurement of glomerular filtration rate (GFR) in clinical practice. Previous studies have noted possible differences in renal handling of these 2 agents, but clarity about the differences has been lacking. STUDY DESIGN Study of diagnostic test accuracy. SETTING & PARTICIPANTS 150 participants with a wide range of GFRs were studied in an outpatient clinical laboratory facility. INDEX TESTS Simultaneous urinary clearances of iothalamate, iohexol, and creatinine. REFERENCE TEST None. OUTCOME Relative differences between the urinary clearances. Iohexol and iothalamate in plasma and urine were assayed concurrently by a novel liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay. RESULTS Mean iohexol, iothalamate, and creatinine clearances were 52±28 (SD), 60±34, and 74±40 mL/min/1.73 m(2), respectively. The proportional bias of iohexol to iothalamate urinary clearance was 0.85 (95% CI, 0.83-0.88) and was proportional across the GFR range. The mean proportional bias of iohexol clearance compared with creatinine clearance is 1.27 (95% CI, 1.20-1.34), whereas that of iothalamate clearance compared with creatinine clearance is 1.09 (95% CI, 1.03-1.15). LIMITATIONS Lack of reference standard. CONCLUSIONS This study reveals a significant and consistent difference between urinary clearances of iothalamate and iohexol. Comparison of studies reporting renal clearance measurements using iohexol versus iothalamate must account for this observed bias.
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Affiliation(s)
- Jesse C Seegmiller
- Department of Laboratory Medicine, University of Minnesota, Rochester, MN
| | - Bradley E Burns
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Carrie A Schinstock
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John C Lieske
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Timothy S Larson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
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Shafi T, Levey AS, Inker LA, Schwartz GJ, Knight C, Abraham AG, Eckfeldt JH, Coresh J. Plasma Iohexol Clearance for Assessing Residual Kidney Function in Dialysis Patients. Am J Kidney Dis 2015. [PMID: 26209541 DOI: 10.1053/j.ajkd.2015.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tariq Shafi
- Johns Hopkins University, Baltimore, Maryland.
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Cerdá J, Liu KD, Cruz DN, Jaber BL, Koyner JL, Heung M, Okusa MD, Faubel S. Promoting Kidney Function Recovery in Patients with AKI Requiring RRT. Clin J Am Soc Nephrol 2015; 10:1859-67. [PMID: 26138260 DOI: 10.2215/cjn.01170215] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AKI requiring RRT is associated with high mortality, morbidity, and long-term consequences, including CKD and ESRD. Many patients never recover kidney function; in others, kidney function improves over a period of many weeks or months. Methodologic constraints of the available literature limit our understanding of the recovery process and hamper adequate intervention. Current management strategies have focused on acute care and short-term mortality, but new data indicate that long-term consequences of AKI requiring RRT are substantial. Promotion of kidney function recovery is a neglected focus of research and intervention. This lack of emphasis on recovery is illustrated by the relative paucity of research in this area and by the lack of demonstrated effective management strategies. In this article the epidemiologic implications of kidney recovery after AKI requiring RRT are discussed, the available literature and its methodologic constraints are reviewed, and strategies to improve the understanding of factors that affect kidney function recovery are proposed. Measures to promote kidney function recovery are a serious unmet need, with a great potential to improve short- and long-term patient outcomes.
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Affiliation(s)
- Jorge Cerdá
- Department of Medicine, Division of Nephrology, Albany Medical College, Albany, New York;
| | - Kathleen D Liu
- Division of Nephrology, Department of Medicine University of California, San Francisco, San Francisco, California
| | - Dinna N Cruz
- Department of Medicine, Division of Nephrology, University of California San Diego, San Diego, California
| | - Bertrand L Jaber
- Department of Medicine, St. Elizabeth's Medical Center Tufts University School of Medicine, Boston, Massachussetts
| | - Jay L Koyner
- Department of Nephrology, University of Chicago, Chicago, Illinois
| | - Michael Heung
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Mark D Okusa
- Department of Medicine, University of Virginia, Charlottesville, Virginia; and
| | - Sarah Faubel
- Department of Medicine, Division of Nephrology, University of Colorado Denver, Denver, Colorado
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Wong J, Vilar E, Davenport A, Farrington K. Incremental haemodialysis. Nephrol Dial Transplant 2015; 30:1639-48. [DOI: 10.1093/ndt/gfv231] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 04/21/2015] [Indexed: 12/15/2022] Open
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Trimarchi H, Raña MS, Karl A, Andrews J, Dicugno M, Pomeranz V, Young P, Forrester M, Alonso M, Lombi F, Muryan A. Residual urinary output in high body mass index individuals on chronic hemodialysis: A disregarded life vest? World J Nephrol 2014; 3:317-323. [PMID: 25374828 PMCID: PMC4220367 DOI: 10.5527/wjn.v3.i4.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 07/12/2014] [Accepted: 09/24/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess residual diuresis and diverse variables according to body mass index (BMI).
METHODS: Cross-sectional study (n = 57), with 3 groups. Group A: BMI < 25, n = 22; Group B: BMI 25-30, n = 15; Group C: BMI > 30, n = 20. Diuresis, hematocrit, albumin, C-reactive protein, Malnutrition inflammatory score, Pro-BNP, Troponin T, leptin and insulin levels are expressed as median and ranges (r).
RESULTS: Albumin (g/dL): GA vs GC, 3.70 (r2.20-4.90) vs 3.85 (r3.40-4.90), P = 0.02. Diuresis (mL/d): GA 690 (r0-1780); GB 660 (r60-1800); GC 840 (r40-2840). Diuresis GA vs GC, P = 0.01. Leptin (ng/mL): GA vs GC, 3.81 (r0.78-69.60) vs GC, 32.80 (r0.78-124.50), P < 0.001. Insulin (µU/mL): GA vs GB, 7 (r2-44) vs 11.50 (r4-38), P = 0.02; GA vs GC, 7 (r2-44) vs 19.5 (r5-155), P = 0.0001. Troponin T and Pro-BNP levels were not different. Significant correlations: GC, Insulin-UF: ρ = 0.53; P = 0.03; TroponinT-diuresis: ρ = -0.48, P < 0.05; Pro-BNP-diuresis: ρ = -0.39, P < 0.01; Troponin T-ProBNP: ρ = 0.77, P < 0.0001; albumin-Troponin T: ρ = -0.66, P < 0.0001; albumin-ProBNP: ρ = -0.44, P < 0.05.
CONCLUSION: High BMI associated positively with higher diuresis and albuminemia, and negatively with TropT and Pro-BNP. High BMI-associated better survival may be explained by better urinary output, lowering cardiovascular stress.
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35
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Strategies for the preservation of residual renal function in pediatric dialysis patients. Pediatr Nephrol 2014; 29:825-36; quiz 832. [PMID: 23868107 DOI: 10.1007/s00467-013-2554-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 06/05/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
In adults with end-stage renal disease (ESRD), the preservation of residual renal function (RRF) has been shown to be associated with decreased mortality and improved control of complications of chronic kidney disease. However, less is known on the benefits of RRF in the pediatric dialysis population. The purpose of this article is to review the clinical significance of RRF and to discuss strategies for the preservation of RRF in children with ESRD.
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Préservation de la fonction rénale résiduelle en dialyse. Nephrol Ther 2013; 9:403-7. [DOI: 10.1016/j.nephro.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 05/02/2013] [Indexed: 11/20/2022]
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Iwasawa H, Nakao T, Matsumoto H, Okada T, Nagaoka Y, Wada T. Phosphate handling by end-stage kidneys and benefits of residual renal function on phosphate removal in patients on haemodialysis. Nephrology (Carlton) 2013; 18:285-91. [DOI: 10.1111/nep.12039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Hideaki Iwasawa
- Department of Nephrology; Tokyo Medical University; Tokyo; Japan
| | - Toshiyuki Nakao
- Department of Nephrology; Tokyo Medical University; Tokyo; Japan
| | | | - Tomonari Okada
- Department of Nephrology; Tokyo Medical University; Tokyo; Japan
| | - Yume Nagaoka
- Department of Nephrology; Tokyo Medical University; Tokyo; Japan
| | - Toshikazu Wada
- Department of Nephrology; Tokyo Medical University; Tokyo; Japan
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Teigen MMB, Duffull S, Dang L, Johnson DW. Dosing of Gentamicin in Patients With End-Stage Renal Disease Receiving Hemodialysis. J Clin Pharmacol 2013; 46:1259-67. [PMID: 17050791 DOI: 10.1177/0091270006292987] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to evaluate dosing schedules of gentamicin in patients with end-stage renal disease and receiving hemodialysis. Forty-six patients were recruited who received gentamicin while on hemodialysis. Each patient provided approximately 4 blood samples at various times before and after dialysis for analysis of plasma gentamicin concentrations. A population pharmacokinetic model was constructed using NONMEM (version 5). The clearance of gentamicin during dialysis was 4.69 L/h and between dialysis was 0.453 L/h. The clearance between dialysis was best described by residual creatinine clearance (as calculated using the Cockcroft and Gault equation), which probably reflects both lean mass and residual clearance mechanisms. Simulation from the final population model showed that predialysis dosing has a higher probability of achieving target maximum concentration (Cmax) concentrations (> 8 mg/L) within acceptable exposure limits (area under the concentration-time curve [AUC] values > 70 and < 120 mg x h/L per 24 hours) than postdialysis dosing.
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Kjaergaard KD, Rehling M, Jensen JD, Jespersen B. Reliability of endogenous markers for estimation of residual renal function in haemodialysis patients. Clin Physiol Funct Imaging 2013; 33:224-32. [PMID: 23522017 DOI: 10.1111/cpf.12018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 12/07/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Residual renal function in haemodialysis patients is of increasing interest. However, reproducibility and agreement between methods to measure and estimate glomerular filtration rate (GFR) require further elucidation. The aim of this study was to evaluate the accuracy and reproducibility of GFR estimates based on endogenous markers in haemodialysis patients. METHODS Twelve patients were examined twice. GFR was estimated by (i) urine clearances of creatinine, urea and the average of creatinine and urea clearance [U-Cl(crea-urea)]; (ii) an equation based on serum concentration of cystatin C [eGFR(CysC)]. These were compared to (51) Cr-EDTA clearance in plasma [P-Cl(EDTA)] and urine [U-Cl(EDTA)]. RESULTS U-Cl(crea-urea) produced results similar to U-Cl(EDTA). eGFR(CysC) had a low week-to-week variability. Visually, eGFR(CysC) differed from y = x when compared to the other methods indicating bias, probably due to extrarenal elimination of cystatin C. Coefficients of variation were significantly different, P<0·001: P-Cl(EDTA), 10%; U-Cl(EDTA), 13%; and U-Cl(crea-urea), 13%. P-Cl(EDTA) was 2·1 ml min(-1) 1·73 m(-2) higher than U-Cl(EDTA) (mean). CONCLUSIONS Glomerular filtration rate in haemodialysis patients can be estimated from U-Cl(crea-urea) when complete urine collection is performed. The available eGFR(CysC) in haemodialysis patients seemed to be biased, and further development and validation is desirable. P-Cl(EDTA) was the most reproducible method and might be useful in special situations.
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41
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Kjaergaard KD, Jensen JD, Rehling M, Jespersen B. Endogenous markers for estimation of renal function in peritoneal dialysis patients. Perit Dial Int 2012; 33:195-204. [PMID: 23032085 DOI: 10.3747/pdi.2011.00220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This method comparison study, conducted at the peritoneal dialysis (PD) outpatient clinic of the Department of Renal Medicine, Aarhus University Hospital, Denmark, set out to evaluate the accuracy and reproducibility of methods for estimating glomerular filtration rate (GFR) based on endogenous markers in PD patients. PATIENTS The 12 consecutive patients included in the study were examined twice while in a stable condition. All patients finished the study. Inclusion criteria were age 18 years or older, ability to collect 24-hour urine, and urine production greater than 300 mL in 24 hours. MAIN OUTCOME MEASURES The methods for estimating GFR using endogenous markers included the average of urinary clearances of creatinine and urea [U-Cl(crea-urea)] and two equations using the serum concentration of cystatin C [eGFR(CysC)]. The resulting GFR estimates were compared with those obtained using urinary and corrected plasma clearances of (51)Cr-EDTA [U-Cl(EDTA) and cP-Cl(EDTA)], the corrected plasma clearance being plasma clearance minus dialysate clearance. RESULTS Compared with the U-Cl(EDTA), the U-Cl(crea-urea) GFR estimate was 12% higher [95% confidence limits (CL): 3%, 21%]. Although significantly different (p = 0.01), the latter two methods showed the best agreement. The estimates obtained using the eGFR(CysC) methods were skewed from y = x compared with the estimates obtained using other methods, indicating strong bias, probably because of extrarenal elimination. The cP-Cl(EDTA) estimate was 34% (95% CL: 26%, 42%), higher than the U-Cl(EDTA) estimate (p < 0.001). The reproducibility (coefficients of variation) differed significantly between methods: cP-Cl(EDTA), 7%; U-Cl(EDTA), 14%; U-Cl(crea-urea), 18%; and both eGFR(CysC) methods, 3%. CONCLUSIONS In PD patients, GFR may be estimated as U-Cl(crea-urea) when complete urine collection is performed, taking into account an overestimation of approximately 12%. The available equations for eGFR(CysC) seem to be inaccurate; further development and validation is desirable. Omitting the eGFR(CysC) methods, cP-Cl(EDTA) was the most reproducible method and might be useful in certain situations.
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42
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Itoh Y, Fujikawa T, Toya Y, Mitsuhashi H, Kobayashi N, Ohnishi T, Tamura K, Hirawa N, Yasuda G, Umemura S. Effect of Renin-Angiotensin System Inhibitor on Residual Glomerular Filtration Rate in Hemodialysis Patients. Ther Apher Dial 2012. [DOI: 10.1111/j.1744-9987.2012.01087.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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White CA, Akbari A. The Estimation, Measurement, and Relevance of the Glomerular Filtration Rate in Stage 5 Chronic Kidney Disease. Semin Dial 2011; 24:540-9. [DOI: 10.1111/j.1525-139x.2011.00943.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Kjaergaard KD, Jensen JD, Peters CD, Jespersen B. Preserving residual renal function in dialysis patients: an update on evidence to assist clinical decision making. NDT Plus 2011; 4:225-30. [PMID: 25949486 PMCID: PMC4421450 DOI: 10.1093/ndtplus/sfr035] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 02/28/2011] [Indexed: 12/29/2022] Open
Abstract
It has been documented that preservation of residual renal function in dialysis patients improves quality of life as well as survival. Clinical trials on strategies to preserve residual renal function are clearly lacking. While waiting for more results from clinical trials, patients will benefit from clinicians being aware of available knowledge. The aim of this review was to offer an update on current evidence assisting doctors in clinical practice.
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Affiliation(s)
- Krista Dybtved Kjaergaard
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark ; Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Jens Dam Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark ; Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Christian Daugaard Peters
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark ; Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark ; Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
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Abstract
Renal function recovery (RFR) from acute kidney injury requiring dialysis occurs at a high frequency. RFR from chronic dialysis, on the other hand, is an uncommon but well-recognized phenomenon, occurring at a rate of 1.0-2.4% according to data from large observational studies. The underlying etiology of renal failure is the single most important predicting factor of RFR in chronic dialysis patients. The disease types with the highest RFR rates are atheroembolic renal disease, systemic autoimmune disease, renovascular diseases, and scleroderma. The disease types with the lowest RFR rates are diabetic nephropathy and cystic kidney disease. Initial dialysis modality does not appear to influence RFR. Careful observation and history taking are needed to recognize the often nonspecific clinical and laboratory signs of RFR. When RFR is suspected in a chronic dialysis patient, a 24-hour urine urea and creatinine clearance should be measured. Based on the renal clearance, along with other clinical factors, the dialysis prescription may be gradually reduced until a complete discontinuation of dialysis. After RFR from maintenance dialysis, patients require close follow-up in an office setting for chronic kidney disease management.
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Affiliation(s)
- Jay K Chu
- Division of Nephrology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York, USA
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46
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Seegmiller JC, Burns BE, Fauq AH, Mukhtar N, Lieske JC, Larson TS. Iothalamate quantification by tandem mass spectrometry to measure glomerular filtration rate. Clin Chem 2010; 56:568-74. [PMID: 20167698 DOI: 10.1373/clinchem.2009.133751] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Glomerular filtration rate (GFR) can be determined by measuring renal clearance of the radiocontrast agent iothalamate. Current analytic methods for quantifying iothalamate concentrations in plasma and urine using liquid chromatography or capillary electrophoresis have limitations such as long analysis times and susceptibility to interferences. We developed a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to overcome these limitations. METHODS Urine and plasma samples were deproteinized using acetonitrile and centrifugation. The supernatant was diluted in water and analyzed by LC-MS/MS using a water:methanol gradient. We monitored 4 multiple reaction monitoring transitions: m/z 614.8-487.0, 614.8-456.0, 614.8-361.1, and 614.8-177.1. We compared the results to those obtained via our standard capillary electrophoresis (CE-UV) on samples from 53 patients undergoing clinical GFR testing. RESULTS Mean recovery was 90%-110% in both urine and plasma matrices. Imprecision was <or=15% for the m/z 614.8-487.0 and 614.8-456.0 transitions over a 10-day period at 1 mg/L. Method comparison for 159 patient samples (53 clearances) provided the following Passing-Bablok regressions: plasma iothalamate LC-MS/MS (y) vs CE-UV (x), y = 0.99x + 0.36; urine iothalamate LC-MS/MS vs CE-UV, y = 1.01x + 0.31; corrected GFR LC-MS/MS vs CE-UV, y = 1.00x + 0.00. Interfering substances prevented accurate iothalamate quantification by CE-UV in 2 patients, whereas these samples could be analyzed by LC-MS/MS. CONCLUSIONS Iothalamate can be quantified by LC-MS/MS for GFR measurement. This method circumvents potential problems with interfering substances that occasionally confound accurate GFR determinations.
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Affiliation(s)
- Jesse C Seegmiller
- Department of Laboratory Medicine and Pathology, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
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Klaboch J, Opatrná S, Matousovic K, Sefrna F, Havlín J, Schück O. Acid-base balance in peritoneal dialysis patients: a Stewart-Fencl analysis. Ren Fail 2009; 31:625-32. [PMID: 19817518 DOI: 10.3109/08860220903134076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evaluation of acid-base disorders using the Stewart-Fencl principle is based on assessment of independent factors: strong ion difference (SID) and the total concentration of non-volatile weak acids (Atot). This approach allows for a more detailed evaluation of the cause of acid-base imbalance than the conventional bicarbonate-centered approach based on the Henderson-Hasselbalch principle, which is a necessary yet insufficient condition to describe the state of the system. The aim of our study was to assess acid-base disorders in peritoneal dialysis (PD) patients using both of these principles. METHODS A total of 17 patients with chronic renal failure (10 men), aged 60.7 (22-84) years, treated by PD for 25.7 (1-147) months were examined. A control group included 17 healthy volunteers (HV) (8 males), with a mean age of 42.7 (22-77) years and normal renal function. Patients were treated with a solution containing bicarbonate (25 mmol/L) and lactate (15 mmol/L) as buffers; eleven of them used, during the nighttime dwell, a solution with icodextrin buffered by lactate at a concentration of 40 mmol/L. The following equations were employed for calculations of acid-base parameters according to the Stewart-Fencl principle. The first is SID = [Na+] + [K+] + 2[Ca(2+)] + 2[Mg(2+)] - [Cl-] - [UA-], where SID is the strong ion difference and [UA-] is the concentration of undetermined anions. For practical calculation of SID, the second equation, SID = [HCO3-] + [Alb-] + [Pi-], was used, where [Alb-] and [Pi-] are the charges carried by albumin and phosphates. The third is Atot, the total concentration of weak non-volatile acids, albumin [Alb] and phosphates [Pi]. RESULTS The capillary blood pH in PD group was 7.41 (7.27-7.48), [HCO3-] levels 23.7 (17.6-29.5) mmol/L, SID 36.3 (29.5-41.3) mmol/L, sodium-chloride difference 39.0 (31.0-44.0) mmol/L, [Pi] 1.60 (0.83-2.54) mmol/L, and [Alb] 39.7 (28.8-43.4) g/L (median, min-max). Bicarbonate in blood correlated positively with SID (Rho = 0.823; p < 0.001), with the sodium-chloride difference (Rho = 0.649; p < 0.01) and pH (Rho = 0.754; p < 0.001), and negatively with residual renal function (Rho = -0.517; p < 0.05). Moreover, the sodium-chloride difference was also found to correlate with SID (Rho = 0.653; p < 0.01). While the groups of PD and HV patients did not differ in median bicarbonate levels, significantly lower median value of SID were observed in PD patients, 36.3 vs. 39.3 mmol/L (p < 0.01); additionally, PD patients were shown to have significantly lower mean value of serum sodium levels, 138 vs. 141 mmol/L (p < 0.01), and serum chlorides levels, 100 vs. 104 mmol/L (p < 0.001). Despite the higher [UA-] levels in PD patients, 9.1 vs. 5.4 mmol/L (p < 0.001), this parameter was not found to correlate with bicarbonate levels. CONCLUSIONS The results suggest that the decreased bicarbonate in PD patients results from a combination of decreased sodium-chloride difference and mildly increased unmeasured anions.
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Affiliation(s)
- Jan Klaboch
- Department of Medicine I, Charles University, Medical School and Teaching Hospital, Plzen 304 60, Czech Republic
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