Rationale and Strategies for Preserving Residual Kidney Function in Dialysis Patients

Background: Residual kidney function (RKF) conveys a survival benefit among dialysis patients, but the mechanism remains unclear. Improved volume control, clearance of protein-bound and middle molecules, reduced inflammation and preserved erythropoietin and vitamin D production are among the proposed mechanisms. Preservation of RKF requires techniques to measure it accurately to be able to uncover factors that accelerate its loss and interventions that preserve it and ultimately to individualize therapy. The average of renal creatinine and urea clearance provides a superior estimate of RKF in dialysis patients, when compared with daily urine volume. However, both involve the difficult task of obtaining an accurate 24-h urine sample. Summary: In this article, we first review the definition and measurement of RKF, including newly proposed markers such as serum levels of beta2-microglobulin, cystatin C and beta-trace protein. We then discuss the predictors of RKF loss in new dialysis patients. We review several strategies to preserve RKF such as renin-angiotensin-aldosterone system blockade, incremental dialysis, use of biocompatible membranes and ultrapure dialysate in hemodialysis (HD) patients, and use of biocompatible solutions in peritoneal dialysis (PD) patients. Despite their generally adverse effects on renal function, aminoglycoside antibiotics have not been shown to have adverse effects on RKF in well-hydrated patients with end-stage renal disease (ESRD). Presently, the roles of better blood pressure control, diuretic usage, diet, and dialysis modality on RKF remain to be clearly established. Key Messages: RKF is an important and favorable prognostic indicator of reduced morbidity, mortality, and higher quality of life in both PD an HD patients. Further investigation is warranted to uncover factors that protect or impair RKF. This should lead to improved quality of life and prolonged lifespan in patients with ESRD and cost-reduction through patient centeredness, individualized therapy, and precision medicine approaches.

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Preserving Residual Kidney Function

Kidney Protection ◽

10.1093/med/9780190611620.003.0020 ◽

2019 ◽

pp. 201-208

Author(s):

Miten J. Dhruve ◽

Joanne M. Bargman ◽

Joanne M. Bargman

Keyword(s):

Quality Of Life ◽

Peritoneal Dialysis ◽

Kidney Function ◽

Urine Volume ◽

Volume Control ◽

Dialysis Patients ◽

Renin Angiotensin Aldosterone System ◽

Residual Kidney Function ◽

Transplant Kidney

Residual kidney function is strongly associated with benefits in survival, morbidity, and quality of life in both hemodialysis and peritoneal dialysis patients. Possible explanations include better volume control in dialysis patients who maintain significant urine volume, better middle molecule and other toxin clearance by the kidneys, and a lower level of systemic inflammation associated with ongoing kidney function. The residual kidney function should be monitored and preserved if at all possible. Practices such as incremental dialysis, avoidance of interim hemodialysis in those choosing peritoneal dialysis, avoidance of peritonitis and nephrotoxic medications, use of renin–angiotensin–aldosterone system blockade, and maintenance of transplant kidney function with ongoing low-level immunosuppression are all methods that can be implemented to help protect this vital function.

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P1109HDX: IS IT A BETTER WAY TO DIALYSE?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1109 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Nageen Anwar ◽

Noshaba Naz ◽

Anna Reynolds ◽

Ruby Chumber

Keyword(s):

Quality Of Life ◽

Adverse Effects ◽

Blood Cell ◽

Red Blood Cell ◽

Blood Parameters ◽

The Body ◽

Red Blood Cell Transfusion ◽

Dialysis Patients ◽

Middle Molecules

Abstract Background and Aims Inadequate dialysis has been linked to reduced quality of life, increased symptom burden and increased risk of cardiovascular illness in patients with chronic kidney disease. This is especially significant in long-term haemodialysis patients who have little to no residual urine output and are thus almost entirely dependent on good quality dialysis to remove toxins and fluid. In most conventional haemodialysis modes middle molecule clearance is inadequate. This in turn plays an important part in causing multiple complications. HDx is a new type of haemodialysis being introduced using Theranova® dialyzer. This claims to have medium cut-off membranes, functioning similar to a kidney, hence providing better clearance of middle molecules, whilst selectively preventing loss of proteins from the body. In order to test the safety and efficacy of HDx using Theranova® we tried it in a cohort of our patients in the form of an audit. Our primary objective was to find out the effect of HDx on quality of life. Secondary objective was to determine whether HDx improves blood biochemistry, with a reduction in medication & transfusion needs. Method Thirty seven Haemodialysis patients were switched from hemodiafiltration to HDx, out of these 3 patients were transplanted, 2 patients died, 1 patient switched back and 7 patients were transferred to satellite units. Audit was continued with the remaining 24 patients. All patients completed an Integrated Palliative Care Outcome Score (IPOS) prior to commencing on HDx and then at six months. Blood parameters including phosphorous, calcium, haemoglobin, Ferritin and CRP were measured monthly and mean values of 6 months before and after HDx initiation were compared. Comparison of erythropoietin, intravenous iron and packed red blood cell transfusion requirements pre and post HDx commencement were also undertaken. Results No obvious adverse effects were noted with use of HDx dialysis. All patients had an improvement in overall IPOS scores after being on HDx for 6 months. Shorter post dialysis symptom recovery times were also noted. 13 patients had a decrease in their erythropoietin requirements, in 2 patients requirement remained the same, 9 patients had increase in their requirement however 3 of these patients had been requiring packed red blood cell transfusion prior to HDx commencement, no longer required transfusion. We found an overall improvement in patients iron infusion need. 11 patients had a dose reduction, with 4 of these patients no longer requiring iron. 9 patients continued to have the same requirements. 4 patients had an increase in iron dose, but 3 of these patients previously being transfusion dependant no longer required regular transfusions. We also noted that with use of HDx clotting risk was reduced and patients who were switched from Evodial (heparin coated dialyzer membranes) to HDx did not have increased circuit clotting. With regards to inflammation we noted no significant changes in CRP, ferritin levels and other blood parameters. Conclusion Looking at our cohort of patients we concluded that HDx is safe to use with no obvious adverse effects. It seems that use of HDx is particularly helpful in improving quality of life in dialysis patients as indicated by improvement in IPOS scores. IPOS is a validated questionnaire to measure symptoms and concerns in patients with advanced illnesses. As life quality is a major concern in dialysis patients, this outcome is of particular significance. HDx was also helpful in reducing the overall burden of transfusions, iron and erythropoietin requirements. This is beneficial in overall patient health and cost burden. Based on the above we found out that HDX was safe and effective in our patient cohort, however large-scale studies will be required for more conclusive evidence.

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Residual Kidney Function and Quality of Life in Incident Hemodialysis Patients

American Journal of Kidney Diseases ◽

10.1053/j.ajkd.2010.09.020 ◽

2011 ◽

Vol 57 (1) ◽

pp. 179-179 ◽

Cited By ~ 1

Author(s):

Gildete Barreto Lopes ◽

Antonio Alberto Lopes

Keyword(s):

Quality Of Life ◽

Kidney Function ◽

Hemodialysis Patients ◽

Residual Kidney Function

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Effectiveness of Renin-Angiotensin-Aldosterone System Blockade on Residual Kidney Function and Peritoneal Membrane Function in Peritoneal Dialysis Patients: A Network Meta-Analysis

Scientific Reports ◽

10.1038/s41598-019-55561-5 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 2

Author(s):

Sirayut Phatthanasobhon ◽

Surapon Nochaiwong ◽

Kednapa Thavorn ◽

Kajohnsak Noppakun ◽

Setthapon Panyathong ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Kidney Function ◽

Active Control ◽

Meta Analysis ◽

Urine Volume ◽

Peritoneal Membrane ◽

Dialysis Patients ◽

Membrane Function ◽

Raas Blockade ◽

Residual Kidney Function

AbstractWe performed a network meta-analysis of randomised controlled trials (RCTs) and non-randomised studies in adult peritoneal dialysis patients to evaluate the effects of specific renin-angiotensin aldosterone systems (RAAS) blockade classes on residual kidney function and peritoneal membrane function. Key outcome parameters included the following: residual glomerular filtration rate (rGFR), urine volume, anuria, dialysate-to-plasma creatinine ratio (D/P Cr), and acceptability of treatment. Indirect treatment effects were compared using random-effects model. Pooled standardised mean differences (SMDs) and odd ratios (ORs) were estimated with 95% confidence intervals (CIs). We identified 10 RCTs (n = 484) and 10 non-randomised studies (n = 3,305). Regarding changes in rGFR, RAAS blockade with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) were more efficacious than active control (SMD 0.55 [0.06–1.04] and 0.62 [0.19–1.04], respectively) with the protective effect on rGFR observed only after usage ≥12 months, and no differences among ACEIs and ARBs. Compared with active control, only ACEIs showed a significantly decreased risk of anuria (OR 0.62 [0.41–0.95]). No difference among treatments for urine volume and acceptability of treatment were observed, whereas evidence for D/P Cr is inconclusive. The small number of randomised studies and differences in outcome definitions used may limit the quality of the evidence.

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In Reply to ‘Residual Kidney Function and Quality of Life in Incident Hemodialysis Patients’

American Journal of Kidney Diseases ◽

10.1053/j.ajkd.2010.10.006 ◽

2011 ◽

Vol 57 (1) ◽

pp. 179-180

Author(s):

Tariq Shafi ◽

Laura C. Plantinga ◽

Neil R. Powe ◽

Josef Coresh

Keyword(s):

Quality Of Life ◽

Kidney Function ◽

Hemodialysis Patients ◽

Residual Kidney Function

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P1519A TWICE-WEEKLY HEMODIALYSIS : A SINGLE CENTER STUDY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1519 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Sirine Bchir ◽

Malek Mojaat ◽

Mariem Ben salem ◽

Boukadida Amine ◽

Insaf Handous ◽

...

Keyword(s):

Quality Of Life ◽

Kidney Function ◽

University Hospital ◽

Good Survival ◽

Biological Parameters ◽

Medical Reason ◽

Interdialytic Weight Gain ◽

Residual Kidney Function ◽

The Mean

Abstract Background and Aims Conventional hemodialysis consists of a thrice-weekly in-center Hemodialysis with a mean duration of 4 hours per session. The concept of incremental dialysis has allowed a better adjustment of its prescription guided by clinical and biological parameters. Thereby a twice-weekly regimen may maintain a good quality of life, a good survival rate and adequate dialysis in comparison to a thrice-weekly hemodialysis. The aim of our study was to investigate the profile of patients undergoing a twice-weekly regimen in our center. Method It is a monocenter transversal-descriptive study gathering patients on a twice-weekly regimen in the center of hemodialysis of Fattouma Bourguiba University Hospital in Monastir Tunisia. Results We identified 32 patients with a sex ratio of 2.2 (22 men and 10 women) with a mean age of 48,96 +/- 13,74 years. Regarding the intitial nephropathy, a chronic glomerulopathy was seen in 16 patients, a chronic tubulo-interstitial nephritis In 5 patients, and kidney polykystosis among 3 patients and in 8 patients the initial nephropathy remained undetermined. The indications for a twice-weekly HD regimen were: defavourable socio-economic conditions in 9 patients, a medical reason in 17 patients and a rejection of thrice-weekly regimen in 6 patients. The mean diuresis was 850 +/- 560 cc/24h and only one patient with anuria. The mean interdialytic weight gain was 2, 64 +/- 0, 83 Kg. Normal blood pressure and volemia were reported in 27 patients (84, 37 %). The mean number of anti-hypertensive drugs used was 1,5 per patient. The mean percentage of Urea reduction was 68, 8 % and a mean Kt/V of 1.26. The average of both kalemia and calcemia was respectively 5.27 mmol/l and 1, 94 mmol/l and the mean dosage of phosphoremia was 1, 63 mmol/l. The average of PTH and Hemoglobine was respectively 403 pg/ml and 9, 97 g/dl. Conclusion According to these results, a twice-weekly hemodialysis should be guided by the residual kidney function, clinical status (volemia), cardiovascular symptoms and comorbidities, biological parameters (Hemoglobine, potassium, phosphore) and the nutritional state. By meeting the above criteria, many studies have shown that a twice-weekly regimen or incremental dialysis help preserve the residual kidney function with a good quality of life.

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Increasing the Hematocrit Has a Beneficial Effect on Quality of Life and Is Safe in Selected Hemodialysis Patients

Journal of the American Society of Nephrology ◽

10.1681/asn.v112335 ◽

2000 ◽

Vol 11 (2) ◽

pp. 335-342

Author(s):

FUENSANTA MORENO ◽

DÁMASO SANZ-GUAJARDO ◽

JUAN MANUEL LÓPEZ-GÓMEZ ◽

ROSA JOFRE ◽

FERNANDO VALDERRÁBANO

Keyword(s):

Quality Of Life ◽

Adverse Effects ◽

Functional Status ◽

Vascular Access ◽

Hemodialysis Patients ◽

Uncontrolled Hypertension ◽

Cumulative Probability ◽

Dialysis Patients ◽

Number Of Patients

Target hematocrit/hemoglobin values in dialysis patients are still controversial. The Spanish Cooperative Renal Patients Quality of Life Study Group (including 34 hemodialysis units) conducted a prospective, 6-mo study of the effect on patient functional status and quality of life of using epoetin to achieve normal hematocrit in hemodialysis patients with anemia. The possible adverse effects of increased hematocrit, patient hospitalization, and epoetin requirements were also studied. The study included 156 patients (age range, 18 to 65 yr). Given the minimal experience in the safety of increasing hematocrit in dialysis patients to normal levels with epoetin, stable patients on hemodialysis who had received epoetin treatment for at least 3 mo and had a stable hemoglobin level of ≥9 g/dl were included in the study. Patients with antecedents of congestive cardiac failure, ischemic cardiopathy, diabetes mellitus, uncontrolled hypertension, cerebrovascular accident or seizures, malfunction of the vascular access or severe comorbidity (defined by a comorbidity index), and those over 65 yr of age were excluded from the study. Quality of life was measured with the Sickness Impact Profile (SIP) and Karnofsky scale. Patients completed questionnaires at home at onset and conclusion of the 6-mo study. Mean hematocrit increased from 30.9 to 38.4% and hemoglobin from 10.2 to 12.5 g/dl during the study. Health indicator scores improved significantly: mean Physical Dimension (SIP) from 5.38 to 4.1 (P < 0.005); mean Psychosocial Dimension from 9.2 to 7 (P < 0.001); mean global SIP from 8.9 to 7.25 (P < 0.001); mean Karnofsky scale score from 75.6 to 78.4 (P < 0.01). (SIP is scaled so that lower scores represent better functional status, and vice versa for the Karnofsky scale). Therefore, functional status and quality of life improved with increased hematocrit. No deaths occurred. Three patients (2%) were censored for hypertension and nine (5.7%) for thrombosis of the vascular access. The cumulative probability of thrombosis of the vascular access was 0.067. The average epoetin dose rose from 93 ± 62 U/kg per wk at onset to 141 ± 80 U/kg per wk at conclusion, a 51% increase. The number of patients hospitalized decreased and hospital lengths of stay were shorter during the study period than in the same patients in the 6-mo period preceding the study (P < 0.05). Nine patients (5.7%) had thrombosis of the vascular access. There were no changes in the prevalence of arterial hypertension, but three patients (2%) showed hypertension that was difficult to control. It is concluded that normalization of hematocrit in selected hemodialysis patients, i.e., nondiabetic patients without severe cardiovascular or cerebrovascular comorbidities, improves quality of life and decreases morbidity without significant adverse effects.

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The evaluation of residual kidney function in patients with ckd vd and approaches of its preservation

Ukrainian Journal of Nephrology and Dialysis ◽

10.31450/ukrjnd.2(58).2018.07 ◽

2018 ◽

pp. 41-48

Author(s):

L. Surzhko

Keyword(s):

Kidney Function ◽

Residual Renal Function ◽

Objective Data ◽

Dialysis Patients ◽

Dialysis Dose ◽

Residual Kidney Function ◽

Wide Range ◽

Incremental Hemodialysis ◽

The Relationship

The work is a literature review. Residual kidney function (RKF) is one of the crucial indicators of mortality and quality of life in patients with chronic kidney disease. Residual renal function provides better control of hydration, blood pressure, clearance of substances with low and middleweight, anemia, Ca/P metabolism, chronic inflammation. However, approaches to preservation of RKF in dialysis patients have been studied not enough, the importance of RKF preservation is underlined. The wide range of predictors of RKF loss are presented in the article, approaches to measurement of RKF, the relationship between level and presence of RKF with survival and mortality of patients with CKD 5D were analyzed. The possibility of RKF preservation and extension using different approaches by correction of dialysis prescription were estimated. There is no standardized method for applying incremental hemodialysis in practice. Onceto twice-weekly hemodialysis regimens are often used randomly, without knowing the benefit for current patient or how to escalate the dialysis dose if RKF declines over time. It is important to change the HD/HDF prescription according to the range of RRF using objective data.

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