Pregnancy and delivery in women treated with renal replacement therapy: A literature review

The problem of pregnancy and delivery in women with end-stage kidney disease is becoming increasingly important, and the number of such women who are pregnant, receiving kidney replacement therapy, is growing every year. Improvements in dialysis therapy have led to improved obstetric and perinatal outcomes, but the risk of various obstetric and perinatal complications remains extremely high. In this review, we analyzed recently published data on management and outcomes of pregnancy in women with end-stage kidney disease receiving dialysis.

Structural and functional abnormalities of cell membranes in the end-stage chronic kidney disease

Background: Chronic kidney disease (CKD) is associated with abnormalities in all functions of the body systems including changes in intracellular processes. Assessment of erythrocyte electrophoretic mobility (EEM) in patients with CKD stage 5 on dialysis (5d) has becoming increasingly relevant, since this method characterizes the pathophysiological state of the patient and gives the possibility to modify treatment.Aim: To identify EEM characteristics in patients on programmed hemodialysis and their association with clinical and laboratory parameters.Materials and methods: We performed a cross-sectional observational study in 220 patients with confirmed CKD 5d. The average age of the patients was 56.5±1.4 years (26 to 85 years) and the duration of dialysis therapy was 3.7±0.4 years. The Kt/V urea adequacy index was 1.54±0.08. The control group included 60 healthy blood donors, comparable for their age and sex. EEM was assessed with Cyto-Expert kit (Axion Holding, Izhevsk, 2010) and the WT-Cell program (LLC Westtrade LTD, 2019). Statistical analysis was performed with BioStat 2019 software.Results: The patients on the programmed hemodialysis had lower values of oscillation amplitude (10.2±0.5 μm and 21.2±2.1 μm, p<0.001) and lower proportion of mobile red blood cells (69.5±1.8%, 89.7±9.9%, p<0.001), compared to the control group. Lower values of the oscillation amplitude were found in the age group of 25 to 44 years (9.0±1.0 μm, p<0.05). There was a weak positive correlation between age and amplitude of erythrocyte oscillation (R=0.20, p<0.05). There were differences in the oscillation amplitude values in the patients with various dialysis experience: 1 to 2 years, 11.3±0.8 μm, 2 to 5 years, 9.9±0.7 μm, 6 to 10 years, 9.4±1.3 μm, and over 11 years, 7.4±0.9 μm (p<0.05). The duration of dialysis therapy demonstrated a weak negative correlation with the amplitude of erythrocyte oscillation (R=-0.24, p<0.01). The erythrocyte oscillation amplitude was associated with systolic blood pressure before hemodialysis procedure (R=0.34, p<0.05) and with pulse pressure before hemodialysis (R=0.37, p<0.05). The proportion of mobile erythrocytes correlated with parathyroid hormone level (R=0.32, p<0.05).Conclusion: EEM in the patients receiving programmed hemodialysis have their specific characteristics related to a significant decrease in the oscillation amplitude proportional to the effective cell charge and lower proportions of mobile erythrocytes compared to those in the healthy control. The erythrocyte oscillation amplitude is negatively correlated with age and duration of dialysis therapy and is associated with blood pressure parameters and mineral bone indices.

Urgent-start peritoneal dialysis for end-stage renal disease patients: literature review and worldwide evidence-based practice

The prevalence of end-stage renal disease (ESRD) is on the rise worldwide. Meanwhile, the number of older people requiring dialysis therapy is increasing as a result of this population. We found that starting dialysis in an unplanned manner is a common occurrence, even for patients with nephrology follow-up. Most centers choose hemodialysis with a high rate of central venous catheter use at the time of initiation of dialysis. Current data has found that central venous catheter use is independently associated with increased mortality and high bacteremia rates. Peritoneal dialysis is one option to avoid bacteremia. The International Society for Peritoneal Dialysis guidelines suggests a break-in period of at least two weeks prior to an elective start of peritoneal dialysis, without mentioning urgent-start peritoneal dialysis. For unplanned ESRD patients, it is unrealistic to wait for two weeks before initiating peritoneal dialysis therapy. Urgent-start peritoneal dialysis has been suggested to be a practical approach of prompt initiation of peritoneal dialysis after catheter insertion, which may avoid an increased risk of central venous catheter-related complications, including bacteremia, central venous stenosis, and thrombosis associated with the temporary use of hemodialysis. Peritoneal dialysis is the alternative option, and many studies have presented an interest in urgent-start peritoneal dialysis. Some reports have compared urgent-start hemodialysis to peritoneal dialysis and found that urgent-start peritoneal dialysis is a safe and effective alternative to hemodialysis for an unplanned dialysis patient. This review aims to compare each literature report regarding techniques, prescriptions, outcomes, complications, and costs of urgent-start peritoneal dialysis.

Shared decision making for the initiation and continuation of dialysis: a proposal from the Japanese Society for Dialysis Therapy

Background In Japan, forgoing life-sustaining treatment to respect the will of patients at the terminal stage is not stipulated by law. According to the Guidelines for the Decision-Making Process in Terminal-Stage Healthcare published by the Ministry of Health, Labor and Welfare in 2007, the Japanese Society for Dialysis Therapy (JSDT) developed a proposal that was limited to patients at the terminal stage and did not explicitly cover patients with dementia. This proposal for the shared decision-making process regarding the initiation and continuation of maintenance hemodialysis was published in 2014. Methods and results In response to changes in social conditions, the JSDT revised the proposal in 2020 to provide guidance for the process by which the healthcare team can provide the best healthcare management and care with respect to the patient's will through advance care planning and shared decision making. For all patients with end-stage kidney disease, including those at the nonterminal stage and those with dementia, the decision-making process includes conservative kidney management. Conclusions The proposal is based on consensus rather than evidence-based clinical practice guidelines. The healthcare team is therefore not guaranteed to be legally exempt if the patient dies after the policies in the proposal are implemented and must respond appropriately at the discretion of each institution.

Dialysis Access and Preemptive Kidney Transplantation

Sustainable vascular or peritoneal access for dialysis is very important for patients undergoing dialysis therapy, and access trouble is occasionally involved with unexpected occurrence of complications. Once access trouble occurs, dialysis therapy might be discontinued and be followed by a life-threatening state of patients with end-stage kidney disease. Bacterial infection, massive bleeding, and thrombosis in patients undergoing hemodialysis and acute infectious peritonitis and chronic encapsulating peritoneal sclerosis in patients undergoing peritoneal dialysis are important clinical issues. Preemptive kidney transplantation prior to dialysis has several advantages over transplantation after exposure to dialysis therapy. One of the notable advantages is the lack of necessity of dialysis access, which avoids access operations before transplantation. However, some transplant recipients may need short-term dialysis therapy due to the unexpected progression of chronic renal dysfunction. Dialysis access is required in a short preoperative period for preconditioning. The selection of renal replacement therapy without complications in a short-term dialysis before transplant surgery is important for the success of kidney transplantation. Appropriate preparation of short-term dialysis therapy and access is a key to success of preemptive kidney transplantation.

Peritoneal Dialysis Guidelines 2019 Part 2: Main Text (Position paper of the Japanese Society for Dialysis Therapy)

Background This article is a duplicated publication from the Japanese version of “2019 JSDT Guidelines for Peritoneal Dialysis” with permission from the Japanese Society for Dialysis Therapy (JSDT). This clinical practice guideline (CPG) was developed primarily by the Working Group on Revision of Peritoneal Dialysis (PD) Guidelines of the Japanese Society for Dialysis Therapy. Recently, the definition and creation process for CPGs have become far more rigorous; traditional methods and formats no longer adhere to current standards. To improve the reliability of international transmission of our findings, CPGs are created in compliance with the methodologies developed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Part 2 of this PD guideline is the first CPG developed by our society that conforms to the GRADE approach. Methods Detailed processes were created in accordance with the Cochrane handbook and the GRADE approach developed by the GRADE working group. Results Clinical question (CQ)1: Is the use of renin-angiotensin system inhibitors (RAS inhibitors), such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), effective in PD patients? Recommendation: We suggest the usage of RAS inhibitors (ACEI and ARB) in PD patients (GRADE 2C). CQ2: Icodextrin or glucose solution: which is more useful as a dialysate among patients with PD? Recommendation: We suggest using icodextrin when managing body fluids in PD patients (GRADE 2C). CQ3: Is it better to apply or not apply mupirocin/gentamicin ointment to the exit site? Recommendation: We suggest not applying mupirocin/gentamicin ointment to the exit sites of PD patients (GRADE 2C). CQ4: Which surgical approach is more desirable when a PD catheter is placed, open surgery or laparoscopic surgery? No recommendation. CQ5: Which administration route of antibiotics is better in PD patients with peritonitis, intravenous or intraperitoneal? Recommendation: We suggest intraperitoneal administration of antibiotics in PD patients with peritonitis (GRADE 2C). Note: The National Insurance does not currently cover intraperitoneal administration. CQ6: Is peritoneal dialysis or hemodialysis better as the first renal replacement therapy in diabetic patients? No recommendation. Conclusions In the future, we suggest that society members construct their own evidence to answer CQs not brought up in this guideline, and thereby show the achievements of Japan worldwide.

Risk Factors for Herpes Zoster in Patients with Chronic Kidney Disease: A Case-Control Study

(1) Background: Chronic kidney disease (CKD) increases the susceptibility to the presence of herpes zoster (HZ). Little is known about the risk factors of HZ in CKD patients; (2) Methods: This is a case-control study. CKD patients diagnosed with HZ between January 2015 and June 2021 in a tertiary hospital were identified. One age- and gender- matched control was paired for each case, matched to the date of initial HZ diagnosis. Conditional multiple logistic regression was used to evaluate the risk factors associated with the presence of HZ; (3) Results: Forty-seven HZ patients and controls were identified. In general, about 73.40% (69 out of 94) patients were classified at IV to V stages of CKD. Immunosuppressive agents (p = 0.0012) and dialysis therapy (p = 0.021) were reported more frequently in the HZ cohort. Compared with the control group, the total white cell count and lymphocyte count were significantly lower in the HZ group (p value of 0.032 and 0.003, respectively). The conditional logistics regression model revealed that previous immunosuppressants administration (odds ratio: 10.861, 95% CI: 2.092~56.392, p = 0.005) and dialysis therapy (odds ratio: 3.293, 95% CI: 1.047~10.355, p = 0.041) were independent risk factors of HZ in the CKD population; (4) Conclusions: Dialysis and immunosuppressants therapy were associated with greater risk of HZ disease in CKD patients. Further guideline may highlight the necessity of zoster vaccine for patients with CKD, who undertake associated treatment.