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Garofalo C, Borrelli S, Liberti ME, Chiodini P, Peccarino L, Pennino L, Polese L, De Gregorio I, Scognamiglio M, Ruotolo C, Provenzano M, Conte G, Minutolo R, De Nicola L. Secular Trend in GFR Decline in Non-Dialysis CKD Based on Observational Data From Standard of Care Arms of Trials. Am J Kidney Dis 2024; 83:435-444.e1. [PMID: 37956953 DOI: 10.1053/j.ajkd.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 11/21/2023]
Abstract
RATIONALE & OBJECTIVE The standard of care (SoC) group of randomized controlled trials (RCTs) is a useful setting to explore the secular trends in kidney disease progression because implementation of best clinical practices is pursued for all patients enrolled in trials. This meta-analysis evaluated the secular trend in the change of glomerular filtration rate (GFR) decline in the SoC arm of RCTs in chronic kidney disease (CKD) published in the last 30 years. STUDY DESIGN Systematic review and meta-analysis of the SoC arms of RCTs analyzed as an observational study. SETTING & STUDY POPULATIONS Adult patients with CKD enrolled in the SoC arm of RCTs. SELECTION CRITERIA FOR STUDIES Phase 3 RCTs evaluating GFR decline as an outcome in SoC arms. DATA EXTRACTION Two independent reviewers evaluated RCTs for eligibility and extracted relevant data. ANALYTICAL APPROACH The mean of GFR declines extracted in the SoC arm of selected RCTs were pooled by using a random effects model. Meta-regression analyses were performed to identify factors that may explain heterogeneity. RESULTS The SoC arms from 92 RCTs were included in the meta-analysis with a total of 32,202 patients. The overall mean GFR decline was-4.00 (95% CI, -4.55 to-3.44) mL/min/1.73m2 per year in the SoC arms with a high level of heterogeneity (I2, 98.4% [95% CI, 98.2-98.5], P<0.001). Meta-regression analysis showed an association between publication year (β estimate, 0.09 [95% CI, 0.032-0.148], P=0.003) and reduction in GFR over time. When evaluating publication decade categorically, GFR decline was-5.44 (95% CI, -7.15 to-3.73), -3.92 (95% CI, -4.82 to-3.02), and -3.20 (95% CI, -3.75 to -2.64) mL/min/1.73m2 per year during 1991-2000, 2001-2010, and 2011-2023, respectively. Using meta-regression, the heterogeneity of GFR decline was mainly explained by age and proteinuria. LIMITATIONS Different methods assessing GFR in selected trials and observational design of the study. CONCLUSIONS In the last 3 decades, GFR decline has decreased over time in patients enrolled in RCTs who received the standard of care. TRIAL REGISTRATION Registered at PROSPERO with record number CRD42022357704. PLAIN-LANGUAGE SUMMARY This study evaluated the secular trend in the change in glomerular filtration rate (GFR) decline in the placebo arms of randomized controlled trials (RCTs) that were studying approaches to protect the kidneys in the setting of chronic kidney disease. The placebo groups of RCTs are useful for examining whether the rate of progression of kidney disease has changed over time. We found an improvement in the slope of change in GFR over time. These findings suggest that adherence to standards of kidney care as implemented in clinical trials may be associated with improved clinical outcomes, and these data may inform the design of future RCTs in nephrology.
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Affiliation(s)
- Carlo Garofalo
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy.
| | - Silvio Borrelli
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Maria Elena Liberti
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Laura Peccarino
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Luigi Pennino
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Lucio Polese
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Ilaria De Gregorio
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Chiara Ruotolo
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giuseppe Conte
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Roberto Minutolo
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
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Garofalo C, Ruotolo C, Annoiato C, Liberti ME, Minutolo R, De Nicola L, Conte G, Borrelli S. Sustained Recovery of Kidney Function in Patients with ESKD under Chronic Dialysis Treatment: Systematic Review and Meta-Analysis. Nutrients 2023; 15:nu15071595. [PMID: 37049436 PMCID: PMC10096619 DOI: 10.3390/nu15071595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/17/2023] [Accepted: 03/24/2023] [Indexed: 03/28/2023] Open
Abstract
The prevalence of recovery of kidney function (RKF) in patients under maintenance dialysis is poorly defined mainly because of different definitions of RKF. Therefore, to gain more insights into the epidemiology of RKF, we performed a systematic review and meta-analysis of studies addressing the prevalence of sustained (at least for 30 days) RKF in patients under maintenance dialysis. Acute kidney injury (AKI) and RKF in the first 90 days of dialysis were the main exclusion criteria. Overall, 7 studies (10 cohorts) including 2,444,943 chronic dialysis patients (range: 430–1,900,595 patients) were meta-analyzed. The period of observation ranged from 4 to 43 years. The prevalence of RKF was 1.49% (95% C.I.:1.05–2.11; p < 0.001] with high heterogeneity I2: 99.8%, p < 0.001. The weighted mean dialysis vintage before RKF was 294 ± 165 days; RKF persisted for a weighted mean of 27.5 months. The percentage of RKF was higher in studies from the U.S. (1.96% [95% C.I.: 1.24–3.07]) as compared to other countries (1.04% [95%C.I.: 0.66–1.62]; p = 0.049). In conclusion, sustained RKF unrelated to AKI occurs in about 1.5% of patients under maintenance dialysis. On average, RKF patients discontinue chronic dialysis about ten months after starting treatment and live free of dialysis for more than two years. The higher prevalence of RKF reported in the U.S. versus other countries suggests a major role of country-specific policies for dialysis start.
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Buades JM, Craver L, Del Pino MD, Prieto-Velasco M, Ruiz JC, Salgueira M, de Sequera P, Vega N. Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options? J Clin Med 2021; 10:2943. [PMID: 34209083 PMCID: PMC8268456 DOI: 10.3390/jcm10132943] [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: 05/23/2021] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.
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Affiliation(s)
- Juan M. Buades
- Department of Nephrology, Hospital Universitario Son Llàtzer, Balearic Islands, 07198 Palma de Mallorca, Spain
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma de Mallorca, Spain
| | - Lourdes Craver
- Department of Nephrology, Hospital Universitario Arnau de Vilanova, 25198 Lleida, Spain;
| | - Maria Dolores Del Pino
- Department of Nephrology, Complejo Hospitalario Torrecárdenas de Almería, 04009 Almería, Spain;
| | - Mario Prieto-Velasco
- Department of Nephrology, Complejo Asistencial Universitario de Leon, 24001 León, Spain;
| | - Juan C. Ruiz
- Department of Nephrology, Valdecilla Hospital, University of Cantabria, 39008 Santander, Spain;
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain
| | - Mercedes Salgueira
- Department of Nephrology, Hospital Universitario Virgen Macarena, 41009 Seville, Spain;
- Biomedical Engineering Group, Medicine Department, University of Seville, 41092 Seville, Spain
- Center for Biomedical Research Network in Bioengineering Biomaterials and Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - Patricia de Sequera
- Department of Nephrology, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain;
- Medicine Department, Universidad Complutense de Madrid, 28031 Madrid, Spain
| | - Nicanor Vega
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain;
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Highlights from the 60th national meeting of the Italian Society of Nephrology: celebrating the role of the nephrologist. J Nephrol 2020; 33:1139-1142. [PMID: 32880883 PMCID: PMC7471491 DOI: 10.1007/s40620-020-00856-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Provenzano M, Chiodini P, Minutolo R, Zoccali C, Bellizzi V, Conte G, Locatelli F, Tripepi G, Del Vecchio L, Mallamaci F, Di Micco L, Russo D, Heerspink HJL, De Nicola L. Reclassification of chronic kidney disease patients for end-stage renal disease risk by proteinuria indexed to estimated glomerular filtration rate: multicentre prospective study in nephrology clinics. Nephrol Dial Transplant 2020; 35:138-147. [PMID: 30053127 DOI: 10.1093/ndt/gfy217] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/09/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In non-dialysis chronic kidney disease (CKD), absolute proteinuria (Uprot) depends on the extent of kidney damage and residual glomerular filtration rate (GFR). We therefore evaluated, as compared with Uprot, the strength of association of proteinuria indexed to estimated GFR (eGFR) with end-stage renal disease (ESRD) risk. METHODS In a multi-cohort prospective study in 3957 CKD patients of Stages G3-G5 referred to nephrology clinics, we tested two multivariable Cox models for ESRD risk, with either Uprot (g/24 h) or filtration-adjusted proteinuria (F-Uprot) calculated as Uprot/eGFR ×100. RESULTS Mean ± SD age was 67 ± 14 years, males 60%, diabetics 29%, cardiovascular disease (CVD) 34%, eGFR 32 ± 13 mL/min/1.73 m2, median (interquartile range) Uprot 0.41 (0.12-1.29) g/24 h and F-Uprot 1.41 (0.36-4.93) g/24 h per 100 mL/min/1.73 m2 eGFR. Over a median follow-up of 44 months, 862 patients reached ESRD. At competing risk analysis, ESRD risk progressively increased when F-Uprot was 1.0-4.9 and ≥5.0 versus <1.0 g/24 h per 100 mL/min/1.73 m2 eGFR in Stages G3a-G4 (P < 0.001) and Stage G5 (P = 0.002). Multivariable Cox analysis showed that Uprot predicts ESRD in Stages G3a-G4 while in G5 the effect was not significant; conversely, F-Uprot significantly predicted ESRD at all stages. The F-Uprot model allowed a significantly better prediction versus the Uprot model according to Akaike information criterion. Net reclassification improvement was 12.2% (95% confidence interval 4.2-21.1), with higher reclassification in elderly, diabetes and CVD, as well as in diabetic nephropathy and glomerulonephritis, and in CKD Stages G4 and G5. CONCLUSIONS In patients referred to nephrology clinics, F-Uprot predicts ESRD at all stages of overt CKD and improves, as compared with Uprot, reclassification of patients for renal risk, especially in more advanced and complicated disease.
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Affiliation(s)
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Roberto Minutolo
- Nephrology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carmine Zoccali
- Nephrology Center of National Research Institute of Biomedicine and Molecular Immunology, Reggio Calabria, Italy
| | - Vincenzo Bellizzi
- Division of Nephrology, Dialysis and Transplantation, Salerno Medical School, University Hospital San Giovanni di Dio e Ruggi d'Aragona Unit-University, Salerno, Italy
| | - Giuseppe Conte
- Nephrology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Giovanni Tripepi
- Nephrology Center of National Research Institute of Biomedicine and Molecular Immunology, Reggio Calabria, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, A. Manzoni Hospital, Lecco, Italy
| | - Francesca Mallamaci
- Nephrology Center of National Research Institute of Biomedicine and Molecular Immunology, Reggio Calabria, Italy
| | - Lucia Di Micco
- Division of Nephrology, A. Landolfi Hospital, Solofra, Avellino, Italy
| | - Domenico Russo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Luca De Nicola
- Nephrology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
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Nephroprotection by SGLT2 Inhibition: Back to the Future? J Clin Med 2020; 9:jcm9072243. [PMID: 32679744 PMCID: PMC7408701 DOI: 10.3390/jcm9072243] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023] Open
Abstract
The introduction of sodium/glucose cotransporter 2 inhibitors (SGLT2i) has opened new perspectives for the management of diabetic population at risk of or with chronic kidney disease (CKD). More important, recent, large real-world studies have repositioned the nephroprotective efficacy of SGLT2i emerged from randomized trials within the frame of effectiveness. Furthermore, the salutary effects of these agents may extend to the nondiabetic population according to the positive results of current studies. Nevertheless, the clear benefits of these agents on the prevention of organ damage contrast with their unexpected, limited use in clinical practice. One potential barrier is the acute decline in glomerular filtration rate (GFR) commonly observed at the beginning of treatment. This phenomenon is reminiscent of the early response to the traditional nephroprotective interventions, namely blood pressure lowering, dietary protein and salt restriction and the inhibition of the renin–angiotensin system. Under this perspective, the “check-mark” sign observed in the GFR trajectory over the first weeks of SGT2i therapy should renew interest on the very basic goal of CKD treatment, i.e., alleviate hyperfiltration in viable nephrons in order to prolong their function.
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Verberne WR, van den Wittenboer ID, Voorend CGN, Abrahams AC, van Buren M, Dekker FW, van Jaarsveld BC, van Loon IN, Mooijaart SP, Ocak G, van Delden JJM, Bos WJW. Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review. Nephrol Dial Transplant 2020; 36:1418-1433. [DOI: 10.1093/ndt/gfaa078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/18/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background
Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment.
Methods
We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD.
Results
Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start.
Conclusions
The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings.
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Affiliation(s)
- Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Carlijn G N Voorend
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Nephrology, Haga Hospital, The Hague, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Brigit C van Jaarsveld
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands
| | - Ismay N van Loon
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gurbey Ocak
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes J M van Delden
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Chang YL, Wang JS, Yeh HC, Ting IW, Huang HC, Chiang HY, Hsiao CT, Chu PL, Kuo CC. Dialysis timing may be deferred toward very late initiation: An observational study. PLoS One 2020; 15:e0233124. [PMID: 32401817 PMCID: PMC7219782 DOI: 10.1371/journal.pone.0233124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/28/2020] [Indexed: 01/20/2023] Open
Abstract
The optimal timing to initiate dialysis among patients with an estimated glomerular filtration rate (eGFR) of <5 mL/min/1.73 m2 is unknown. We hypothesized that dialysis initiation time can be deferred in this population even with high uremic burden. A case-crossover study with case (0-30 days before dialysis initiation [DI]) and control (90-120 days before DI) periods was conducted in 1,079 hemodialysis patients aged 18-90 years at China Medical University Hospital between 2006 and 2015. The uremic burden was quantified based on 7 uremic indicators that reached the predefined threshold in case period, namely hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate. Dialysis timing was classified as standard (met 0-2 uremic indicators), late (3-5 indicators), and very late (6-7 indicators). Median eGFR-DI of the 1,079 patients was 3.4 mL/min/1.73 m2 and was 2.7 mL/min/1.73 m2 in patients with very late initiation. The median follow-up duration was 2.42 years. Antibiotics, diuretics, antihypertensive medications, and non-steroidal anti-inflammatory drugs (NSAIDs) were more prevalently used during the case period. The fully adjusted hazards ratios of all-cause mortality for the late and very late groups were 0.97 (95% confidence interval 0.76-1.24) and 0.83 (0.61-1.15) compared with the standard group. It is safe to defer dialysis initiation among patients with chronic kidney disease (CKD) having an eGFR of <5 mL/min/1.73 m2 even when patients having multiple biochemical uremic burdens. Coordinated efforts in acute infection prevention, optimal fluid management, and prevention of accidental exposure to NSAIDs are crucial to prolong the dialysis-free survival.
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Affiliation(s)
- Yun-Lun Chang
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Jie-Sian Wang
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chieh Yeh
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - I-Wen Ting
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Han-Chun Huang
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiung-Tzu Hsiao
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medical Laboratory Science and Biotechnology, China Medical University, Taichung, Taiwan
| | - Pei-Lun Chu
- Division of Nephrology, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chin-Chi Kuo
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
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Bianchi S, Regolisti G. Pivotal clinical trials, meta-analyses and current guidelines in the treatment of hyperkalemia. Nephrol Dial Transplant 2019; 34:iii51-iii61. [DOI: 10.1093/ndt/gfz213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Indexed: 01/14/2023] Open
Abstract
Abstract
Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with advanced stages of chronic kidney disease (CKD), is a potentially life-threatening clinical condition due to an increased risk of fatal arrhythmias, and strongly impacts the quality of life and prognosis of CKD patients. Moreover, while renin–angiotensin–aldosterone system inhibitors (RAASIs) represent the most cardio-nephro-protective drugs used in clinical practice, the treatment with these drugs per se increases serum potassium (sK) values, particularly when heart failure and diabetes mellitus coexist. In fact, the onset or recurrence of HK is frequently associated with not starting, down-titrating or withdrawing RAASIs, and is an indication to begin renal replacement treatment in end-stage renal disease. Current strategies aimed at preventing and treating chronic HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials. Indeed, dietary potassium restriction, the use of sodium bicarbonate or diuretics, the withdrawal or down-titration of RAASIs, or the administration of old potassium binders, namely sodium polystyrene sulphonate and calcium polystyrene sulphonate, have limited efficacy and are poorly tolerated; therefore, these strategies are not suitable for long-term control of sK. As such, there is an important unmet need for novel therapeutic options for the chronic management of patients at risk for HK. The development of new potassium binders may change the treatment landscape in the near future. This review summarizes the current evidence on the treatment of chronic HK in cardio-renal patients.
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Affiliation(s)
- Stefano Bianchi
- Nephrology and Dialysis Unit, Department of Internal Medicine, ASL Toscana Nordovest, Regione Toscana, Livorno, Italy
| | - Giuseppe Regolisti
- Unit of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Ren Q, Shi Q, Ma T, Wang J, Li Q, Li X. Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review. Health Qual Life Outcomes 2019; 17:78. [PMID: 31053092 PMCID: PMC6500052 DOI: 10.1186/s12955-019-1146-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 04/22/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Older patients with end-stage renal disease (ESRD) have experienced diminished quality of life and debilitating symptoms. Conservative management may be a potential treatment option. Currently, limited studies have been conducted about the main outcome of conservative management, including quality of life, symptoms and sleep quality. The aim of this systematic review was to examine the quality of life, symptoms and sleep quality of elderly patients with ESRD undergoing conservative management. METHODS Evidence-based medicine database (JBI and Cochrane) and original literature database (PubMed, Medline, EMbase, Web of Science) were searched up to March 12, 2018. The quality of included papers was evaluated with the Newcastle-Ottawa Scale. RESULTS Eight studies met the inclusion criteria. The total of 1229 patients were involved with an average age of 60.6 ~ 82 years. Patients choosing conservative management were older and more functionally impaired compared to those opting for dialysis. 55% patients undergoing conservative management had stable or improved quality of life and symptoms in prospective cohort study. However, the results revealed that there were no significant differences in quality of life and symptom between conservative management and renal replacement therapy. Only one study assessed quality of life of older patients using SF-36, with a lower score in physical health subscale of conservative management patients than those of renal replacement therapy. Although more than 40% of the patients had poor sleep quality, no significant difference was found between conservative management and renal replacement therapy. Sleep disorders were associated with fatigue and other symptoms. CONCLUSIONS Although there is a limited literature, conservative management is likely to improve quality of life and alleviate symptoms of end-stage renal disease patients with considerable clinical implications mainly in elderly patients. Future study should pay more attention to the various treatment outcomes of conservative management, providing abundant evidence.
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Affiliation(s)
- Qingli Ren
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Qifang Shi
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Tong Ma
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Jing Wang
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Qian Li
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Xiaomei Li
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
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11
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Davison SN, Tupala B, Wasylynuk BA, Siu V, Sinnarajah A, Triscott J. Recommendations for the Care of Patients Receiving Conservative Kidney Management: Focus on Management of CKD and Symptoms. Clin J Am Soc Nephrol 2019; 14:626-634. [PMID: 30819670 PMCID: PMC6450361 DOI: 10.2215/cjn.10510917] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Conservative kidney management is increasingly accepted as an appropriate treatment option for patients with eGFR category 5 CKD who are unlikely to benefit from dialysis and/or who choose a nondialysis care option. However, there remains great variation in the delivery of their care. As part of the development of a conservative kidney management pathway that is undergoing evaluation, a set of recommendations specific to conservative kidney management for managing the complications of CKD and common symptoms was developed. These recommendations focus on the patient's values and preferences and aim to optimize comfort and quality of life. Explanations for the interventions are provided to support the shared decision-making process between health care professionals, patients, and family members. The recommendations generally emphasize the preservation of function (cognitive, physical, and kidney) and address symptom burden, acknowledging that management priorities can change over time. The recommendations should be used in conjunction with other key elements of conservative kidney management, including clear communication and shared decision making for choosing conservative kidney management, advance care planning, and psychosocial support. Although there are limitations to the existing evidence specific to conservative kidney management, these recommendations are intended as a starting point toward reaching consensus and generating further evidence.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine and
| | - Beth Tupala
- Covenant Health Palliative Institute, Covenant Health, Edmonton, Alberta, Canada
| | - Betty Ann Wasylynuk
- Northern Alberta Renal Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - Valerie Siu
- Pharmacy Services, Alberta Health Services, University of Alberta Hospital, Edmonton, Alberta, Canada; and
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Jean Triscott
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
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12
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Pacilio M, Borrelli S, Conte G, Minutolo R, Musumeci A, Brunori G, Veniero P, De Falco V, Provenzano M, De Nicola L, Garofalo C. Central Venous Stenosis after Hemodialysis: Case Reports and Relationships to Catheters and Cardiac Implantable Devices. Cardiorenal Med 2019; 9:135-144. [DOI: 10.1159/000496065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/05/2018] [Indexed: 11/19/2022] Open
Abstract
The appropriate vascular access for hemodialysis in patients with cardiac implantable electronic devices (CIED) is undefined. We describe two cases of end-stage renal disease patients with CIED and tunneled central venous catheter (CVC) who developed venous cava stenosis: (1) a 70-year-old man with sinus node disease and pacemaker in 2013, CVC, and a Brescia-Cimino forearm fistula in 2015; (2) a 75-year-old woman with previous ventricular arrhythmia with implanted defibrillator in 2014 and CVC in 2016. In either case, after about 1 year from CVC insertion, patients developed superior vena cava (SVC) syndrome due to stenosis diagnosed by axial computerized tomography. In case 1, the patient was not treated by angioplasty of SVC and removed CVC with partial resolving of symptoms. In case 2, a percutaneous transluminal angioplasty with placement of a new CVC was required. To analyze these reports in the context of available literature, we systematically reviewed studies that have analyzed the presence of central venous stenosis associated with the simultaneous presence of CIED and CVC. Five studies were found; two indicated an increased incidence of central venous stenosis, while three did not find any association. While more studies are definitely needed, we suggest that these patients may benefit from epicardial cardiac devices and the insertion of devices directly into the ventriculus. If the new devices are unavailable or contraindicated, peritoneal dialysis or intensive conservative treatment in older patients may be proposed as alternative options.
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14
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Incremental dialysis in ESRD: systematic review and meta-analysis. J Nephrol 2019; 32:823-836. [DOI: 10.1007/s40620-018-00577-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/18/2018] [Indexed: 12/15/2022]
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15
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De Nicola L, Di Lullo L, Paoletti E, Cupisti A, Bianchi S. Chronic hyperkalemia in non-dialysis CKD: controversial issues in nephrology practice. J Nephrol 2018; 31:653-664. [PMID: 29882199 PMCID: PMC6182350 DOI: 10.1007/s40620-018-0502-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/23/2018] [Indexed: 02/06/2023]
Abstract
Chronic hyperkalemia is a major complication of chronic kidney disease (CKD) that occurs frequently, heralds poor prognosis, and necessitates careful management by the nephrologist. Current strategies aimed at prevention and treatment of hyperkalemia are still suboptimal, as evidenced by the relatively high prevalence of hyperkalemia in patients under stable nephrology care, and even in the ideal setting of randomized trials where best treatment and monitoring are mandatory. The aim of this review was to identify and discuss a range of unresolved issues related to the management of chronic hyperkalemia in non-dialysis CKD. The following topics of clinical interest were addressed: diagnosis, relationship with main comorbidities of CKD, therapy with inhibitors of the renin-angiotensin-aldosterone system, efficacy of current dietary and pharmacological treatment, and the potential role of the new generation of potassium binders. Opinion-based answers are provided for each of these controversial issues.
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Affiliation(s)
- Luca De Nicola
- Division of Nephrology, University of Campania, Piazza L. Miraglia, 1, 80138, Naples, Italy.
| | - Luca Di Lullo
- Nephrology and Dialysis Unit, Parodi-Delfino Hospital, Colleferro, Rome, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Bianchi
- Nephrology Unit, Azienda USL Toscana Nord Ovest, Leghorn, Italy
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16
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Kurella Tamura M, Desai M, Kapphahn KI, Thomas IC, Asch SM, Chertow GM. Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD. J Am Soc Nephrol 2018; 29:2169-2177. [PMID: 29789430 DOI: 10.1681/asn.2017121273] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/27/2018] [Indexed: 11/03/2022] Open
Abstract
Background Appropriate patient selection and optimal timing of dialysis initiation among older adults with advanced CKD are uncertain. We determined the association between dialysis versus medical management and survival at different ages and levels of kidney function.Methods We assembled a nationally representative 20% sample of United States veterans with eGFR<30 ml/min per 1.73 m2 between 2005 and 2010 (n=73,349), with follow-up through 2012. We used an extended Cox model to determine associations among the time-varying exposures, age (<65, 65-74, 75-84, and ≥85 years), eGFR (<6, 6-<9, 9-<12, 12-<15, and 15-<29 ml/min per 1.73 m2), and provision of dialysis, and survival.Result Over the mean±SEM follow-up of 3.4±2.2 years, 15% of patients started dialysis and 52% died. The eGFR at which dialysis, compared with medical management, associated with lower mortality varied by age (P<0.001). For patients aged <65, 65-74, 75-84, and ≥85 years, dialysis associated with lower mortality for those with eGFR not exceeding 6-<9, <6, 9-<12, and 9-<12 ml/min per 1.73 m2, respectively. Dialysis initiation at eGFR<6 ml/min per 1.73 m2 associated with a higher median life expectancy of 26, 25, and 19 months for patients aged 65, 75, and 85 years, respectively. When dialysis was initiated at eGFR 9-<12 ml/min per 1.73 m2, the estimated difference in median life expectancy was <1 year for these patients.Conclusions Provision of dialysis at higher levels of kidney function may extend survival for some older patients.
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Affiliation(s)
| | - Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kristopher I Kapphahn
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center and.,Division of Nephrology and
| | - Steven M Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
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17
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Ladin K, Pandya R, Kannam A, Loke R, Oskoui T, Perrone RD, Meyer KB, Weiner DE, Wong JB. Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists. Am J Kidney Dis 2018; 71:627-635. [PMID: 29396240 PMCID: PMC5916578 DOI: 10.1053/j.ajkd.2017.11.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/06/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community. STUDY DESIGN Interview study of nephrologists. SETTING & PARTICIPANTS National sample of US nephrologists sampled based on sex, years in practice, practice type, and region. METHODOLOGY Qualitative semistructured interviews continued until thematic saturation. ANALYTICAL APPROACH Thematic and narrative analysis of recorded and transcribed interviews. RESULTS Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. LIMITATIONS Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians. CONCLUSIONS Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, MA; Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA.
| | - Renuka Pandya
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Allison Kannam
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Rohini Loke
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Tira Oskoui
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | | | | | | | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
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18
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Controversial issues in CKD clinical practice: position statement of the CKD-treatment working group of the Italian Society of Nephrology. J Nephrol 2016; 30:159-170. [PMID: 27568307 DOI: 10.1007/s40620-016-0338-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/12/2016] [Indexed: 01/13/2023]
Abstract
This position paper of the study group "Conservative treatment of Chronic Kidney Disease-CKD" of the Italian Society of Nephrology addresses major practical, unresolved, issues related to the conservative treatment of chronic renal disease. Specifically, controversial topics from everyday clinical nephrology practice which cannot find a clear, definitive answer in the current literature or in nephrology guidelines are discussed. The paper reports the point of view of the study group. Concise and practical advice is given on several common issues: renal biopsy in diabetes; dual blockade of the renin-angiotensin-aldosterone system (RAAS); management of iron deficiency; low protein diet; dietary salt intake; bicarbonate supplementation; treatment of obesity; the choice of conservative therapy vs. dialysis. For each topic synthetic statements, guideline-style, are reported.
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