Managing hyperphosphatemia in patients with chronic kidney disease on dialysis with ferric citrate: latest evidence and clinical usefulness.

Ferric citrate is a novel phosphate binder that allows the simultaneous treatment of hyperphosphatemia and iron deficiency in patients being treated for end-stage renal disease with hemodialysis (HD). Multiple clinical trials in HD patients have uniformly and consistently demonstrated the efficacy of the drug in controlling hyperphosphatemia with a good safety profile, leading the US Food and Drug Administration in 2014 to approve its use for that indication. A concurrent beneficial effect, while using ferric citrate as a phosphate binder, is its salutary effect in HD patients with iron deficiency being treated with an erythropoietin-stimulating agent (ESA) in restoring iron that becomes available for reversing chronic kidney disease (CKD)-related anemia. Ferric citrate has also been shown in several studies to diminish the need for intravenous iron treatment and to reduce the requirement for ESA. Ferric citrate is thus a preferred phosphate binder that helps resolve CKD-related mineral bone disease and iron-deficiency anemia.

Ferric Citrate Reduces Intravenous Iron and Erythropoiesis-Stimulating Agent Use in ESRD.

Ferric citrate (FC) is a phosphate binder with shown efficacy and additional effects on iron stores and use of intravenous (iv) iron and erythropoiesis-stimulating agents (ESAs). We provide detailed analyses of changes in iron/hematologic parameters and iv iron/ESA use at time points throughout the active control period of a phase 3 international randomized clinical trial. In all, 441 subjects were randomized (292 to FC and 149 to sevelamer carbonate and/or calcium acetate [active control (AC)]) and followed for 52 weeks. Subjects on FC had increased ferritin and transferrin saturation (TSAT) levels compared with subjects on AC by week 12 (change in ferritin, 114.1±29.35 ng/ml; P<0.001; change in TSAT, 8.62%±1.57%; P<0.001). Change in TSAT plateaued at this point, whereas change in ferritin increased through week 24, remaining relatively stable thereafter. Subjects on FC needed less iv iron compared with subjects on AC over 52 weeks (median [interquartile range] dose=12.9 [1.0-28.9] versus 26.8 [13.4-47.6] mg/wk; P<0.001), and the percentage of subjects not requiring iv iron was higher with FC (P<0.001). Cumulative ESA over 52 weeks was lower with FC than AC (median [interquartile range] dose=5303 [2023-9695] versus 6954 [2664-12,375] units/wk; P=0.04). Overall, 90.3% of subjects on FC and 89.3% of subjects on AC experienced adverse events. In conclusion, treatment with FC as a phosphate binder results in increased iron parameters apparent after 12 weeks and reduces iv iron and ESA use while maintaining hemoglobin over 52 weeks, with a safety profile similar to that of available binders.

A series of unusual complications of the presternal peritoneal dialysis catheter.

An ongoing problem for peritoneal dialysis (PD) patients has been complications associated with an indwelling PD catheter. The indwelling catheter has been through many modifications aimed at reducing complications and providing effective delivery of dialysis solution. In this report, we review four cases of rare complications associated with presternal PD catheters and a brief review of the Tenckhoff, Toronto Western Hospital, and Missouri swan-neck abdominal and presternal PD catheters.

Current trends in the use of peritoneal dialysis catheters.

The Tenckhoff catheter was developed in 1968 and has been widely used since for chronic peritoneal dialysis (PD) patients. Variations of the Tenckhoff catheter have been designed over the years in a search for the ideal PD catheter--an access that can provide reliable dialysate flow rates with few complications. Currently, data derived from randomized, controlled, multicenter trials dedicated to testing how catheter design and placement technique influence long-term catheter survival and function are scarce. As a result, no firm guidelines exist at the national or international levels on optimal PD catheter type or implantation technique. Also, no current statistics on the use of PD catheters are available. The last survey was carried out using an audience response system at the Annual Peritoneal Dialysis Conference in Orlando, Florida, in January 1994. The present analysis is based on a new survey done at the 2005 Annual Dialysis Conference in Tampa, Florida. It is a snapshot of preferences in catheter design and implantation technique in 2004 from an international sample of 65 respondent chronic PD centers. The Tenckhoff catheter remains the most widely used catheter, followed closely by the swan-neck catheter in both adult and pediatric respondent centers. Double-cuff catheters continue to be preferred over single-cuff catheters, and coiled intraperitoneal segments are generally preferred over straight intra-peritoneal segments. Surgical implantation technique remains the prevailing placement method in both pediatric and adult respondent centers.

Automated peritoneal dialysis - indications and management.

Automated peritoneal dialysis (APD) use has increased considerably in the last decade, and its growth has been mainly driven by patient preference and development of new, simpler cyclers. Careful management of the APD prescription can result in adequate solute and fluid removal in vast majority of patients, even anuric and large patients. So far, there are no convincing data that peritonitis rates, decline in residual renal function, protein losses, patient and technique survival, are different for APD and continuous ambulatory peritoneal dialysis (CAPD). APD has the major advantage of allowing positive changes in the life-style of end stage renal disease patients.

Successful use of a right atrial catheter for hemodialysis.

Maintenance of patent hemodialysis access is a major issue in the chronic dialysis population. Patients on chronic hemodialysis are at risk of progressive loss of possible sites for permanent vascular access. This issue becomes increasingly important in patients who are not suitable candidates for any other mode of renal replacement therapy for a variety of clinical reasons. When all conventional access sites are exhausted, a creative approach is often needed to establish an alternative vascular access for dialysis to maintain life. We report the placement of a tunneled dialysis catheter in the right atrium in such a patient. After 14 months, this catheter is still being used to deliver hemodialysis without any complications.