Prurito en pacientes en diálisis. Revisión de la literatura y nuevas perspectivas / Pruritus in dialysis patients. Review and new perspectives

El prurito es uno de los síntomas más incómodos y que más impacta en la calidad de vida de los pacientes en diálisis. Su prevalencia es bastante elevada en pacientes en diálisis (28-70%). La fisiopatología del prurito urémico es desconocida, y este síntoma a menudo pasa desapercibido para el personal sanitario, siendo infradiagnosticado en más del 65% de los centros. Esta falta de reconocimiento deriva en un abordaje terapéutico ineficaz del prurito urémico. Por otro lado, la mayoría de los ensayos farmacológicos para el tratamiento del prurito urémico han sido realizados en poblaciones reducidas y están sujetos a la subjetiva medición del propio síntoma. Por este motivo, hemos propuesto algoritmos de tratamiento, teniendo en cuenta la evidencia que avala a cada fármaco y a la vez la pluripatología y la polifarmacia de cada paciente, con el fin de evitar efectos adversos. (AU)

Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients’ quality of life and has a great prevalence between those (28–70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects. (AU)

The current and future landscape of dialysis.

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis - particularly haemodialysis and most notably in high-income countries (HICs) - the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Clinical efficacy of biomarkers for evaluation of volume status in dialysis patients.

Volume status is a key parameter for cardiovascular-related mortality in dialysis patients. Although N-terminal pro-B-type natriuretic peptide (NT-proBNP), myeloperoxidase, copeptin, and pro-adrenomedullin have been reported as volume markers, the relationship between body fluid status and volume markers in dialysis patients is uncertain. Therefore, we investigated the utility of volume status biomarkers based on body composition monitor (BCM) analyses.We enrolled pre-dialysis, hemodialysis (HD), and peritoneal dialysis (PD) patients and age- and gender-matched healthy Korean individuals (N = 80). BCM and transthoracic echocardiography were performed and NT-proBNP, myeloperoxidase, copeptin, and pro-adrenomedullin concentrations were measured. Relative hydration status (ΔHS, %) was defined in terms of the hydration status-to-extracellular water ratio with a cutoff of 15%, and hyperhydrated status was defined as ΔHS > 15%.Although there were no significant differences in total body water, extracellular water, or intracellular water among groups, mean amount of volume overload and hyperhydrated status were significantly higher in HD and PD patients compared with control and pre-dialysis patients. Mean amount of volume overload and hyperhydrated status were also significantly associated with higher NT-proBNP and pro-adrenomedullin levels in HD and PD patients, although not with myeloperoxidase or copeptin levels. Furthermore, they were significantly associated with cardiac markers (left ventricular mass index, ejection fraction, and left atrial diameter) in HD and PD patients compared with those in the control and pre-dialysis groups.On the basis of increased plasma NT-proBNP and pro-adrenomedullin concentrations, we might be able to make predictions regarding the volume overload status of dialysis patients, and thereby reduce cardiovascular-related mortality through appropriate early volume control.

Cost-Effectiveness and Estimated Health Benefits of Treating Patients with Vitamin D in Pre-Dialysis.

Background The optimal timing of treatment with vitamin D therapy for patients with chronic kidney disease (CKD), vitamin D insufficiency, and secondary hyperparathyroidism (SHPT) is a pressing question in nephrology with economic and patient outcome implications. Objective The objective of this study was to estimate the cost-effectiveness of earlier vitamin D treatment in CKD patients not on dialysis with vitamin D insufficiency and SHPT. Design A cost-effectiveness analysis based on a Markov model of CKD progression was developed from the Medicare perspective. The model follows a hypothetical cohort of 1000 Stage 3 or 4 CKD patients over a 5-year time horizon. The intervention was vitamin D therapy initiated in CKD stages 3 or 4 through CKD stage 5/end-stage renal disease (ESRD) versus initiation in CKD stage 5/ESRD only. The outcomes of interest were cardiovascular (CV) events averted, fractures averted, time in CKD stage 5/ESRD, mortality, quality-adjusted life years (QALYs), and costs associated with clinical events and CKD stage. Results Vitamin D treatment in CKD stages 3 and 4 was a dominant strategy when compared to waiting to treat until CKD stage 5/ESRD. Total cost savings associated with treatment during CKD stages 3 and 4, compared to waiting until CKD stage 5/ESRD, was estimated to be $19.9 million. The model estimated that early treatment results in 159 averted CV events, 5 averted fractures, 269 fewer patient-years in CKD stage 5, 41 fewer deaths, and 191 additional QALYs. Conclusions Initiating vitamin D therapy in CKD stages 3 or 4 appears to be cost-effective, largely driven by the annual costs of care by CKD stage, CV event costs, and risks of hypercalcemia. Further research demonstrating causal relationships between vitamin D therapy and patient outcomes is needed to inform decision making regarding vitamin D therapy timing.

Processes toward the end of life and dialysis withdrawal Physicians' and nurses' perspectives.

BACKGROUND: Nurses and physicians in nephrology settings provide care for patients with end-stage kidney disease receiving hemodialysis treatment along a complex illness trajectory. AIM: The aim was to explore physicians' and nurses' perspectives on the trajectories toward the end of life involving decisions regarding hemodialysis withdrawal for patients with end-stage kidney disease. RESEARCH DESIGN AND PARTICIPANTS: A qualitative research approach was used. Four mixed focus group interviews were conducted with renal physicians (5) and nurses (17) in Sweden. Qualitative content analysis was used to analyse data. ETHICAL CONSIDERATIONS: Ethical approval was obtained (Dnr 2014/304-31). FINDINGS AND DISCUSSION: Findings illuminated multi-faceted, intertwined processes encompassing healthcare professionals, patients, and family members. The analysis resulted in four themes: Complexities of initiating end-of-life conversations, Genuine attentiveness to the patient's decision-making process, The challenge awaiting the family members' processes, and Negotiating different professional responsibilities. Findings showed complexities and challenges when striving to provide good, ethical care which are related to beneficence, nonmaleficence, and self-determination, and which can give rise to moral distress. CONCLUSION: There are ethical challenges and strains in the dialysis context that healthcare professionals may not always be prepared for. Supporting healthcare professionals in not allowing complexities to hinder the patient's possibilities for shared decision-making seems important. An open and continual communication, including family meetings, from dialysis initiation could serve to make conversations involving decisions about hemodialysis withdrawal a more natural routine, as well as build up a relationship of trust necessary for the advance care planning about the end of life. Healthcare professionals should also receive support in ethical reasoning to meet these challenges and handle potential moral distress in the dialysis context.

Awareness, Understanding and Treatment Practices when Managing Cachexia in End-Stage Kidney Disease.

BACKGROUND: Cachexia is a wasting syndrome found within a range of chronic illnesses/life-limiting conditions, however awareness and understanding of cachexia amongst renal Health Care Professionals has not been investigated. OBJECTIVES: To ascertain the awareness, understanding and treatment practices of Health Care Professionals who provide care for people with cachexia and end-stage renal disease. METHODS: Health Care Professionals were recruited via the European Dialysis and Transplant Nurses Association/European Renal Care Association in September 2018. This was an exploratory study using a mixed-methods approach with those who provide care for patients with end-stage renal disease and cachexia. An online survey and two focus groups were conducted. Descriptive statistics and inductive thematic analysis were used to explore current knowledge and practices in renal cachexia. RESULTS: A total of 93 participants from 30 countries completed the online survey. Twelve Health Care Professionals agreed to participate in the focus groups. Reduced appetite, weight loss and muscle loss in relation to cachexia were accurately described, but the percentage of weight loss was unknown. The importance of multi-professional collaboration was recognised, however, the current management of cachexia was wide-ranging. Quality of life, patient-clinician communication and specialist support for carers were regarded as vital. CONCLUSION: Timely identification and management of cachexia are needed to improve the quality of life for patients and appropriately support families. In order for these goals to be achieved, there is a need to increase awareness and understanding of cachexia amongst renal nurses.

Effects of Virtual Reality in Patients Undergoing Dialysis: Study Protocol.

Dialysis is often considered slow, repetitive, and with programmed intervals. Patients often perceive it as time taken from their lives with a sense of ineluctability and emptiness, engendering a negative emotional and cognitive perception of the world and one's place in it. Today, it is possible to improve the quality of life of patients during hemodialysis using virtual reality (VR). This creation of a true multisensory experience may absorb the patient's perceptions during hemodialysis, improving his/her quality of life. An Italian multicenter, longitudinal experimental study will be conducted with a randomized, pre-post test design, with balanced allocation 1:1, in parallel groups with a control group in the standard care of patients diagnosed with chronic renal failure who are, undergoing hemodialysis treatment. A sample of 186 patients calculated with sample size (power = 80%, ß = 0.2, α = 0.05) will be randomized into an experimental group exposed to VR, and a control group in standard care. The 2 groups will be studied over a period of 1 month, with 12 applications of VR and with measurements of the following outcomes: anxiety, fatigue, pruritus, arterial pressure, heart rate, respiration rate, and duration of the session at each hemodialysis session. This is the first international experimental protocol that examines the application of VR in patients undergoing hemodialysis. If the results show statistically and clinically significant differences, the VR could be an additional holistic intervention, which is evidence based, linked to the humanization of chronic, repetitive interventions, complementary to and synergistic with standard of care.

Cause of kidney disease and cardiovascular events in a national cohort of US patients with end-stage renal disease on dialysis: a retrospective analysis.

AIMS: End-stage renal disease (ESRD) is a strong cardiovascular risk factor. We aimed to determine the extent to which cause of kidney disease independently contributes to this risk. METHODS AND RESULTS: Using a national US ESRD registry, we selected patients with eight different causes of ESRD who initiated dialysis 1997-2014. We used proportional sub-distribution hazard models, with non-cardiovascular death or kidney transplantation as competing risks, to estimate hazard ratios (HRs) for a first composite cardiovascular event (myocardial infarction, ischaemic stroke, or cardiovascular or cerebrovascular death), by cause of ESRD. The population was restricted to those using Medicare insurance at Day 91 after dialysis initiation (when most patients become Medicare eligible). Outcomes were ascertained from Medicare claims or Death Notifications. Among the 658 168 patients identified, composite event rates ranged from 3.5/100 person-years in IgA nephropathy to 14.6/100 person-years in diabetic nephropathy (DN). After adjusting for demographics, socioeconomic factors, comorbidities, dialysis modality, and laboratory values, cardiovascular event HRs differed significantly by cause of ESRD. Comparing to IgA nephropathy, the adjusted HR was highest for DN [aHR = 2.97, 95% confidence interval (CI) 2.77-3.20], next highest for lupus nephritis (aHR = 1.86, 95% CI 1.71-2.03), and thereafter ranged from 1.29 (95% CI 1.19-1.39) in autosomal dominant polycystic kidney disease to 1.67 (95% CI 1.52-1.83) in membranous nephropathy. CONCLUSION: High cardiovascular event rates in dialysis patients vary considerably by cause of ESRD. Determining underlying reasons for these differences might provide new insights in to cardiovascular disease mechanisms as well as inform future drug development and clinical trial design.

Trends in African Americans' Attitudes and Behaviors About Living Donor Kidney Transplantation.

BACKGROUND: Due to marginal efforts to increase living donor kidney transplantation, it is unclear whether interventions to improve African Americans' interest and pursuit of living donation should be tailored to address patients' exposure to or familiarity with dialysis or transplant settings. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional secondary analysis of baseline data from 3 separate randomized clinical trials among African Americans with varying degrees of experience with dialysis or transplantation (predialysis, on dialysis but not on transplant list, and on transplant wait-list) settings. METHODS: Interest in living donation was described using a 0 to 10 scale and pursuit of living donor kidney transplantation by achievement of at least 1 pursuant behavior. In multivariable logistic regression analyses, we assessed the association of knowledge, health literacy, and trust in health care with interest in or pursuit of living donation. RESULTS: Interest among the 3 study cohorts was high (predialysis, 62.9%; dialysis, 67.4%; and transplant wait-list, 74.2%). The dialysis and transplant wait-list study cohorts pursued living donation more readily than those not on dialysis (73%, 92%, and 45%, respectively). Interest and pursuit were not statistically significantly associated with knowledge, health literacy, or the 3 factors reflecting medical mistrust. CONCLUSION: Interest and pursuit of living donation were greater among study participants with greater exposure to dialysis or transplant settings. Efforts to promote patients' early interest and pursuit of living donor transplants may consider novel strategies to educate patients with less experience about the benefits of living donor kidney transplantation.

Hyperkalemia and Dialysis in the Deployed Setting.

Acute kidney injury is a recognized complication of combat trauma. The complications associated with acute kidney injury, such as life-threatening hyperkalemia, are usually delayed in onset. In the recent conflicts, rapid evacuation of U.S. and coalition personnel generally resulted in these complications occurring at higher echelons of care where renal replacement therapies were available. In the future however, deployed providers may not have this luxury and should be prepared to temporize patients while they await transport. In this clinical practice guideline, recommendations are made for the management of patients with, or at risk for, acute kidney injury and hyperkalemia in the austere, deployed environment.

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman's Day / Lo que hacemos y lo que no sabemos sobre las mujeres y las enfermedades renales; preguntas sin respuesta y respuestas no cuestionadas: reflexión sobre el Día Mundial del Riñón y el Día Internacional de la Mujer

Chronic kidney disease affects approximately 10% ofthe world's adult population: itis within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoinmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide (AU)

No disponible

El dializador en el año 2017: mucho más que una membrana / The dialyser in the year 2017: much more than a membrane

No disponible

Variation in the Treatment of Children Hospitalized With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis in the US.

OBJECTIVE: There are few reports on the treatment of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) in children. This study characterizes the use of cyclophosphamide, rituximab, and plasma exchange in children hospitalized with AAV in the US. METHODS: We conducted a retrospective cohort study of children hospitalized with AAV from 2004-2014 utilizing an administrative and billing database from 47 tertiary care pediatric hospitals. All patients had an International Classification of Diseases, Ninth Revision, Clinical Modification discharge code of 446.4 and ≥1 charge for glucocorticoids. Treatment receipt was determined using billing data. Mixed-effects logistic regression was used to evaluate factors associated with the likelihood of receipt of each of the 3 treatments. RESULTS: During the 11-year study period there were 1,290 admissions for 393 children. The median age at index admission was 14.6 years, and 61% were female. Dialysis or mechanical ventilation was required by 16% and 17% of the children, respectively. The median length of stay was 9 days. The percentages of children receiving cyclophosphamide, rituximab, or both were 57%, 21%, and 10%, respectively, and 22% received plasma exchange. Mechanical ventilation was associated with the receipt of cyclophosphamide and plasma exchange, but not rituximab. There was an increasing trend in the use of rituximab over time during the study period (P < 0.05), and a decreasing trend in the use of cyclophosphamide (P < 0.05). Treatment use varied significantly between hospitals, especially for plasma exchange. CONCLUSION: The treatment of children with severe AAV is shifting from cyclophosphamide to rituximab, and their need for dialysis, mechanical ventilation, and prolonged hospitalization remains common. Use of plasma exchange is highly variable.

Variables de la desnutrición en pacientes en diálisis / Variables of malnutrition in dialysis patients

Introducción: El paciente en diálisis va a sufrir una desnutrición proteico-calórica, con diferentes factores implicados en su aparición, lo cual se asocia con una elevadísima morbilidad cardiovascular y mortalidad. Se ha estimado una prevalencia de desnutrición en la población en hemodiálisis del 18-75%, siendo por tanto, un problema de especial relevancia en este tipo de pacientes. Objetivo: Realizar una revisión bibliográfica de los artículos científicos existentes sobre las variables que intervienen en la desnutrición del paciente en diálisis. Metodología: Se ha realizado una revisión bibliográfica mediante las bases de datos PubMed, Scielo, Pro-Quest. La búsqueda se ha realizado con términos Mesh, con una antigüedad no mayor de 5 años y con distintas palabras clave. Resultados: Se han revisado 19 artículos. La mayoría de los artículos fueron estudios observacionales y de revisión. Los factores que se asocian con desnutrición son la edad, pérdida de masa muscular, baja actividad física y dieta pobre en micronutrientes. Otro factor muy importante, es la inflamación. En cuanto a los métodos diagnósticos, son variados y diferentes, debido a la gran cantidad de variables que influyen en la desnutrición. Conclusiones: La desnutrición en pacientes en diálisis depende de distintas variables y no solamente de la dieta. Los factores que se asocian con desnutrición son mayor edad, pérdida de masa muscular, baja actividad física y dieta pobre en micronutrientes. Además, habría que añadir el doble papel que juega la inflamación en este proceso, pues puede ser tanto consecuencia como factor predisponente a la desnutrición (AU)

Introduction: The patient on dialysis will suffer from protein-caloric malnutrition, with different factors involved in its onset, which is associated with very high cardiovascular morbidity and mortality. A prevalence of malnutrition in the hemodialysis population of 18- 75% has been estimated, being therefore a problem of special relevance in this type of patients. Objective: A literature review of the existing scientific articles on the variables involved in malnutrition of patients on dialysis was carried out. Methods: A bibliographic review has been done using the PubMed, Scielo, ProQuest databases. The search used Mesh terms, with an age of no more than 5 years and with different keywords. Results: Nineteen articles were reviewed. Most articles were observational and review studies. The factors that are associated with malnutrition are age, loss of muscle mass, low physical activity and diet deficient in micronutrients. Another very important factor is inflammation. Regarding the diagnostic methods are varied and different, due to the large number of variables that influence malnutrition. Conclusions: Malnutrition in dialysis patients depends on different variables and not only on the diet. The factors that are associated with malnutrition are older age, loss of muscle mass, low physical activity and diet deficient in micronutrients. In addition, we should add the dual role of inflammation in this process as it can be both a consequence and a predisposing factor to malnutrition (AU)

La calidad de vida en mayores con insuficiencia renal crónica estadio V / Quality of life in elderly with chronic kidney disease stage V

No disponible

Laboratory dialysis--past, present and future.

Laboratory dialysis, one of the most widely used techniques in biological research is truly a ' gateway technology' . The analogy is to that of a ' gate' of a building through which everybody has to pass, even though they may wish to go to different departments. Similarly, researchers may be working in altogether different areas but all may need to use laboratory dialysis at one stage or the other during the course of their research. Biochemists may use it to purify enzymes, an immunologist may use it to purify monoclonal antibodies from culture supernatants, a chemist may use it as a step in the crystallography process or for purification of ionic liquids, a biotechnologist may use it to study the effectiveness of enzyme immobilization and a drug discovery scientist may use it for determining drug-protein interaction. The present article reviews patents in the field of laboratory dialysis from inception till date, focusing on the various developmental and innovation related milestones during evolution of the technique. It captures the full panorama of a very interesting technique which continues to be as relevant today as it was in 1866 when the term ' dialysis' was first coined.