Consolidation in dialysis Markets-Causes, consequences, and the role of policy.
Abstract The dialysis industry is one of the most highly concentrated healthcare sectors in the United States. Despite decades of growth in the number of patients with end-stage renal disease and in the size of dialysis markets, two large dialysis organizations currently care for more than two-thirds of the dialysis population. Economies of scale, bargaining leverage with suppliers and private insurers, barriers to entry, and government regulations have contributed to highly concentrated dialysis markets by conferring advantages to larger organizations. Consolidated dialysis markets have coincided with both positi...
Source: Seminars in Dialysis - January 12, 2020 Category: Urology & Nephrology Authors: Saeed MK, Ho V, Erickson KF Tags: Semin Dial Source Type: research

The authority of courage and compassion: Healthcare policy leadership in addressing the kidney disease public health epidemic.
Abstract Recent developments in US kidney-related healthcare policy have made chronic kidney disease (CKD) a societal focus in the United States. In the biggest policy change since the 1972 Social Security Amendments that extended Medicare coverage to patients with kidney failure regardless of age, a 2019 presidential executive order pledged to reduce end-stage kidney disease, slow CKD progression, increase kidney transplants, and focus on home dialysis care. This manuscript seeks to outline key factors that can enable this milestone moment to evolve a policy framework that improves the health of society while bei...
Source: Seminars in Dialysis - January 9, 2020 Category: Urology & Nephrology Authors: Maddux FW Tags: Semin Dial Source Type: research

Calcium balance in hemodialysis: More uncertainty than certainty.
In conclusion, with the existing evidence the choice of DCa needs to be individualized and contextualized in the setting of each patient's calcium balance needs and homeostatic response, taking also into account oral calcium intake (dietary and medicinal), any other relevant therapy administered, such as vitamin D analogues, the type of renal mineral bone disorder, and associated cardiovascular comorbidity. PMID: 31913542 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - January 8, 2020 Category: Urology & Nephrology Authors: Kirmizis D, Basile C Tags: Semin Dial Source Type: research

Assessing quality care in kidney disease: The double-edged sword versus the Gordian knot.
Abstract Assessing quality is essential for optimizing clinical care but remains challenging. Too many measures can result in dilution of quality improvement efforts, distracting providers from delivering the most meaningful care, whereas too few measures can devalue important domains of care. Similarly, performance standards that are too high can result in unintended consequences, including diminishment of patient input into their individualized care and cherry picking. Valid quality metrics assess measureable aspects of care that are both clinically meaningful and modifiable, and, in the absence of quality metri...
Source: Seminars in Dialysis - January 8, 2020 Category: Urology & Nephrology Authors: Weiner DE Tags: Semin Dial Source Type: research

The dialysis care-policy issues: Guest Editors' introductory remarks.
PMID: 31908044 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - January 7, 2020 Category: Urology & Nephrology Authors: Erickson KF, Lin E, Winkelmayer WC Tags: Semin Dial Source Type: research

Four years into MACRA: What has changed?
Abstract In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), a policy intended to transition Medicare away from pure fee-for-service care to value-based care. MACRA does this by evaluating the cost and quality of providers, resulting in financial bonuses and penalties in Medicare reimbursement. MACRA offers two tracks for participation, the Merit-based Incentive Payment System and the Advanced Alternative Payment Models. Although the payment rules are different for each of the tracks, common to both is an emphasis on holding providers accountable for high-quality, cost-efficient care...
Source: Seminars in Dialysis - January 7, 2020 Category: Urology & Nephrology Authors: Cheng J, Kim J, Bieber SD, Lin E Tags: Semin Dial Source Type: research

Barriers to providing optimal dialysis care for undocumented immigrants: Policy challenges and solutions.
Abstract Access to hemodialysis for undocumented immigrants with end stage renal disease (ESRD) is widely variable across the United States and highly dependent upon state policy. Some states have enacted policies to provide coverage for standard dialysis to undocumented immigrants, while other states do not provide coverage. Patients living in some states which do not provide coverage rely on emergency federal coverage through the Emergency Medical Treatment and Active Labor Act. However, this act requires that patients present with an acute, life-threatening condition in order to receive dialysis, which is then ...
Source: Seminars in Dialysis - January 7, 2020 Category: Urology & Nephrology Authors: Welles CC, Cervantes L Tags: Semin Dial Source Type: research

Conflicts of interest in dialysis: A barrier to policy reforms.
Abstract Conflicts of interest involving physicians are commonplace in the US, occurring across many different specialties and subspecialties in a variety of clinical settings. In nephrology, two important scenarios in which conflicts of interest arise are dialysis facility joint venture (JV) arrangements and financial participation in End-stage Kidney Disease Seamless Care Organizations (ESCOs). Whether conflicts of interest occurring in either of these settings influence decision-making or patient care outcomes is not known due to a lack of transparent, publicly available information, and opportunities to conduc...
Source: Seminars in Dialysis - January 3, 2020 Category: Urology & Nephrology Authors: Glickman A, Lin E, Berns JS Tags: Semin Dial Source Type: research

Achieving equity in dialysis care and outcomes: The role of policies.
Abstract Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis ca...
Source: Seminars in Dialysis - January 3, 2020 Category: Urology & Nephrology Authors: Crews DC, Novick TK Tags: Semin Dial Source Type: research

Avoiding problems in tunneled dialysis catheter placement.
Abstract Tunneled dialysis catheters (TDCs) remain the predominant vascular access for initiation of hemodialysis (HD) worldwide. TDCs are also utilized in a significant number of prevalent patients for continuation of dialysis and during the periods of complications related to arteriovenous (AV) accesses. TDC placement is a routine procedure, but can be associated with mechanical and infectious complications related to placement. Imaging guidance with ultrasound and fluoroscopy has made the placement of TDC safer and more successful. Adequate operator training, careful technique, utilization of a checklist, and b...
Source: Seminars in Dialysis - November 1, 2019 Category: Urology & Nephrology Authors: Agarwal AK, Haddad N, Boubes K Tags: Semin Dial Source Type: research

PTH determination in hemodialyzed patients-A laboratory perspective.
Abstract Parathyroid hormone (PTH) is a key player of bone remodelling in patients suffering from Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Serum PTH concentrations are thus frequently measured in CKD patients. Nevertheless, this determination is far from simple. PTH stability can be an issue and degradation of the peptide can be important if storage is not properly done. Biologically active PTH circulates together with fragments, which can be detected by some immunoassays. There is, up to now, no standardization of the assays available on the market, which can lead to some confusion when patient...
Source: Seminars in Dialysis - October 21, 2019 Category: Urology & Nephrology Authors: Cavalier E, Souberbielle JC, Delanaye P Tags: Semin Dial Source Type: research

Some parting words.
PMID: 31633835 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - October 21, 2019 Category: Urology & Nephrology Authors: Sherman RA Tags: Semin Dial Source Type: research

The changing of the guard.
PMID: 31633841 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - October 21, 2019 Category: Urology & Nephrology Authors: Rodby R, Perazella MA, Berns JS Tags: Semin Dial Source Type: research

Anemia management in cancer patients with chronic kidney disease.
This article examines the recently published guidelines for ESA use in cancer patients from the American Society of Clinical Oncology and American Society of Hematology and attempts to contextualize them to the care of patients with coexistent CKD, cancer, and anemia. PMID: 31596520 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - October 9, 2019 Category: Urology & Nephrology Authors: Latcha S Tags: Semin Dial Source Type: research

The relationship of volume overload and its control to hypertension in hemodialysis patients.
Abstract Hypertension is highly prevalent and associated with poor clinical outcomes among individuals receiving maintenance hemodialysis (HD). Volume overload is a key modifiable contributor to hypertension and cardiovascular disease in the HD population. Despite their importance, assessment and treatment of volume overload and hypertension remain major clinical challenges and have substantial implications for both clinical outcomes and patient experiences of care. This review will summarize current data on the diagnosis, epidemiology, pathophysiology, and clinical consequences of hypertension and volume overload...
Source: Seminars in Dialysis - September 29, 2019 Category: Urology & Nephrology Authors: Flythe JE, Bansal N Tags: Semin Dial Source Type: research

Pathogenesis and management of vascular calcification in CKD and dialysis patients.
This article reviews current evidence and therapeutic guidelines in the management of mineral metabolism in CKD and dialysis. PMID: 31464003 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - August 29, 2019 Category: Urology & Nephrology Authors: Kakani E, Elyamny M, Ayach T, El-Husseini A Tags: Semin Dial Source Type: research

Systolic and diastolic hypertension among patients on hemodialysis: Musings on volume overload, arterial stiffness, and erythropoietin.
Abstract Hypertension among patients on hemodialysis is predominantly systolic (either isolated or combined with diastolic hypertension), whereas the scenario of isolated diastolic hypertension is rare and more common in younger patients. Uncontrolled hypertension that persists despite aggressive antihypertensive drug therapy is a reflection of the volume overload that is a prominent mediator of systolic and diastolic BP elevation. Clinical-trial evidence supports the notion that dry-weight probing is an effective strategy to improve BP control, even when overt clinical signs and symptoms of volume overload are no...
Source: Seminars in Dialysis - August 28, 2019 Category: Urology & Nephrology Authors: Georgianos PI, Agarwal R Tags: Semin Dial Source Type: research

Recurrent reversible neurologic deficits during hemodialysis.
Abstract Acute neurologic complications in patients receiving dialysis may be secondary to either underlying comorbid diseases, or to the dialysis procedure itself. An incident hemodialysis patient suffered recurrent consecutive episodes of transient ischemic attacks (TIA) that occurred only during hemodialysis and resolved upon discontinuation of the procedure. Eventual work-up demonstrated an almost complete occlusion of left internal carotid artery. It is likely that the decrease in cerebral blood flow that occurs during hemodialysis, in conjunction with the severely stenotic internal carotid artery, explained ...
Source: Seminars in Dialysis - August 1, 2019 Category: Urology & Nephrology Authors: Parmar MS Tags: Semin Dial Source Type: research

Vascular access for renal replacement therapy in acute kidney injury: Are nontunneled catheters the right choice?
Abstract Renal replacement therapy (RRT) in the setting of acute kidney injury (AKI) is generally provided by either tunneled or nontunneled dialysis catheters (TDCs or NTDCs), used immediately after insertion. Current consensus guidelines suggest using NTDCs rather than TDCs for vascular access in AKI primarily for logistical reasons, including ease of insertion and timeliness. However, there is increasing evidence that, compared to NTDCs, TDCs are associated with fewer complications (mechanical and infectious) and better dialysis delivery. Nevertheless, this evidence must be balanced by the feasibility and pract...
Source: Seminars in Dialysis - August 1, 2019 Category: Urology & Nephrology Authors: Kelly YP, Mendu ML Tags: Semin Dial Source Type: research

The obesity paradox: A further consideration in dialysis patients.
Abstract Several epidemiological cohorts have demonstrated that higher body mass index (BMI) is associated with lower mortality risk among patients receiving hemodialysis. However, BMI may be an inaccurate indicator of nutritional status among dialysis patients because it does not differentiate between muscle and fat mass or provide information about body fat distribution. More sophisticated methods of body composition analysis are therefore required to address the question of which component is associated with greater survival. Recent evidence has also shown that changes in body weight and body composition are mo...
Source: Seminars in Dialysis - July 23, 2019 Category: Urology & Nephrology Authors: Kittiskulnam P, Johansen KL Tags: Semin Dial Source Type: research

Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient.
This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX. PMID: 31313380 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - July 16, 2019 Category: Urology & Nephrology Authors: Kakani E, Sloan D, Sawaya BP, El-Husseini A, Malluche HH, Rao M Tags: Semin Dial Source Type: research

Social support and treatment adherence in patients with end-stage renal disease: A systematic review.
edo D Abstract Successful dialysis in end-stage renal disease (ESRD) largely depends on the patients' ability to adhere to several clinical requirements and life-style changes. Social support has been consistently linked to better health outcomes in a number of chronic diseases. The current study presents a systematic review of the literature on the relationship between social support and treatment adherence in ESRD. The search was performed on Web of Science, PsycInfo, ScienceDirect, and Scopus from January 19 to May 15, 2019. Two hundred and twenty-four records were identified. After quality assessment, 17 studi...
Source: Seminars in Dialysis - July 15, 2019 Category: Urology & Nephrology Authors: Sousa H, Ribeiro O, Paúl C, Costa E, Miranda V, Ribeiro F, Figueiredo D Tags: Semin Dial Source Type: research

Cachexia/Protein energy wasting syndrome in CKD: Causation and treatment.
Abstract Cachexia is a multifactorial syndrome defined by significant body weight loss, fat and muscle mass reduction, and increased protein catabolism. Protein energy wasting (PEW) is characterized as a syndrome of adverse changes in nutrition and body composition being highly prevalent in patients with CKD, especially in those undergoing dialysis, and it is associated with high morbidity and mortality in this population. Multiple mechanisms are involved in the genesis of these adverse nutritional changes in CKD patients. There is no obvious distinction between PEW and cachexia from a pathophysiologic standpoint ...
Source: Seminars in Dialysis - July 8, 2019 Category: Urology & Nephrology Authors: Oliveira EA, Zheng R, Carter CE, Mak RH Tags: Semin Dial Source Type: research

An introduction to Exercise and Physical Activity in Dialysis Patients: Preventing the unacceptable journey to physical dysfunction.
PMID: 31264290 [PubMed - in process] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - July 1, 2019 Category: Urology & Nephrology Authors: Bennett PN, Thompson S, Wilund KR Tags: Semin Dial Source Type: research

Warfarin in nonvalvular atrial fibrillation-Time for a change?
Abstract Warfarin is the most commonly prescribed anticoagulant in hemodialysis (HD) patients with nonvalvular atrial fibrillation (NVAF). Recent trends show that Nephrologists are increasingly prescribing novel oral anticoagulants, despite the fact that no randomized clinical trials have been conducted in dialysis patients. Difficulties maintaining international normalized ratio in the therapeutic range, increased risk of intracranial hemorrhage and concerns regarding warfarin-induced vascular calcification and calciphylaxis may be responsible. Anticoagulation quality is poor in HD patients. A variety of factors ...
Source: Seminars in Dialysis - June 17, 2019 Category: Urology & Nephrology Authors: Reilly RF, Jain N Tags: Semin Dial Source Type: research

Vascular access for hemodialysis: A perpetual challenge.
This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large-scale clinical trials to validate practice, the ever-changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit fro...
Source: Seminars in Dialysis - June 17, 2019 Category: Urology & Nephrology Authors: Murea M, Geary RL, Davis RP, Moossavi S Tags: Semin Dial Source Type: research

Palliative dialysis: Addressing the need for alternative dialysis delivery modes.
Abstract For some patients with kidney failure, particularly those who have limited life expectancy or severe comorbidities, the "standard" dialysis treatment regimen may be perceived as excessively burdensome and may not align well with the patient's own priorities. For such patients, a palliative approach to the provision of dialysis-whereby treatment is tailored to the needs of the individual so as to optimize quality of life and minimize disease-related symptoms, but limit treatment burden-might offer a way to better align the delivery of care with the life goals of the patient. Here, we discuss the ...
Source: Seminars in Dialysis - June 2, 2019 Category: Urology & Nephrology Authors: Tentori F, Hunt A, Nissenson AR Tags: Semin Dial Source Type: research

Xerostomia in patients on chronic hemodialysis: An update.
Abstract Xerostomia, or dryness of oral cavity, is relatively common in patients on chronic hemodialysis and significantly impairs their quality of life. Xerostomia is often the consequence of reduced salivary flow resulting from atrophy and fibrosis of the salivary glands, an event that is of uncertain origin. Many medications commonly used in dialysis patients may also cause or exacerbate xerostomia. Its consequences may be serious and disturbing and include difficulties in chewing, swallowing, tasting, and speaking; increased risk of oral disease, including lesions of the mucosa, gingiva and tongue; bacterial a...
Source: Seminars in Dialysis - May 22, 2019 Category: Urology & Nephrology Authors: Bossola M Tags: Semin Dial Source Type: research

Sustained exercise programs for hemodialysis patients: The characteristics of successful approaches in Portugal, Canada, Mexico, and Germany.
We describe the unique approaches they have used to fund and manage their programs, the varied exercise prescriptions they incorporate, the unique challenges they face, and discuss the benefits they have seen. While the programs differ in many regards, a consistent theme is that they each have substantial and committed support from the entire clinic staff, including the nephrologists, administration, nurses, dietitians, and technicians. This suggests that exercise programs in HD clinics can be successfully implemented and sustained provided significant effort is made to foster a culture of physical activity throughout the ...
Source: Seminars in Dialysis - May 13, 2019 Category: Urology & Nephrology Authors: Viana JL, Martins P, Parker K, Madero M, Pérez Grovas H, Anding K, Degenhardt S, Gabrys I, Raugust S, West C, Cowan TE, Wilund KR Tags: Semin Dial Source Type: research

The effect of gender on survival for hemodialysis patients: Why don't women live longer than men?
Abstract Women in the general population have a survival advantage over men, but this advantage is not sustained in end-stage kidney disease (ESKD) patients treated by hemodialysis. To understand why gender may affect survival we need to understand confounders which may affect dialysis practices. The current paradigm is to prescribe hemodialysis to achieve a target dialyzer urea clearance adjusted to total body water volume (Kt/Vurea ). Estimated glomerular filtration calculated from serum creatinine is often used to determine when patients start dialysis; as creatinine generation rates are lower in women, this ma...
Source: Seminars in Dialysis - May 1, 2019 Category: Urology & Nephrology Authors: Vongsanim S, Davenport A Tags: Semin Dial Source Type: research

Assessment of physical functioning in the clinical care of the patient with advanced kidney disease.
Abstract Maintenance of independent living is the top health priority among patients with advanced chronic kidney disease (CKD). Mobility limitation is often the first sign of functional limitation leading to loss of independence. Regular assessments of physical capacity can help provide kidney health providers identify patients at risk of frailty and other adverse health-related outcomes that contribute to the loss of functional independence. These physical capacities can be measured with commonly used self-reported measures of physical function or by objective physical performance testing. The current review des...
Source: Seminars in Dialysis - May 1, 2019 Category: Urology & Nephrology Authors: Roshanravan B, Patel KV Tags: Semin Dial Source Type: research

Is oxidative stress an issue in peritoneal dialysis?
Abstract During the last two decades, oxidative stress (OS) has emerged as a novel risk factor for a variety of adverse events, including atherosclerosis and mortality in chronic kidney disease (CKD) patients. Increased OS occurs even in early stages of the disease, progresses with deterioration of renal function and is further aggravated by hemodialysis (HD), due to the bioincompatibility of the method. Compared to HD, peritoneal dialysis (PD) is a more biocompatible dialysis modality, characterized by a significantly reduced, but still high, OS status. The culprit for OS in PD is mainly the composition of PD sol...
Source: Seminars in Dialysis - May 1, 2019 Category: Urology & Nephrology Authors: Roumeliotis S, Eleftheriadis T, Liakopoulos V Tags: Semin Dial Source Type: research

Addressing myths about exercise in hemodialysis patients.
Abstract Despite decades of research, there are few published guidelines related to the safety and efficacy of exercise training in hemodialysis patients. This has led to disparate recommendations regarding the type, intensity, and timing for exercise, especially for patients with multiple comorbidities. Many common recommendations are not supported by research data, so their justification is uncertain. These recommendations include exercising in the first hour of dialysis; not exercising if hypertensive, cramping, or volume overloaded; avoiding heavy weights on vascular access limb; clinicians managing an exercis...
Source: Seminars in Dialysis - April 25, 2019 Category: Urology & Nephrology Authors: Wilund KR, Jeong JH, Greenwood SA Tags: Semin Dial Source Type: research

A swan song for Kt/Vurea.
This article reviews the flaws of Kt/V, starting with a lack of proof of concept in three randomized controlled hard outcome trials (RCTs), and continuing with a long list of conditions where the concept of Kt/V was shown to be flawed. This information leaves little room for any conclusion other than that Kt/V, as an indicator of dialysis adequacy, is obsolete. The dialysis patient might benefit more if, instead, the nephrology community concentrates in the future on pursuing the optimal dialysis dose that conforms with adequate quality of life and on factors that are likely to affect outcomes more than Kt/V. These include...
Source: Seminars in Dialysis - April 25, 2019 Category: Urology & Nephrology Authors: Vanholder R, Van Biesen W, Lameire N Tags: Semin Dial Source Type: research

Acetate metabolism, organic acid production, and the independent effects of bicarbonate and acetate as alkalinizing agents in dialysis bath solutions.
PMID: 31006902 [PubMed - as supplied by publisher] (Source: Seminars in Dialysis)
Source: Seminars in Dialysis - April 21, 2019 Category: Urology & Nephrology Authors: Gennari FJ, Sargent JA Tags: Semin Dial Source Type: research

The role of exercise in improving patient-reported outcomes in individuals on dialysis: A scoping review.
Abstract Exercise improves objective measures of physical function in individuals on hemodialysis, but its effect on patient-reported outcomes (PROs) is largely unknown. We performed a scoping review to characterize the existing knowledge base on exercise and PROs in dialysis patients to make recommendations for future research. We searched Medline, Embase, Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials, CINAHL, and SPORT Discus from inception to November 28, 2018 and then screened results for randomized controlled trials comparing aerobic/resistance exercise, or both, with...
Source: Seminars in Dialysis - April 21, 2019 Category: Urology & Nephrology Authors: Bohm C, Schick-Makaroff K, MacRae JM, Tan M, Thompson S Tags: Semin Dial Source Type: research

Achieving a person-centered approach to dialysis discontinuation: An historical perspective.
Abstract In this essay, we describe the evolution of attitudes toward dialysis discontinuation in historical context, beginning with the birth of outpatient dialysis in the 1960s and continuing through the present. From the start, attitudes toward dialysis discontinuation have reflected the clinical context in which dialysis is initiated. In the 1960s and 1970s, dialysis was only available to select patients and concerns about distributive justice weighed heavily. Because there was strong enthusiasm for new technology and dialysis was regarded as a precious resource not to be wasted, stopping treatment had negativ...
Source: Seminars in Dialysis - April 10, 2019 Category: Urology & Nephrology Authors: O'Hare AM, Murphy E, Butler CR, Richards CA Tags: Semin Dial Source Type: research

Are dialysis patients too frail to exercise?
Abstract Clinical manifestations of functional and morphological muscular abnormalities in dialysis patients are muscle weakness and low exercise capacity, possibly leading to a sedentary life style with low physical activity. Low cardiorespiratory fitness and muscle atrophy and weakness contribute to the development of frailty and affect patients' ability to physically navigate their environment. While many dialysis patients may appear too frail to participate in moderate-to-vigorous aerobic exercise training, those who can complete such programs appear to derive substantial benefit. Less vigorous aerobic exercis...
Source: Seminars in Dialysis - April 10, 2019 Category: Urology & Nephrology Authors: Wang CJ, Johansen KL Tags: Semin Dial Source Type: research

Unexplained inflammation in end-stage kidney disease: Is the combination of enhanced gastrointestinal permeability and reticuloendothelial dysfunction its cause?
Abstract Unexplained chronic inflammation is prevalent in end-stage kidney disease, and contributes toward accelerated cardiovascular disease, and premature death. The source of inflammation is unclear, although increased gastrointestinal permeability is a likely contributory factor. Whether a "leaky" gut leads to penetration of the systemic circulation by gut-derived pathogens is at least partly dependent on Kupffer cell function. These resident liver macrophages are an important part of the reticuloendothelial system (RES), and there is evidence for Kupffer cell and reticuloendothelial dysfunction in c...
Source: Seminars in Dialysis - April 9, 2019 Category: Urology & Nephrology Authors: Swift O, Vilar E, Farrington K Tags: Semin Dial Source Type: research

The effects of intradialytic exercise on hemodialysis adequacy: A systematic review.
Abstract Dialysis adequacy is an independent predictor of high mortality rates in hemodialysis patients. Intradialytic exercise is a potential strategy to increase uremic solute removal by increasing blood flow to low perfusion tissue beds. The purpose of this review is to establish the efficacy of intradialytic exercise for hemodialysis adequacy. Additionally, this review aims to provide practical information to aid health care professionals implement intradialytic exercise for dialysis adequacy. Database and hand searches identified 15 published interventional studies that implemented intradialytic exercise for ...
Source: Seminars in Dialysis - April 9, 2019 Category: Urology & Nephrology Authors: Kirkman DL, Scott M, Kidd J, Macdonald JH Tags: Semin Dial Source Type: research

Antibiotic locks for the treatment of catheter-related blood stream infection: Still more hope than data.
Abstract Antibiotic lock therapy (ALT), in conjunction with systemic antibiotics, is recommended by scientific societies as a treatment of uncomplicated catheter-related bloodstream infections (CRBSI) in hemodynamically stable hemodialysis patients for whom catheter salvage is the goal. The rationale for this strategy is the eradication of intraluminal biofilms by the highly concentrated antibiotic used in the lock. However, the available evidence supporting this recommendation is scanty, and only includes small, short-term, observational studies (most of them single-arm), with different definitions of CRBSI cure ...
Source: Seminars in Dialysis - April 4, 2019 Category: Urology & Nephrology Authors: Labriola L Tags: Semin Dial Source Type: research

Common errors in temporary hemodialysis catheter insertion.
Abstract Non-tunneled hemodialysis catheter (NTHC) insertion is an essential skill for nephrology practice and remains a requirement of training. However, improper insertion technique can increase the risk of potentially fatal infectious and mechanical complications. Evidence-based strategies can reduce the rates of such complications and should be integrated into practice and training. Ultrasound (US) guidance should routinely be used for NTHC insertion at the femoral and internal jugular sites (with avoidance of the subclavian site). Nephrologists should receive proper training in the use of US for line insertio...
Source: Seminars in Dialysis - April 4, 2019 Category: Urology & Nephrology Authors: Samaha D, Clark EG Tags: Semin Dial Source Type: research

Changing dialysate composition to optimize acid-base therapy.
Abstract In response to rapid alkali delivery during hemodialysis, hydrogen ions (H+ ) are mobilized from body buffers and from stimulation of organic acid production in amounts sufficient to convert most of the delivered bicarbonate to CO2 and water. Release of H+ from nonbicarbonate buffers serves to back-titrate them to a more alkaline state, readying them to buffer acids that accumulate in the interval between treatments. By contrast, stimulation of organic acid production only serves to remove added bicarbonate (HCO3 - ) from the body; the organic anions produced by this process are lost into the dialysate, i...
Source: Seminars in Dialysis - April 3, 2019 Category: Urology & Nephrology Authors: Sargent JA, Marano M, Marano S, Gennari FJ Tags: Semin Dial Source Type: research

Obesity as a barrier to kidney transplantation: Time to eliminate the body weight bias?
Abstract There is clear evidence that survival rates following transplantation far exceed those for remaining on dialysis, regardless of body size measured by body mass index (BMI). Studies over the past 15 years also suggest little to no difference in long-term outcomes, including graft survival and mortality, irrespective of BMI, in contrast to earlier evidence. However, weight bias still exists, as access to kidney transplantation remains inequitable in centers using arbitrary BMI limits. Clinicians faced with the decision regarding listing based on body size are not helped by conflicting recommendations i...
Source: Seminars in Dialysis - April 2, 2019 Category: Urology & Nephrology Authors: MacLaughlin HL, Campbell KL Tags: Semin Dial Source Type: research

Hepato-splanchnic circulatory stress: An important effect of hemodialysis.
Abstract The gastro-intestinal tract is being increasingly recognized as the site of key pathophysiological processes in the hemodialysis patient. Intestinal dysbiosis, increased intraluminal toxin production, and increased intestinal permeability are commonly observed processes which contribute to the pathogenesis of cardiovascular disease and thus elevated mortality. The acute circulatory effects of dialysis itself may contribute significantly to the development of gastrointestinal dysfunction as a result of both local and distant effects. Additionally, the liver, a relatively unknown entity in this process, has...
Source: Seminars in Dialysis - April 1, 2019 Category: Urology & Nephrology Authors: Grant CJ, Huang SS, McIntyre CW Tags: Semin Dial Source Type: research

Barriers and facilitators for engagement and implementation of exercise in end-stage kidney disease: Future theory-based interventions using the Behavior Change Wheel.
Abstract Theory-driven interventions are required to increase the adoption and implementation of physical activity and exercise programs among patients with ESKD. The Behavior Change Wheel (BCW) represents a synthesis of behavior change theories and can be used to aid the systematic development of theory-driven interventions designed to change exercise behavior. The goal of this review was to synthesize barriers and facilitators to engagement and implementation of exercise and develop theory-based recommendations for exercise behavior change interventions in patients with ESKD. We applied the BCW in the current co...
Source: Seminars in Dialysis - April 1, 2019 Category: Urology & Nephrology Authors: Clarke AL, Jhamb M, Bennett PN Tags: Semin Dial Source Type: research

Alkali delivery in chronic hemodialysis: Would more acetate be helpful?
Abstract The dialysate alkali used in hemodialysis to replace low body alkali levels in end stage renal disease (ESRD) patients has changed over time from bicarbonate to acetate and finally back to bicarbonate with a small addition of acetate. The ideal way to replace alkali in dialysis patients remains uncertain. Elsewhere in this issue of the journal, Sargent and Gennari, who have contributed greatly to our understanding of dialysis and acid-base kinetics, suggest that decreasing the currently used concentration of bicarbonate while increasing concentration of acetate in the dialysate may be a much more phy...
Source: Seminars in Dialysis - April 1, 2019 Category: Urology & Nephrology Authors: Uribarri J, Oh MS Tags: Semin Dial Source Type: research

The promise of bioimpedance for volume management in American dialysis patients: An unfulfilled opportunity.
Abstract Evidence from both observational and randomized controlled studies indicates that the use of bioimpedance in the care of chronic hemodialysis patients is associated with improved outcomes, in particular better volume and blood pressure control. Bioimpedance as a means to assess fluid status in dialysis patients has been approved by numerous regulatory agencies and is being used in dozens of countries around the globe. The most notable exception to the worldwide acceptance of this technique is the US where no BIA device has been approved by the US Food and Drug Administration for use in dialysis patients. ...
Source: Seminars in Dialysis - March 29, 2019 Category: Urology & Nephrology Authors: Kotanko P Tags: Semin Dial Source Type: research

Intradialytic virtual reality exercise: Increasing physical activity through technology.
;a-Testal A Abstract Intradialytic exercise can improve physical function and health-related quality of life (HRQoL) in hemodialysis (HD) patients, but is not implemented in routine clinical practice. Virtual reality (VR) exercise has resulted in benefits in non-dialysis contexts, but implementation in HD patients has been limited. The aim of this review was to provide an overview of VR, present the results of a 12-week intradialytic VR exercise intervention, and compare VR to conventional exercise. The secondary aim was to review the effect of VR exercise during the last 30 minutes of the HD session on hemod...
Source: Seminars in Dialysis - March 27, 2019 Category: Urology & Nephrology Authors: Segura-Ortí E, García-Testal A Tags: Semin Dial Source Type: research

Exercise and physical activity for people receiving peritoneal dialysis: Why not?
Abstract People with end-stage kidney disease (ESKD) receiving peritoneal dialysis (PD) are physically inactive leading to low physical function and poor health outcomes. Guidelines recommend that nephrologists encourage PD patients to increase their activity levels; however, PD patients are often discouraged from participating in exercise programs because of perceived barriers and a lack of precision about the appropriate exercise regimen. This review suggests ways forward to assist nephrology professionals to encourage PD patients to exercise, instead of creating barriers. The paper draws on the literature in ad...
Source: Seminars in Dialysis - March 24, 2019 Category: Urology & Nephrology Authors: Isnard-Rouchon M, West M, Bennett PN Tags: Semin Dial Source Type: research