Renal Replacement Therapy

Globally, the prevalence of chronic kidney disease is estimated to be approximately 850 million cases, with approximately 4 million individuals needing kidney replacement therapy for kidney failure. By 2050, chronic kidney disease is projected to become the fifth leading underlying cause of death worldwide. Despite its numerous causes, chronic kidney disease can be screened for, diagnosed, and staged with simple laboratory tests. Individuals with chronic kidney disease are at increased risk of kidney failure and many other health implications. Risk of premature cardiovascular disease is particularly noteworthy, as most patients with chronic kidney disease develop a disability or die from cardiovascular disease before ever progressing to kidney failure. Since 2019, large randomised trials have identified several effective treatments that both slow progressive kidney function decline and reduce cardiovascular risk, greatly expanding available treatments for chronic kidney disease. The wide range of complications associated with chronic kidney disease means that patients encounter many different specialties. Active engagement in chronic kidney disease identification and timely initiation of cost-effective interventions by all clinicians could now substantially reduce the global burden of complications of chronic kidney disease and kidney failure.

Author/s:

William G. Herrington, Parminder K. Judge, Morgan E Grams, Christoph Wanner

Arteriovenous Access for Hemodialysis: A Review

Erin Blanchette — Tue, 30 Apr 2024 16:53:17 +0000

Date Added:

April 30, 2024

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

March 18, 2024

Issue:

Volume:

331

Pages:

1307-1317

URL:

Arteriovenous Access for Hemodialysis: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.0535

Keywords

PMID (1):

38497953

MeSH

renal insufficiency

Kidney Failure

Chronic

Kidney Transplantation

renal dialysis

Renal Replacement Therapy

Arteriovenous Shunt

Surgical

Ways that primary care clinicians can help patients with impending renal failure insure arteriovenous access for dialysis. James W. Mold, MD, MPH

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Importance: Hemodialysis requires reliable vascular access to the patient’s blood circulation, such as an arteriovenous access in the form of an autogenous arteriovenous fistula or nonautogenous arteriovenous graft. This Review addresses key issues associated with the construction and maintenance of hemodialysis arteriovenous access.

Observations: All patients with kidney failure should have an individualized strategy (known as Patient Life-Plan, Access Needs, or PLAN) for kidney replacement therapy and dialysis access, including contingency plans for access failure. Patients should be referred for hemodialysis access when their estimated glomerular filtration rate progressively decreases to 15 to 20 mL/min, or when their peritoneal dialysis, kidney transplant, or current vascular access is failing. Patients with chronic kidney disease should limit or avoid vascular procedures that may complicate future arteriovenous access, such as antecubital venipuncture or peripheral insertion of central catheters. Autogenous arteriovenous fistulas require 3 to 6 months to mature, whereas standard arteriovenous grafts can be used 2 to 4 weeks after being established, and “early-cannulation” grafts can be used within 24 to 72 hours of creation. The prime pathologic lesion of flow-related complications of arteriovenous access is intimal hyperplasia within the arteriovenous access that can lead to stenosis, maturation failure (33%-62% at 6 months), or poor patency (60%-63% at 2 years) and suboptimal dialysis. Nonflow complications such as access-related hand ischemia (“steal syndrome”; 1%-8% of patients) and arteriovenous access infection require timely identification and treatment. An arteriovenous access at high risk of hemorrhaging is a surgical emergency.

Conclusions and Relevance: The selection, creation, and maintenance of arteriovenous access for hemodialysis vascular access is critical for patients with kidney failure. Generalist clinicians play an important role in protecting current and future arteriovenous access; identifying arteriovenous access complications such as infection, steal syndrome, and high-output cardiac failure; and making timely referrals to facilitate arteriovenous access creation and treatment of arteriovenous access complications.

Author/s:

Charmaine E Lok, Thomas S Huber, Ani Orchanian-Cheff, Dheeraj K Rajan

Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline

Saige Blanchard — Wed, 23 Jun 2021 05:00:00 +0000

Date Added:

June 23, 2021

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

June 22, 2021

URL:

Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M21-0834

Keywords

PMID (1):

34152826

MeSH

blood pressure

renal dialysis

Renal Replacement Therapy

referral and consultation

risk assessment

renal insufficiency, chronic

Eleven guideline recommendations for management of elevated BP in patients with CKD from the Kidney Disease: Improving Global Outcomes (KDIGO). James W. Mold, MD, MPH

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Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis is an update of the KDIGO 2012 guideline on the same topic and reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. It is intended to support shared decision making by health care professionals working with patients with CKD worldwide. This article is a synopsis of the full guideline.

Methods: The KDIGO leadership commissioned 2 co-chairs to convene an international Work Group of researchers and clinicians. After a Controversies Conference in September 2017, the Work Group defined the scope of the evidence review, which was undertaken by an evidence review team between October 2017 and April 2020. Evidence reviews were done according to the Cochrane Handbook. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to guide the development of the recommendations and rate the strength and quality of the evidence. Practice points were included to provide guidance when evidence was insufficient to make a graded recommendation. The guideline was revised after public consultation between January and March 2020.

Recommendations: The updated guideline comprises 11 recommendations and 20 practice points. This synopsis summarizes key recommendations pertinent to the diagnosis and management of high BP in adults with CKD, excluding those receiving kidney replacement therapy. In particular, the synopsis focuses on recommendations for standardized BP measurement and a target systolic BP of less than 120 mm Hg, because these recommendations differ from some other guidelines.

Author/s:

Tomson, C. R. V., Cheung, A. K., Mann, J. F. E., Chang, T. I., Cushman, W. C., Furth, S. L., Hou, F. F., Knoll, G. A., Muntner, P., Pecoits-Filho, R., Tobe, S. W., Lytvyn, L, Craig, J. C., Tunnicliffe, D. J., Howell, M., Tonelli, M., Cheung, M., Earley, A., Ix, J. H., Sarnak, M. J.