Hemodialysis.com : Kidney Disease Research Interviews
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Hemodialysis.com : Kidney Disease Research Interviews

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Nephrology research interviews from major kidney disease publications. Exclusive to Hemodialysis.com.

Nephrology research interviews from major kidney disease publications. Exclusive to Hemodialysis.com.

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Hemodialysis.com : Kidney Disease Research Interviews Hemodialysis.com : Kidney Disease Research Interviews Presentation Transcript

  • Hemodialysis.com Hemodialysis research, author interviews, dialysis updates and information on chronic kidney disease and end stage renal failure. Editor: Marie Benz, MD info@hemodialysis.com July 9 2013 For Informational Purposes Only: Not for Specific Medical Advice.
  • Medical Disclaimer | Terms and Conditions • The contents of the Hemodialysis.com Site, such as text, graphics, images, and other material contained on the Hemodialysis.com Site ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Hemodialysis.com Site! • If you think you may have a medical emergency, call your doctor or 911 immediately. Hemodialysis.com does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by Hemodialysis.com or other Eminent Domains Inc (EDI) websites, EDI employees, others appearing on the Site at the invitation of Hemodialysis.com or EDI, or other visitors to the Site is solely at your own risk. • The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an "as is" basis. Read more interviews on Hemodialysis.com
  • Toward a Wearable Portable Dialysis Machine: Using Reusable Sorbents to Regenerate Dialysate Hemodialysis.com Interview with Maarten Wester Department of Nephrology and Hypertension, University Medical Center Utrecht,|Utrecht, The Netherlands • Hemodialysis.com Interview with Maarten Wester Department of Nephrology and Hypertension, University Medical Center Utrecht,|Utrecht, The Netherlands • Hemodialysis.com: What are the main findings of the study? • Answer: Wearable or portable dialysis could provide benefit for dialysis patients by offering prolonged and more frequent dialysis. This may be achieved by sorbent-based dialysate regeneration, by reducing the amount of dialysate needed, thus limiting weight and size of dialysis machines. • Our study shows that sodium polystyrene/divinylbenzenesulphonate and iron oxide hydroxide are suitable, regenerable – and thereby reusable – sorbents for potassium and phosphate removal in dialysate regeneration. We also showed that calcium and magnesium preloading could limit removal of these electrolytes by the sorbents, which means that there will be no need for post sorbent cartridge infusion of these electrolytes. • Hemodialysis.com: Were any of the findings unexpected? • Answer: The tested sorbents performed surprisingly well, not only in the (static) batch binding assays but also in the (dynamic) experiments with bovine blood. Combined with their substantial regenerability, this may mean that relatively small amounts of sorbents will suffice to remove the daily required amounts of potassium and phosphate. Read the rest of the interview on Hemodialysis.com
  • Toward a Wearable Portable Dialysis Machine: Using Reusable Sorbents to Regenerate Dialysate Hemodialysis.com Interview with Maarten Wester Department of Nephrology and Hypertension, University Medical Center Utrecht,|Utrecht, The Netherlands • Hemodialysis.com: What should clinicians and patients take away from this study? • Answer: Dialysate regeneration based on toxin and excess electrolyte removal by reusable sorbents may be the key to limiting dialysis device weight and dimensions. This offers the perspective of prolonged and more frequent dialysis through wearable or portable devices. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Answer: Future research should encompass more detailed, in vivo investigation into efficacy, possible side-effects and toxicity of the sorbents that were used in our study. • Citation: • A regenerable potassium and phosphate sorbent system to enhance dialysis efficacy and device portability: an in vitro study • Maarten Wester, Frank Simonis, Karin G. Gerritsen, Walther H. Boer, Will K. Wodzig, Jeroen P. Kooman, and Jaap A. Joles • A regenerable potassium and phosphate sorbent system to enhance dialysis efficacy and device portability: an in vitro study Nephrol. Dial. Transplant. first published online July 3, 2013 doi:10.1093/ndt/gft205 Read the rest of the interview on Hemodialysis.com
  • Kidney Transplant Rejection and Withdrawal of Calcineurin Inhibition after PTLD Diagnosis Hemodialysis.com Interview with: Olivier Thaunat Service de Transplantation et d‟Immunologie Clinique Hôpital Edouard Herriot, 5 Place d‟Arsonval, Lyon, France • Hemodialysis.com: What are the main findings of the study? • Response: Several data of the literature (Caillard et al 2012, Kasiske et al 2010) have reported an increased incidence of graft rejection episodes and graft loss after the diagnosis of post transplant lymphoproliferative disorder (PTLD). This is likely the consequence of immunosuppression reduction introduced as the first line therapy to restore immune surveillance mechanisms in recipients. To our knowledge, there are no studies available comparing the impact of these different reduction immunosuppression strategies on graft survival and overall survival. • Our retrospective bicentric study shows that the withdrawal of calcineurin inhibition after PTLD diagnosis is an independent risk factor for allograft loss. • Histological analysis revealed that maintaining a CNI at reduced dose (25 to 50% of the initial dose) reduces the risk of developing de novo anti-HLA antibodies and humoral rejection. Remarkably, the maintenance of calcineurin inhibition was not associated with a worse PTLD outcome, suggesting that it is a safe therapeutic strategy. Read the rest of the interview on Hemodialysis.com
  • Kidney Transplant Rejection and Withdrawal of Calcineurin Inhibition after PTLD Diagnosis Hemodialysis.com Interview with: Olivier Thaunat Service de Transplantation et d‟Immunologie Clinique Hôpital Edouard Herriot, 5 Place d‟Arsonval, Lyon, France • Hemodialysis.com: Were any of the findings unexpected? • Response: Immunosuppression reduction strategies after the diagnosis of PTLD are not consensual. If most transplant physicians agree to continue the steroids after a PTLD diagnosis, many are reluctant to maintain calcineurin inhibitors, which have direct pro-neoplasic effects. This attitude, was the one we were following in our center and before initiating this study, we had the general impression that graft outcome were good in patients left on corticosteroids alone after chemotherapy. • Instead, statistical analyses revealed a higher risk for graft loss for patients left on corticosteroids alone. This was mainly due to a defective control of the humoral arm of recipients immune system, leading to more antibody-mediated rejection (both acute and chronic). On the other hand, maintaining calcineurin inhibition was safe and did not increase the rate of death or disease progression. Read the rest of the interview on Hemodialysis.com
  • Kidney Transplant Rejection and Withdrawal of Calcineurin Inhibition after PTLD Diagnosis Hemodialysis.com Interview with: Olivier Thaunat Service de Transplantation et d‟Immunologie Clinique Hôpital Edouard Herriot, 5 Place d‟Arsonval, Lyon, France • Hemodialysis.com: What should clinicians and patients take away from this study? • Response: At the diagnosis of PTLD, clinicians have to carefully take into consideration immunological risks of each patient and the severity of PTLD in order to apply the fairest immunosuppression reduction strategy. • Over the past ten years, the standardization of chemotherapies‟ protocols and the use of rituximab have considerably improved PTLD outcome. Consequently,the aim is now to cure PTLD with the concurrent goal of preserving allograft function. • To achieve this goal, our data suggests that most PTLD patients should be kept on a reduced dose (25 to 50% of the initial dose) of calcineurin inhibitor after PTLD diagnosis. Read the rest of the interview on Hemodialysis.com
  • Kidney Transplant Rejection and Withdrawal of Calcineurin Inhibition after PTLD Diagnosis Hemodialysis.com Interview with: Olivier Thaunat Service de Transplantation et d‟Immunologie Clinique Hôpital Edouard Herriot, 5 Place d‟Arsonval, Lyon, France • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Response: Our study is a first insight of the impact of immunosuppressive reduction strategies on graft survival. We are aware of the limitations of our work, especially due to its retrospective aspect and the small number of patients included in the analysis. • A similar study carried out in a larger population from national registries should be undertaken to validate our findings on a larger scale. In particular it would be interesting to better assess the risk for patient kept on steroid plus mTOR inhibitor. • Citation: • Maintaining calcineurin inhibition after the diagnosis of post-transplant lymphoproliferative disorder improves renal graft survival • Jean-Emmanuel Serre, David Michonneau, Emmanuel Bachy, Laure-Hélène Noël, Valérie Dubois, Caroline Suberbielle, Henri Kreis, Christophe Legendre, Marie-France Mamzer-Bruneel, Emmanuel Morelon and Olivier Thaunat • Kidney International , (26 June 2013) | doi:10.1038/ki.2013. Read the rest of the interview on Hemodialysis.com
  • Forty-eight hour kidney transplant admissions Hemodialysis.com Interview with: Eric Siskind, MD Department of Transplantation, North Shore Long Island Jewish Health System, 306 Community Drive, 1E, Manhasset, NY 11030, USA. • Hemodialysis.com: What are the main findings of the study? • Dr. Siskind: Forty eight hour kidney transplantation admissions are a feasible option in selected recipients of live donor allografts through the use of standardized postoperative protocols, multidisciplinary team patient care, and intensive follow up at outpatient centers. Age, gender, and pretransplant dialysis status did not impact the ability to achieve 48 hour admissions. We did not identify any other preoperative risk factors that contributed to increased length of stay. Although ABO and highly sensitized recipients had longer lengths of stay, the subgroup was too small to achieve statistical significance. We did not encounter any readmissions within the first seven postoperative days. Further improvements in clinical management will enhance the potential to shorten the length of hospital stay for all kidney transplant recipients. • Hemodialysis.com: Were any of the findings unexpected? • Dr. Siskind: Two-day renal transplant admissions are a novel approach and departure from the reported standardized protocols that vary from six to ten days in uncomplicated cases. We were quite pleased with our outcomes and believe this is the first such report. Read the rest of the interview on Hemodialysis.com
  • Forty-eight hour kidney transplant admissions Hemodialysis.com Interview with: Eric Siskind, MD Department of Transplantation, North Shore Long Island Jewish Health System, 306 Community Drive, 1E, Manhasset, NY 11030, USA. • Hemodialysis.com: What should clinicians and patients take away from this study? • Dr. Siskind: With the use of standardized postoperative protocols, we have made living donor kidney transplantation into a short stay procedure of only two days. This exemplifies the progress made in kidney transplantation, transforming it into a more streamlined and predictable procedure. We hope these efforts will enhance the view of kidney transplantation to end stage renal disease patients and their health care providers, and encourage them to pursue transplantation as their best treatment option. We also hope that these improved outcomes with living donor kidney transplantation will influence more donors to participate; knowing their donation will be successful. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Dr. Siskind: We hope to expand our accelerated postoperative protocol to ABO incompatible and highly sensitized recipients, as well as deceased donor kidney transplantation, as these subgroups • Citation: • Forty-eight hour kidney transplant admissions. • Siskind E, Villa M, Jaimes N, Huntoon K, Alex A, Blum M, Tyrell R, Sameyah E, Kuncewitch M, Giangola M, Agorastos S, Deutsch G, Plumley L, Shen A, Robinson M, Alexander M, Israel E, Lumermann L, Bhaskaran M, Calderon K, Jhaveri KD, Sachdeva M, Bellucci A, Mattana J, Fishbane S, D‟Agostino C, Nicastro J, Coppa G, Molmenti E. • Department of Transplantation, North Shore Long Island Jewish Health System, Manhasset, NY, USA. Clin Transplant. 2013 Jun 27. doi: 10.1111/ctr.12178. [Epub ahead of print] Read the rest of the interview on Hemodialysis.com
  • Study addresses which uremic toxins are associated with mortality in hemodialysis patients? Hemodialysis.com Interview with: Michal L. Melamed, MD, MHS Associate Professor of Medicine and Epidemiology & Population Health Nephrology Fellowship Program Director Albert Einstein College of Medicine/ Montefiore Medical Center • Hemodialysis.com: What are the main findings of the study? • Dr. Melamed: The search for THE uremic toxin has been a long one. There are over 200 solutes retained in patients with kidney disease and dialysis does not clear all of them. Urea in itself does not cause significant toxicity in the body. In the study we found that of 4 retained solutes that we tested, methylamine, dimethylamine, p-cresol sulfate and indoxyl sulfate, only high levels of indoxyl sulfate were associated with a higher risk of all-cause mortality. • Hemodialysis.com: Were any of the findings unexpected? • Dr. Melamed: We expected to find that elevated p-cresol sulfate levels were also associated with poor outcomes but they were not. There have been other studies that show that total levels, which is what we tested, were not associated with poor outcomes but that free levels were. We intend to go back and measure free p-cresol sulfate levels to see if there is an association. Read the rest of the interview on Hemodialysis.com
  • Study addresses which uremic toxins are associated with mortality in hemodialysis patients? Hemodialysis.com Interview with: Michal L. Melamed, MD, MHS Associate Professor of Medicine and Epidemiology & Population Health Nephrology Fellowship Program Director Albert Einstein College of Medicine/ Montefiore Medical Center • Hemodialysis.com: What should clinicians and patients take away from this study? • Dr. Melamed: Clinicians and patients need to remember that with our current dialysis therapy, there are still many substances that are retained that may be causing toxicity. Of the 4 we tested, only one was associated with all-cause mortality. Indoxyl sulfate is a protein bound molecule and as such, is not cleared by current hemodialysis. There are ways to increase the removal of protein bound solutes, such as increasing the dialyzer size and the dialysis flow rate during longer dialysis sessions. Once the toxicity of solutes is firmly established, there are potentially easy methods to clear the toxic substances. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Dr. Melamed: I believe there needs to be more research into which substances are causing toxicity in kidney disease patients so that we can tailor dialysis therapy to clear the actual substances that are causing toxicity. These studies will include observational studies like the study we just completed and also interventional studies to show if the uremic toxins are removed there are better patient outcomes. • Citation: • Retained organic solutes, patient characteristics and all-cause and cardiovascular mortality in hemodialysis: results from the retained organic solutes and clinical outcomes (ROSCO) investigators. • Melamed ML, Plantinga L, Shafi T, Parekh R, Meyer TW, Hostetter TH, Coresh J, Powe NR. • BMC Nephrol. 2013 Jun 27;14(1):134. [Epub ahead of print] Read the rest of the interview on Hemodialysis.com
  • Patient Survival after Onset of Acute Kidney Injury: Natural History Hemodialysis.com Interview with: Dr. Jane H. Zhang Cooperative Studies Program Coordinating Center Veterans Affairs Connecticut Health Care System 950 Campbell A venue, West Haven, CT 06516. • Hemodialysis.com: What are the main findings of the study? • Dr. Zhang: Based on our clinical impression of the natural history of acute kidney injury (AKI), we hypothesized that survival curves after an episode of renal replacement therapy-requiring AKI might exhibit distinct acute and convalescent phases. Using data from the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) study, we analyzed the change in hazard of death over time within the first year after an episode of severe AKI and confirmed the presence of these two distinct phases – an early phase extending over the first 6 weeks and a late phase from 6 weeks to 1 year. Analyzing the change in hazard function within each of these phases, we were able to identify an early hyper-acute phase (day 0-4) and a subsequent phase extending from day 4 to day 42. Similarly, the convalescent phase appears to have two components, an early convalescent phase extending from day 42 to approximately day 148 and a late convalescent phase after day 148. Through this analysis we have better defined the natural history of survival after an episode of AKI – approximately half of the patients die during the acute phase of AKI (from the start of dialysis to day 42) and another 1 in 7 die during the “convalescent” phase (day 42 to one year). Read the rest of the interview on Hemodialysis.com
  • Patient Survival after Onset of Acute Kidney Injury: Natural History Hemodialysis.com Interview with: Dr. Jane H. Zhang Cooperative Studies Program Coordinating Center Veterans Affairs Connecticut Health Care System 950 Campbell Avenue, West Haven, CT 06516. • Hemodialysis.com: Were any of the findings unexpected? • Dr. Zhang: These findings were not surprising, but should help inform the design of future trials of AKI. For example, prior studies of intensity of renal replacement therapy in AKI have utilized a variety of survival endpoints, ranging from 15 days after discontinuation of therapy to 90 days after initiation of renal support. Our results suggest that a primary survival endpoint of approximately within the 95% confidence interval for the duration of the acute phase (22 days to 66 days) would be appropriate and support the use follow-up intervals for primary survival endpoints of the survival endpoints of between 4 weeks and 2 months that have been used in the majority of previously conducted trials. • Hemodialysis.com: What should clinicians and patients take away from this study? • Dr. Zhang: Our finding suggests that patients with an episode of severe AKI requiring renal support are at greatest risk of death within the first 4 days after initiation of renal replacement therapy, with an acute phase with high mortality risk extending out to six weeks. Although patients are still at increased risk of death, the mortality risk is substantially attenuated after the first six weeks. Read the rest of the interview on Hemodialysis.com
  • Patient Survival after Onset of Acute Kidney Injury: Natural History Hemodialysis.com Interview with: Dr. Jane H. Zhang Cooperative Studies Program Coordinating Center Veterans Affairs Connecticut Health Care System 950 Campbell Avenue, West Haven, CT 06516. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Dr. Zhang: We believe that our findings can be used to inform the design of future clinical trials in acute kidney injury and suggest that the optimal duration of follow-up for a primary mortality endpoint is at approximately 6 weeks, although our results support the use of follow-up intervals ranging from approximately four weeks to two months. • We would like to acknowledge funding by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development and by the National Institute of Diabetes and Digestive and Kidney in support of this work. • Citation: • Piecewise Analysis of Patient Survival after Onset of AKI • Jane H. Zhang, Paul M. Palevsky, Glenn M. Chertow, John Hartigan, Theresa Z. O‟Connor, Peter Guarino, and Bingqing Zhou • Piecewise Analysis of Patient Survival after Onset of AKI CJASN CJN.07250712; published ahead of print June 27, 2013, doi:10.2215/CJN.07250712 Read the rest of the interview on Hemodialysis.com
  • Dialysis Fistula First Strategy: Best for the Elderly? Hemodialysis.com Interview with: Dr. Ranil N. DeSilva Division of Nephrology, Beth Israel Deaconess Medical Center 185 Pilgrim Rd, FA 8, Boston, MA 02215. • Hemodialysis.com: What are the main findings of the study? • Dr. DeSilva: „Fistula First‟ is an intention to treat strategy, we hoped to better assess vascular access outcomes based upon the access first placed rather than that first used at the start of hemodialysis in the elderly ESRD population. It is well recognized and confirmed in our study that a central venous catheter is a clearly inferior strategy with a much higher mortality than either a fistula or a graft. But since the elderly have the highest rate of fistula complications, including failure to mature for use, patients over 80 years old who underwent placement of a graft first did just as well as those with a fistula placed first (even in those over 67 years old, a fistula first strategy was only little better). A large part of the explanation is likely because in those with a fistula placed first 43% started dialysis with a catheter, whereas only 24% of those with a graft placed first required a catheter at dialysis initiation. • Hemodialysis.com What should clinicians and patients take away from this study? • Dr. DeSilva: In an era using more standardized quality outcomes measures, we must remain cautious generalizing many outcome measures to our growing elderly population. In the case of our study, „Fistula First‟, a strategy that is clearly superior in young individuals requiring hemodialysis for ESRD, does not appear to be the clearly superior strategy. When comparing placement of an arteriovenous fistula first to an alternative placement of an arteriovenous graft first strategy in octogenarians and nonagenarians, both had similar mortality results over 4 years of hemodialysis. It appears that the optimal vascular access choice should be tailored to the specific patient in this elderly population. Read the rest of the interview on Hemodialysis.com
  • Dialysis Fistula First Strategy: Best for the Elderly? Hemodialysis.com Interview with: Dr. Ranil N. DeSilva Division of Nephrology, Beth Israel Deaconess Medical Center 185 Pilgrim Rd, FA 8, Boston, MA 02215. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Dr. DeSilva: As our study aimed more to describe the mortality difference associated between first placing a „Fistula First‟ versus a „Graft First‟ in the elderly population – we feel our results raised the option for a more patient specific focused strategy in this elderly population rather than one size fits all. Understanding more the patients‟ perspective in these different strategies in terms of quality of life I believe would add more to our general understanding of this topic. In addition, a possible more comprehensive cost effective analysis of these two strategies in the elderly may bring light to more „society‟s‟ perspective on this topic. • Citation: • Fistula First Is Not Always the Best Strategy For the Elderly Ranil N. DeSilva, Bhanu K. Patibandla, Yael Vin, Akshita Narra, Varun Chawla, Robert S. Brown, and Alexander S. Goldfarb-Rumyantzev JASN ASN.2012060632; published ahead of print June 27, 2013, doi:10.1681/ASN.2012060632 Read the rest of the interview on Hemodialysis.com
  • CKD: Renal Clearance and Intestinal Generation of p-Cresyl Sulfate and Indoxyl Sulfate Ruben Poesen, MD, On behalf of all C0-Authors Department of Nephrology University Hospitals Leuven, Belgium • Hemodialysis.com: What are the main findings of the study? • Answer: Chronic kidney disease is accompanied by the accumulation of a diverse panel of so-called uremic retention solutes. Analyses show that the gut microbial metabolism contributes substantially to these solutes with p-cresyl sulfate and indoxyl sulfate being among the most discriminating biomarkers of uremia. However, serum levels of these 2 solutes are widely dispersed in patients with chronic kidney disease. We demonstrated that, besides renal function, intestinal generation itself is an important determinant of the interindividual variability of serum levels of both solutes. In addition, our group showed that the eGFR, the currently used marker for renal function, provides an acceptable estimate for their renal handling, a finding which was questioned in the past. Finally, renal clearances of indoxyl sulfate appeared approximately threefold higher than those of p-cresyl sulfate. • Hemodialysis.com: Were any of the findings unexpected? • Answer: Until recently, factors determining interindividual variability of serum levels of p-cresyl sulfate and indoxyl sulfate were largely unknown. It was assumed that differences in renal function, albeit not well described by the currently used markers for renal function, were the main cause of differences in these serum levels. We, however, demonstrated that eGFR does provide an acceptable marker for the renal handling of these solutes, and that intestinal generation itself is an important determinant of this variability. Read the rest of the interview on Hemodialysis.com
  • CKD: Renal Clearance and Intestinal Generation of p-Cresyl Sulfate and Indoxyl Sulfate Ruben Poesen, MD, On behalf of all C0-Authors Department of Nephrology University Hospitals Leuven, Belgium • Hemodialysis.com: What should clinicians and patients take away from this study? • Answer: Clinicians must be aware that the eGFR can be used to estimate the renal clearance of both solutes in patients not yet on dialysis, and that renal clearances of indoxyl sulfate are approximately threefold higher than those of p-cresyl sulfate. Additionally, for both renal patients and clinicians, it is intriguing to know that intestinal generation itself is an important determinant of serum levels of both solutes, making the gut a novel target for therapeutic intervention in the future. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Answer: As the intestinal generation of p-cresyl sulfate and indoxyl sulfate is an important determinant of their serum levels, and both solutes are related with cardiovascular disease, overall mortality and renal disease progression, effort should be made to gain more insights in mechanisms governing this intestinal generation. In turn, this could lead to novel treatment strategies in patients with chronic kidney disease. • Citation: • Renal Clearance and Intestinal Generation of p-Cresyl Sulfate and Indoxyl Sulfate in CKD • Ruben Poesen, Liesbeth Viaene, Kristin Verbeke, Kathleen Claes, Bert Bammens, Ben Sprangers, Maarten Naesens, Yves Vanrenterghem, Dirk Kuypers, Pieter Evenepoel, and Björn Meijers • CJASN CJN.00300113; published ahead of print June 27, 2013, doi:10.2215/CJN.00300113 Read the rest of the interview on Hemodialysis.com
  • Kidney Dialysis: Initial Impact of Medicare’s New Prospective Payment System Hemodialysis.com Interview with: Richard A. Hirth, Ph.D Associate Chair, Department of Health Management and Policy Professor Department of Health Management and Policy Ann Arbor, Michigan 48109-202 • Hemodialysis.com: What are the main findings of the study? • Dr. Hirth: There were substantial changes in practice patterns in the year following the implementation of the expanded bundled payment system for dialysis. These included a reduction per treatment use of injectable medications, a shift in agents (more patients received iron relative to ESAs, and changes in the mix of iron and vitamin D products). In terms of home dialysis, the pre-bundle growth trend in the share of patients receiving home hemodialysis was unchanged, but there was a substantial acceleration in the share of first and second year patients receiving peritoneal dialysis. • Hemodialysis.com: Were any of the findings unexpected? • Dr. Hirth: The most surprising aspect of the findings was that when we looked at monthly trends the decline in use of injectables continued throughout the first year after the bundle. Therefore, we will need to track 2012 in 2013 trends to determine when steady-state practice patterns are reached. Read the rest of the interview on Hemodialysis.com
  • Kidney Dialysis: Initial Impact of Medicare’s New Prospective Payment System Hemodialysis.com Interview with: Richard A. Hirth, Ph.D Associate Chair, Department of Health Management and Policy Professor Department of Health Management and Policy Ann Arbor, Michigan • Hemodialysis.com: What should clinicians and patients take away from this study? • Dr. Hirth: Practices appear quite responsive to changes in financial incentives and other factors such as the new FDA warning label on ESAs that was issued in June 2011. This makes monitoring quality of care a significant issue. The trend towards an increase in the use of peritoneal dialysis is encouraging and clinicians and patients should actively assess the best modality for the patient‟s individual circumstances. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Dr. Hirth: Clearly, ongoing monitoring of utilization, access to care, and quality of care is necessary. It is yet to be established what the steady-state level of utilization of injectables will be, and what the long-term effect on the distribution of patients across dialysis modalities will be. • Finally, we would like to acknowledge funding by CMS in support of this work while noting that the opinions and interpretations of the data expressed here are solely those of the manuscript authors and may not reflect CMS‟ views. • Citation: • The Initial Impact of Medicare’s New Prospective Payment System for Kidney Dialysis Richard A. Hirth, Marc N. Turenne, John R.C. Wheeler, Tammie A. Nahra, Kathryn K. Sleeman, Wei Zhang, Joseph A. Messana American Journal of Kidney Diseases – 17 June 2013 (10.1053/j.ajkd.2013.03.044) Read the rest of the interview on Hemodialysis.com
  • Preventing Cyclosporin Renal Toxicity with a New Antioxidant Hemodialysis.com Interview with: Francesco Trepiccione Division of Nephrology Department of Cardio-Thoracic and Respiratory Sciences Second University of Naples, Naples, Italy • Hemodialysis.com: What are the main findings of the study? • Answer: In this study we investigated the potential role of a new antioxidant molecule, rMnSOD, in preventing the renal toxic effect of Cyclosporin A. Cyclosporin A is an immunosuppressant drug that completely renewed the history of transplantation. However, its long term usage leads to renal failure and hypertension. The main outcome of this study is the prevention of cyclosporine A-induced impairment of GFR in rats co-treated with rMnSOD. Quenching the radical oxygen species is the underlying mechanisms we propose. rMnSOD could be a potential novel therapeutic strategy for patients taking immunosuppressant. • Hemodialysis.com: Were any of the findings unexpected? • Answer: Whether rMnSOD, a novel antioxidant, can prevent the cyclosporin induced renal side effect was the question behind the study. Our data confirmed this hypothesis. It was surprising the entity of rMnSOD effect on GFR. Read the rest of the interview on Hemodialysis.com
  • Preventing Cyclosporin Renal Toxicity with a New Antioxidant Hemodialysis.com Interview with: Francesco Trepiccione Division of Nephrology Department of Cardio-Thoracic and Respiratory Sciences Second University of Naples, Naples, Italy • Hemodialysis.com: What should clinicians and patients take away from this study? • Answer: Over the years novel immunosuppressant drugs come up and the management for the transplant patients improved. However the clinicians cannot get rid of the use of cyclosporin yet. It seems crucial especially at the beginning of the transplantation. Thus, the interest of the researchers in preventing cyclosporin side effects is very active and probably new option will be available in a reasonable time. Up to now, this study is in line with previous ones pointing on the importance of antioxidants in this field. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Answer: We are interesting to test whether this antioxidant could be efficacious also in the prevention of the cyclosporine-induced hypertension. A deeper understanding of the pathogenesis of cyclosporine – related hypertension could be helpful not only for transplant patients, but also to generate novel anti- hypertensive approaches. • Citation: • A new recombinant MnSOD prevents the Cyclosporine A-induced renal impairment. • Damiano S, Trepiccione F, Ciarcia R, Scanni R, Spagnuolo M, Manco L, Borrelli A, Capasso C, Mancini R, Schiattarella A, Iervolino A, Zacchia E, Bata-Csere A, Florio S, Anastasio P, Pollastro R, Mancini A, Capasso G. • Division of Nephrology, Department of Cardio-Thoracic and Respiratory Sciences, Second University of Naples, Naples, Italy.Nephrol Dial Transplant. 2013 May 15.[Epub ahead of print] Read the rest of the interview on Hemodialysis.com
  • Low-Protein Vegetarian Diets Supplemented with Keto Analogues Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many? Hemodialysis.com Interview with: Martina Ferraresi and Giorgina B. Piccoli SS Nephrology, University of Turin, Orbassano, Turin, Italy Hemodialysis.com: What are the main findings of the study? • Answer: The diet schema prescribed is based on a simplified approach using a „not-too-strict‟ diet (protein intake of 0.6 g/kg/day), based on allowed and forbidden foods and 1-3 free-choice meals, to reduce the psychological burden and to avoid malnutrition. We wanted to know if there are some clinical and demographic elements for an a priori definition of „good‟ candidates for LPD-KA, considering „prescription success‟ as at least 6 months of follow-up. • Our analysis demonstrates that educational level, diabetes, overall comorbidity and old age are not confirmed as strong relevant factors in attaining the medium-term follow-up of the diet. In this small series, the start of dialysis was the main cause of discontinuation of the diet. • The flexible policy, the allowance of free-choice meals and the strict control policy, probably reduce clinical reasons for discontinuation, and avoid case of malnutrition. • Conversely, psychological reasons for dropping out were more common, underlining the strong negative effect of monotony of the dietary regimen and the need for several „pills‟, usually in the context of a complex polypharmacy. • The low mortality rates (4.4 cases per 100 patient-year), within the limits of relatively small numbers and short follow-up, give further reassurance that there is no negative impact of LPD-KA in our population. • Another interesting aspect of the analysis is the potential reduction of costs of the treatment of kidney patients: in our area, 1 year of dialysis corresponds to 35–60 patient-years on LPD-KA, (35-60000 Euros per year vs 1000 Euros per year). Read the rest of the interview on Hemodialysis.com
  • Low-Protein Vegetarian Diets Supplemented with Keto Analogues Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many? Hemodialysis.com Interview with: Martina Ferraresi and Giorgina B. Piccoli SS Nephrology, University of Turin, Orbassano, Turin, Italy • Hemodialysis.com: Were any of the findings unexpected? • Answer: Interestingly, in stable patients with at least 6 months of follow-up, compliance was impressive, with a median protein intake of 0.5 g/kg/day, calculated at distance from the free meals. This supports the hypothesis that subtle personal preferences, as well as clear motivations, are fundamental in the relationship with food and diet. Therefore, the diet should be proposed to all patients without preclusion. • Hemodialysis.com: What should clinicians and patients take away from this study? • Answer: Our study was neither designed nor sufficiently powerful to demonstrate an effect on the progression of CKD. Routine laboratory data, such as creatinine clearance, lack the precision of isotopic or inulin clearances. Within these limits, the analysis of the progression rate (performed to allow contextualization of our results), suggests that at least patients with longer follow-up may stabilize on the LPD-KA diet, an issue to be confirmed on larger numbers and longer follow-up. Moreover, every patient can follow the diet, without a piori characteristics to expect the diet prescription success. Read the rest of the interview on Hemodialysis.com
  • Low-Protein Vegetarian Diets Supplemented with Keto Analogues Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many? Hemodialysis.com Interview with: Martina Ferraresi and Giorgina B. Piccoli SS Nephrology, University of Turin, Orbassano, Turin, Italy • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Answer: Our favorable data on progression and mortality should be considered as a stimulus for further analysis with larger samples of patients. More importantly, a control group of patients who choose either no diet or a different LPD (for example with commercial food) was not available for the present analysis; such an analysis is planned in the context of a perspective study, including all CKD Stage IV–V patients followed in our unit. • Citation: • Giorgina B. Piccoli, Martina Ferraresi,, Maria C. Deagostini, Federica Neve Vigotti, Valentina Consiglio, Stefania Scognamiglio, Irene Moro, Roberta Clari, Federica Fassio, Marilisa Biolcati, and Francesco Porpiglia • Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many? Nephrol. Dial. Transplant. first published online June 9, 2013 doi:10.1093/ndt/gft092 Read the rest of the interview on Hemodialysis.com
  • Adiponectin in Hypertensive Patients and Kidney Transplant Recipients Hemodialysis.com Interview with: Avshalom Leibowitz, MD Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel. • Hemodialysis.com: What is adiponectin and what is its importance? • Dr. Leibowitz: Adiponectin is an adipocytokine, a hormone secreted exclusively by adipocytes. It circulates in the blood in a relatively high concentration. Unlike other adipocytokines, which are considered proinflammatory hormones, adiponectin appears to have anti-inflammatory, anti-diabetic and anti- atherogenic properties. Overall, clinical data suggests that adiponectin plays a protective role in the cardiovascular system. • Hemodialysis.com: What was the aim of the study? • Dr. Leibowitz: In general, there is an inverse correlation between serum adiponectin levels and traditional cardiovascular risk factors such as obesity, diabetes mellitus, hypertension and an abnormal lipid profile. On the other hand, patients with chronic kidney disease exhibit higher levels of adiponectin. Data regarding adiponectin levels in kidney transplant recipients is ambiguous. Our study was conducted in order to gain more information regarding the role that adiponectin plays in this unique population. Read the rest of the interview on Hemodialysis.com
  • Adiponectin in Hypertensive Patients and Kidney Transplant Recipients Hemodialysis.com Interview with: Avshalom Leibowitz, MD Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel. • Hemodialysis.com: What are the main findings of the study? • Dr. Leibowitz: Our study attempted to answer two main questions: • 1. What is the level of serum adiponectin in kidney transplant recipients compared to controls (both healthy and hypertensive)? • 2. Is there a correlation between adiponectin levels and traditional risk factors in kidney transplant recipients? • In our study, we found that adiponectin levels were similar in both kidney transplant recipients and the healthy control group. However, we found a strong correlation between adiponectin levels and traditional metabolic risk factors such as triglycerides and body weight in the healthy control group. There was no such correlation in kidney transplant recipients or the hypertensive control group. • Hemodialysis.com: Were any of the findings unexpected? • Dr. Leibowitz: We believed that the ambiguity found in literature is due to non-selective patient selection. Renal function and glucose metabolism have major effects on adiponectin levels. As a result, in our study we chose only transplant recipients with normal kidney function and without diabetes. Sure enough, adiponectin levels were found to be at the same level as healthy participants. However, the lack of correlation to metabolic risk factors may suggest that the metabolic “behavior” of adiponectin in kidney transplant recipients is different than in the healthy population. Read the rest of the interview on Hemodialysis.com
  • Adiponectin in Hypertensive Patients and Kidney Transplant Recipients Hemodialysis.com Interview with: Avshalom Leibowitz, MD Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel. • Hemodialysis.com: What should clinicians and patients take away from this study? • Dr. Leibowitz: In my opinion, the lesson to be gained from this study is that until more data is available regarding new protective cardiovascular factors, we as physicians should adhere to traditional evidence- based treatments. Patients should receive the best preventive treatment available, especially blood pressure control. • Citation: • Normal adiponectin levels in kidney transplant patients with hypertension. • Leibowitz A, Peleg E, Ben-David A, Sharabi Y, Kamari Y, Holzman E, Grossman E. • Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Clin Transplant. 2013 Jun 13. doi: 10.1111/ctr.12169. [Epub ahead of print] Read the rest of the interview on Hemodialysis.com
  • Ethnicity, medical insurance, and living kidney donation Hemodialysis.com Interview with Amber M. Reeves-Daniel, D.O. Assistant Professor Internal Medicine- Nephrology at Wake Forest Baptist Medical Center. • Hemodialysis.com: What are the main findings of the study? • Answer: This single-center study examined relationships between ethnicity, medical insurance, and living donation in 447 kidney transplant patients and identified that recipient private medical insurance was positively associated with the likelihood of living donor kidney transplantation (LKT), as well as with preemptive transplantation. In addition, Medicaid insurance was negatively associated with the likelihood of either LKT or preemptive transplantation. These findings were more pronounced in African Americans. African Americans with private medical insurance were 14 times more likely than African Americans without private medical insurance to receive a live donor kidney and African Americans with Medicaid were unlikely to receive LKT. In comparison, European Americans with private medical insurance were 2.2 times more likely than European Americans without private medical insurance to receive LKT. • Hemodialysis.com: Were any of the findings unexpected? • Answer: Yes. An alarming finding is that despite apparent access to kidney transplantation, with successful transplantation of 175 African Americans (40% Medicaid recipients), no African American Medicaid recipient received a living donor kidney transplant during the 2.5 year study period. We suggest that presence or absence of Medicaid insurance may influence the likelihood of LKT or deceased donor transplantation among African Americans at our transplant center. Read the rest of the interview on Hemodialysis.com
  • Ethnicity, medical insurance, and living kidney donation Hemodialysis.com Interview with Amber M. Reeves-Daniel, D.O. Assistant Professor Internal Medicine- Nephrology at Wake Forest Baptist Medical Center. • Hemodialysis.com: What should clinicians and patients take away from this study? • Answer: Recipient insurance status is associated with the likelihood of Iiving donor kidney transplantation (LKT), positively with private insurance and negatively with Medicaid. African Americans were markedly impacted by this phenomenon, potentially contributing to their lower rates of LKT. African American Medicaid recipients appear unlikely to receive LKT. Efforts to assist this population overburdened with chronic kidney disease and underserved with LKT might include utilization of live donor champions. Greater efforts to protect donor employment, including re-imbursement for lost wages from time away from work and assistance with family obligations, may expand the living donor benefit to all Americans eligible under Medicare, but unable to overcome the social constraints seen in those eligible for Medicaid. Read the rest of the interview on Hemodialysis.com
  • Ethnicity, medical insurance, and living kidney donation Hemodialysis.com Interview with Amber M. Reeves-Daniel, D.O. Assistant Professor Internal Medicine- Nephrology at Wake Forest Baptist Medical Center. • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Answer: Future studies could examine the effectiveness of a live donor champion in the Medicaid population. • Citation: • Ethnicity, medical insurance, and living kidney donation • Reeves-Daniel AM, Farney AC, Fletcher AJ, Assimos D, Westcott C, Rogers J, Stratta RJ, Rocco MV, Freedman BI. • Clin Transplant. 2013 Jun 19. doi: 10.1111/ctr.12168. [Epub ahead of print] • PMID: 23781870 [PubMed - as supplied by publisher] Read the rest of the interview on Hemodialysis.com
  • Risk Kidney Injury after Acute Coronary Events same with High-or-Low Potency Statins Hemodialysis.com Interview with: Amy Sarma, M.D., Brigham and Women’s Hospital, Boston, Mass; • Hemodialysis.com: What are the main findings of the study? • Dr. Sarma: Statins have been shown to reduce the risk of recurrent cardiovascular events in patients after an acute coronary syndrome (heart attack or unstable angina). However, two recent studies from large observational databases raised concerns that high-potency statins may increase the risk of acute kidney injury. Since these analyses were observational in nature, the authors could not exclude the possibility that their findings were explained by other factors that may influence the decision to treat with a high-potency statin. To address this issue, we examined the incidence of kidney injury in two randomized trials of intensive versus moderate statin therapy in patients after an acute coronary syndrome. We found that the incidence of kidney injury was the same regardless of whether the patients were treated with a high- or low potency statin. Similarly, the change in serum creatinine (a marker of kidney function) was similar between treatment arms over time. Read the rest of the interview on Hemodialysis.com
  • Risk Kidney Injury after Acute Coronary Events same with High-or-Low Potency Statins Hemodialysis.com Interview with: Amy Sarma, M.D., Brigham and Women’s Hospital, Boston, Mass; • Hemodialysis.com: Were any of the findings unexpected? • Dr. Sarma: Because two large observational data sets had raised concerns that high-potency statin therapy may be associated with an increased risk of acute kidney injury, we were reassured to find that this was not the case when we looked at two large randomized trial databases. • Hemodialysis.com: What should clinicians and patients take away from this study? • Several studies have demonstrated that the use of high-potency statins reduces the risk of recurrent cardiovascular events in patients after an acute coronary syndrome. These new findings provide important reassurance to clinicians and patients that the use of high-potency statins in this population will not increase the risk of kidney injury. Read the rest of the interview on Hemodialysis.com
  • Risk Kidney Injury after Acute Coronary Events same with High-or-Low Potency Statins Hemodialysis.com Interview with: Amy Sarma, M.D., Brigham and Women’s Hospital, Boston, Mass; • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Dr. Sarma: Dr. Sarma: As we enter an era of personalized medicine, further study is warranted to identify patients who might derive both greater cardiovascular benefit from statin therapy, as well as those who are at greater risk for adverse events. For example, patients on dialysis or with very poor renal function (estimated glomerular filtration rate of less than 30 ml/min/1.73m2) were not included in our analysis, therefore further exploration is needed within this high-risk group of patients. However, we did not see any signal toward an increased risk of kidney injury in those patients with moderately diminished renal function. As we increasingly treat patients with a multitude of comorbidities at presentation, a thorough understanding of individualized risk and benefit profiles will be important to optimizing clinical care after an acute coronary syndrome. • Citation: • Sarma A, et al “The incidence of kidney injury for patients treated with intensive versus less potent statin therapy after an acute coronary syndrome” AHA‟s Emerging Science Series, Abstract. Read the rest of the interview on Hemodialysis.com
  • Change in Blood Pressure during Hemodialysis Treatment and Survival Hemodialysis.com Interview with: Jongha Park, MD, PhD Division of Nephrology, Ulsan University Hospital Dr. Kalantar-Zadeh, MD, MPH, PhD University of Ulsan College of MedicineProfessor & Chief, Division of Nephrology & Hypertension University of California Irvine, School of Medicine • Hemodialysis.com: What are the main findings of the study? • Response: This large cohort study sought to find an association of blood pressure (BP) change during hemodialysis (HD) treatment (post-HD BP minus pre-HD BP) with mortality. In 113,255 HD patients, unadjusted models revealed U-shaped associations between Δ systolic and diastolic BP and all-cause mortality. After adjustment for other potential covariates, the U-shaped associations were persisted. In fully adjusted model, modest declines in Δ systolic BP between -30 – 0 mmHg were associated with better survival, while both Δ systolic BP <-30 mmHg and Δ systolic BP >0 mmHg were associated with increased mortality. The greatest survival was observed at Δ systolic BP of -14 mmHg [adjusted hazard ratio (aHR), 0.92; 95% confidence interval (CI), 0.91 – 0.93]. Similarly, Δ diastolic BP between -15 – 5 mmHg showed better survival and the greatest survival was observed at -6 mmHg (aHR, 0.93; 95% CI, 0.91 – 0.94]. When the outcome of interest was cardiovascular mortality, similar U-shaped associations were still observed. Read the rest of the interview on Hemodialysis.com
  • Change in Blood Pressure during Hemodialysis Treatment and Survival Hemodialysis.com Interview with: Jongha Park, MD, PhD Division of Nephrology, Ulsan University Hospital Dr. Kalantar-Zadeh, MD, MPH, PhD University of Ulsan College of MedicineProfessor & Chief, Division of Nephrology & Hypertension University of California Irvine, School of Medicine • Hemodialysis.com: What should clinicians and patients take away from this study? • Response: Intradialytic hypotension is a frequent complication of HD that may be associated with reduced survival, but emerging data suggests that increases in BP during or after HD may also be associated with adverse outcomes. Our study showed modest declines in BP after HD are associated with the greatest survival, whereas any rise as well as large declines in BP is associated with worsened survival. Given on- going debates on strategies of BP control in HD patients, BP changes during HD would have important clinical implications. Read the rest of the interview on Hemodialysis.com
  • Change in Blood Pressure during Hemodialysis Treatment and Survival Hemodialysis.com Interview with: Jongha Park, MD, PhD Division of Nephrology, Ulsan University Hospital Dr. Kalantar-Zadeh, MD, MPH, PhD University of Ulsan College of MedicineProfessor & Chief, Division of Nephrology & Hypertension University of California Irvine, School of Medicine • Hemodialysis.com: What recommendations do you have for future research as a result of your study? • Response: It is possible that large decline in BP during HD causes reduction in coronary blood flow and asymptomatic HD-associated cardiac ischemia, so that is associated with adverse outcome. Further trials are warranted to find effective strategies that promote hemodynamic stability during HD. However, it has been unclear why BP rises during HD in some patients and also how this rise in BP relates to adverse outcomes. Exploration of possible mechanisms underlying intradialytic hypertension warrants further studies. Lastly, it would be interesting to evaluate whether or not a modest BP drop by HD can lead to better survival in clinical trial. • Citation: • A comparative effectiveness research study of the change in blood pressure during hemodialysis treatment and survival • Kidney International , (19 June 2013) | doi:10.1038/ki.2013.237 • Jongha Park, Connie M Rhee, John J Sim, Yong-Lim Kim, Joni Ricks, Elani Streja, Tania Vashistha, Ramin Tolouian, Csaba P Kovesdy and Kamyar Kalantar-Zadeh Read the rest of the interview on Hemodialysis.com