Body Composition and Its Clinical Outcome in Maintenance Hemodialysis Patients

Previous epidemiological cohorts demonstrated that higher body mass index (BMI) was associated with greater survival in patients treated by hemodialysis. Although BMI is a simple measure of adiposity in general population, it may be an inaccurate indicator of nutritional status, particularly among dialysis patients given that it does not differentiate between muscle mass and fat as well as body fat distribution. This problem might be aggravated in end-stage renal disease patients because of wasting or edema. In addition, individuals with higher BMI usually have both higher muscle and fat mass than those with lower BMI. Therefore, more sophisticated tool of body composition analysis is needed to address the query of which component is associated with mortality outcome among patients receiving hemodialysis. We summarized the current state of body composition, including lean and fat tissue evaluated by bioelectrical impedance analysis, dual X-ray absorptiometry, computerized tomography, or magnetic resonance imaging, and its association with clinical outcomes among hemodialysis patients. The studies using anthropometry for the estimation of muscle mass, either mid-arm muscle circumference as a proxy of muscle mass or skinfold thickness and waist circumference as a surrogate of body fat and visceral fat, respectively, were all included in this review

High-efficiency Hemodiafiltration

The high mortality of hemodialysis (HD) patients is partly due to the limited capacity of diffusion-based HD to remove large uremic toxins. Hemodiafiltration (HDF) which combines convection with diffusion could enhance both large and protein-bound uremic toxin removal. Recently, there have been several randomized controlled trials demonstrating that high-efficiency post-dilution online HDF could improve survival. Indeed, high blood flow rate, which is the necessary requirement, could not be achieved in some patients. The alternative HDF techniques that could provide comparative efficacy would be considered. Pre-dilution online HDF could be performed without risk of hemoconcentration. Mid-dilution online HDF could be conducted via either simple way by using two dialyzers with the substitution fluid line in between or using special designed dialyzer. Mixed-dilution online HDF requires additional substitution pump for both pre- and post-dilution. There are interesting HDF techniques that could be performed with the conventional HD machine and these include HD with double high-flux, enhanced internal filtration, or super high-flux dialyzers. These modalities enhance the convective clearance in combination with internal backfiltration within the dialyzer in HD platform. All of these alternative high-efficiency HDF modalities are available and can potentially provide quite equivalent benefits with the high-efficiency post-dilution online HDF

Hemodiafiltration in Acute Kidney Injury

Acute kidney injury (AKI) is one of the most important complications during hospitalization, especially in critically ill patients. Recent data demonstrated that certain biomarkers including pro-inflammatory cytokines are associated with high morbidity and mortality. These biomarkers, most of which have middle molecular weight, and protein-bound uremic toxins are limitedly removed by diffusion mechanism in conventional hemodialysis. Hemodiafiltration (HDF), a new modality that combines convective clearance with diffusion, could effectively enhance removal of middle molecule and protein-bound solutes. Therefore, HDF is increasingly used in several AKI settings such as septic AKI, rhabdomyolysis-associated AKI, myeloma cast nephropathy, and contrast-induced AKI. This chapter summarizes the available HDF techniques including intermittent and continuous modes, and clinical data comprise the benefits of HDF on biomarkers and renal as well as cardiovascular outcomes. Additionally, the topic provides the proposed future directions of HDF in various AKI settings

Sepsis-associated Acute Kidney Injury

Sepsis is a life-threatening condition caused by a dysregulated immune response to infection. Interestingly, sepsis mortality increases with acute kidney injury (AKI) and patients with AKI worsen with sepsis. It is interesting to note that most of the clinical trials on sepsis treatment that derived from the results of translational researches are a failure. This is, in part, because of the complexity of human sepsis in comparison with animal models. Another reason for the failure-translation might be the improper matching of the animal models to the individual patient. It is possible that the main mechanism of sepsis induction in each patient with the variety causes of sepsis might be different. Indeed, immune response to sepsis depends on genetic background, route of immune activation, and organisms. Thus, sepsis treatment classified by “mechanistic approach” to individual patient might be more proper than the classification with “sepsis severity”. Specific treatment of sepsis in individual patient according to the specific immune response characteristic might be a more proper translational strategy. Indeed, the understanding in immune response pattern of sepsis and sepsis pathophysiology is necessary for “sepsis mechanistic approach”. Then, we conclude most of the topics and our hypothesis regarding SA-AKI in this review

Barriers to kidney transplants in Indonesia : a literature review

Background: People living with chronic kidney disease will require renal dialysis or a kidney transplant to maintain life. Although Indonesia has a developing healthcare industry, Indonesia\u27s kidney transplant rates are lower than comparable nations.Purpose: To explore the healthcare literature to identify barriers to kidney transplants in particular in relation to Indonesia.Methods: Healthcare databases were searched (CINAHL, Medline, EBSCOhostEJS, Blackwell Synergy, Web of Science, PubMed, Google Scholar and Proquest 5000) using the search terms: transplant, kidney disease, renal, dialysis, haemodialysis, Indonesia and nursing. The search was limited to English and Indonesian language data sources from 1997 to 2007. Reference lists of salient academic articles were hand searched.Results: The results of our search identified six articles that met our criteria. Costs are the major barrier to kidney transplant in Indonesia, followed by cultural beliefs, perception of the law, lack of information and lack of infrastructure. In addition, kidney disease prevention strategies are required.Conclusions: There are many complex socio-economic, geographical, legal, cultural and religious factors that contribute to low kidney transplant rates in Indonesia. Although an increase in transplantation rates will require strategies from various agencies, healthcare professionals, including nurses, can play a role in overcoming some barriers. Community education programmes, improving their own education levels and by increasing empowerment in nursing we may contribute to improved kidney transplant rates in Indonesia.<br /