Etiology of the Protein-Energy Wasting Syndrome in Chronic Kidney Disease: A Consensus Statement From the International Society of Renal Nutrition andMetabolism (ISRNM)

Protein-energy wasting (PEW), a term proposed by the International Society of Renal Nutrition and Metabolism (ISRNM), refers to the multiple nutritional and catabolic alterations that occur in chronic kidney disease (CKD) and associate with morbidity and mortality. To increase awareness, identify research needs, and provide the basis for future work to understand therapies and consequences of PEW, ISRNM provides this consensus statement of current knowledge on the etiology of PEW syndrome in CKD. Although insufficient food intake (true undernutrition) due to poor appetite and dietary restrictions contribute, other highly prevalent factors are required for the full syndrome to develop. These include uremia-induced alterations such as increased energy expenditure, persistent inflammation, acidosis, and multiple endocrine disorders that render a state of hypermetabolism leading to excess catabolism of muscle and fat. in addition, comorbid conditions associated with CKD, poor physical activity, frailty, and the dialysis procedure per se further contribute to PEW. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.Abbott NutritionShireAbbot Renal NutritionBaxter HealthcareKarolinska Inst, Div Renal Med, Dept Clin Sci Intervent & Technol, Solna, SwedenUniversidade Federal de São Paulo, Div Nephrol, Dept Med, São Paulo, BrazilVanderbilt Univ, Sch Med, Dept Med, Div Nephrol, Nashville, TN 37212 USAUniv Calif Irvine, Med Ctr, Harold Simmons Ctr, Div Nephrol & Hypertens, Orange, CA USAUniv Calif Davis, Dept Internal Med, Davis, CA 95616 USAUniv Calif Davis, Dept Biochem & Mol Med, Davis, CA 95616 USABaylor Coll Med, Dept Med, Div Nephrol, Houston, TX 77030 USAEmory Univ, Sch Med, Div Renal, Dept Med, Atlanta, GA 30306 USAAtlanta Dept Vet Affairs Med Ctr, Res Serv, Decatur, GA 30033 USAUniv Wurzburg, Div Nephrol, Dept Internal Med, D-97070 Wurzburg, GermanyUniv Hong Kong, Dept Med, Queen Mary Hosp, Hong Kong, Hong Kong, Peoples R ChinaVrije Univ Amsterdam Med Ctr, Dept Nephrol, Amsterdam, NetherlandsUniversidade Federal de São Paulo, Div Nephrol, Dept Med, São Paulo, BrazilWeb of Scienc

Resistance to erythropoiesis stimulating agents in patients treated with online hemodiafiltration and ultrapure low-flux hemodialysis: Results from a randomized controlled trial (CONTRAST)

Resistance to erythropoiesis stimulating agents (ESA) is common in patients undergoing chronic hemodialysis (HD) treatment. ESA responsiveness might be improved by enhanced clearance of uremic toxins of middle molecular weight, as can be obtained by hemodiafiltration (HDF). In this analysis of the randomized controlled CONvective TRAnsport STudy (CONTRAST; NCT00205556), the effect of online HDF on ESA resistance and iron parameters was studied. This was a prespecified secondary endpoint of the main trial. A 12 months' analysis of 714 patients randomized to either treatment with online post-dilution HDF or continuation of low-flux HD was performed. Both groups were treated with ultrapure dialysis fluids. ESA resistance, measured every three months, was expressed as the ESA index (weight adjusted weekly ESA dose in daily defined doses [DDD]/hematocrit). The mean ESA index during 12 months was not different between patients treated with HDF or HD (mean difference HDF versus HD over time 0.029 DDD/kg/Hct/week [20.024 to 0.081]; P = 0.29). Mean transferrin saturation ratio and ferritin levels during the study tended to be lower in patients treated with HDF (22.52% [24.72 to 20.31]; P = 0.02 and 249 ng/mL [2103 to 4]; P = 0.06 respectively), although there was a trend for those patients to receive slightly more iron supplementation (7.1 mg/week [20.4 to 14.5]; P = 0.06). In conclusion, compared to low-flux HD with ultrapure dialysis fluid, treatment with online HDF did not result in a decrease in ESA resistance

Fluid balance-adjusted creatinine at initiation of continuous venovenous hemofiltration and mortality. A post-hoc analysis of a multicenter randomized controlled trial.

Introduction Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with high mortality. The creatinine-based stage of AKI is considered when deciding to start or delay RRT. However, creatinine is not only determined by renal function (excretion), but also by dilution (fluid balance) and creatinine generation (muscle mass). The aim of this study was to explore whether fluid balance-adjusted creatinine at initiation of RRT is rel

Nephrology in the Netherlands is not going under

The combination of working in dialysis as well as in general medicine/nephrology after a good training program—along with ongoing interest in clinical research—makes it sufficiently appealing for many trainees to pursue a career in nephrology in the Netherlands

Nephrology in the Netherlands

Nephrology in the Netherlands was organized as a medical society in 1972. In the Netherlands, everybody is obligatory insured. Within the insurance, all care for chronic kidney disease, end-stage renal disease and transplantation is covered. With a population of 17.4 million, 6252 patients are currently on dialysis. Haemodialysis is the main modality of renal replacement therapy, treating 85.7% of the patients on chronic dialysis. The highest number of patients treated with renal replacement therapy nowadays is patients with a renal transplant. Almost 50% of the performed kidney transplants in the Netherlands nowadays are living unrelated kidney transplantations. This chapter presents a general overview of nephrology in the Netherlands addressing historical aspects, the organization of nephrology and important organizations for nephrology in the Netherlands. In addition, chronic kidney disease, paediatric nephrology and renal replacement therapy, including haemodialysis, peritoneal dialysis and kidney transplantation, will be discussed

Impairment of Afferent Arteriolar Myogenic Responsiveness in the Galactose-Fed Rat

Abstract Previous studies from our laboratory have demonstrated impaired afferent arteriolar responsiveness to pressure in rats 4-6 weeks after the induction of diabetes mellitus. Although the responsible mechanisms mediating this renal autoregulatory defect have not been fully defined, increased polyol metabolism has been implicated as a possible factor involved in the pathogenesis of diabetic complications. We therefore investigated the possible role of this metabolic disturbance in renal autoregulation using the galactose-fed rat, a model characterized by increased polyol pathway activity independent of hyperglycemia or insulin deficiency. Hydronephrosis was induced to permit direct visualization of renal microvessels. Pressure-induced vasoconstriction of afferent arterioles was assessed by quantitating vessel diameter following stepwise increments of renal perfusion pressure (RAP; from 80 to 180 mm Hg) in the hydronephrotic kidneys from control rats and rats fed a 50% galactose diet for 2 or 4 weeks. Vessel diameters were measured from video images by computer-assisted image processing. Control rats exhibited progressive afferent arteriolar vasoconstriction when RAP was increased from 80 to 180 mm Hg (-17.3% ± 1.0%; P < 0.001). In contrast, myogenic responses to increases in pressure were absent in the afferent arterioles of rats fed a 50% galactose diet for either 2 (-4.1% ± 1.9%; not significant) or 4 weeks (-2.9 ± 3.4%; not significant). Our demonstration that the impairment of afferent arteriolar responsiveness to increasing RAP in the normoglycemic galactose-fed rat was identical to that observed in the STZ-diabetic rat suggests that increased polyol accumulation may contribute to the impairment of renal auto-regulation in the diabetic rat

Improved outcome of enteric peritonitis in peritoneal dialysis patients aged 50 years and older with temporary discontinuation of peritoneal dialysis and intravenous meropenem

♦ Background: Peritonitis is a major cause of morbidity, mortality, and technique failure in peritoneal dialysis (PD) patients, especially when caused by enteric microorganisms (EM). We have implemented a treatment protocol specifically aimed at improving the outcome in EM peritonitis. The adapted protocol was applied in all PD patients 50 years and older presenting with peritonitis who were considered to be at risk of EM peritonitis and involves 3 interventions: 1) temporary discontinuation of PD without removing the catheter (peritoneal rest), 2) intravenous meropenem, and 3) meropenem intracatheter as lock (Mero-PerRest protocol). ♦ Methods: In this observational study, we compared the outcome of 203 peritonitis episodes in 71 patients treated with the Mero-PerRest protocol, with 217 episodes in 104 patients treated with a more traditional intraperitoneal gentamicin-rifampicin-based regimen. ♦ Results: In EM peritonitis episodes, the Mero-PerRest protocol resulted in a higher primary cure rate (90.0% vs 65.3%, adjusted odds ratio [OR] 4.54 [95% confidence interval (CI) 1.46 – 14.15]) and better technique survival (90.0% vs 69.4%, adjusted OR 3.41 [95% CI 1.07 – 10.87]). This effect was most distinct in patients with polymicrobial EM peritonitis (cure rate 87.5% vs 34.8%, p = 0.0003). Interestingly, primary cure rate (95.6% vs 84.7%, adjusted OR 3.92 [95% CI 1.37 – 11.19]) and technique survival (95.6% vs 85.6%, adjusted OR 3.60 [95% CI 1.25 – 10.32]) were also excellent in non-EM peritonitis episodes. Patient survival did not differ significantly. ♦ Conclusion: The poor outcome of peritonitis caused by EM in PD patients aged 50 years and older could be improved by applying a treatment protocol involving temporary discontinuation of PD without catheter removal and intravenous and intracatheter meropenem