Tag Archive | "dialysis"

Study Finds Another Risk of Fall in Blood Pressure During Dialysis

A recent study led by researchers at the Stanford University School of Medicine found that there is an increased risk of blood clotting at the point where the patient’s blood vessels are connected to the dialysis machine known as the point of vascular access.  Researchers from the University of Utah also contributed to the study.  The study was published in the Journal of the American Society of Nephrology. This is yet another diverse consequence associated with a fall in blood pressure during dialysis for patients

Dialysis is a life-extending procedure for patients with kidney failure.  It involves sitting in a chair three or more times a week connected to an artificial kidney machine.  The patient’s blood is cleansed by exchanging fluid and electrolytes across a membrane during each three to four-hour session.

The fistula is one of the most common forms of vascular access.  It is created surgically from the patient’s own blood vessels.  The tubes used to transport blood to and from the body to the dialysis machine are connected to the body at this access point.  Clotting is one of the problems of an access point and can lead to its closure.

This study was based on results from the Hemodialysis study, known as HEMO, a National Institutes of Health-sponsored randomized clinical trial that collected data from 1,846 patients on hemodialysis from 1995 to 2000.  This study included data from 1,426 of these patients.

The team found that patients who had the most frequent episodes of low blood pressure during dialysis were two times more likely to have a clotted fistula than patients with the least episodes.

Roughly $2 billion a year is spent on vascular access in dialysis patients in the United States. Low blood pressure during dialysis occurs in about 25 percent of dialysis sessions.

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Pre-surgery Protocol for Hard-to-Match Kidney Transplant Patients Improves Survival Chances

A new Johns Hopkins study has found that candidates for kidney transplant who are hard-to-match and who receive a treatment designed to make their bodies more accepting of incompatible organs are twice as likely to survive eight years after transplant surgery as those who stay on dialysis for years awaiting compatible organs.  The study appeared in the New England Journal of Medicine.

Aside from the problem of the scarcity of donor kidneys, the largest barrier to kidney transplant right now is the percentage (nearly one in three) of patients on the waiting list whose immune systems make them likely to reject most kidneys available to them.

Widespread use of a presurgery protocol pioneered by Robert Montgomery, M.D., D. Phil., a professor of surgery at Johns Hopkins University School of Medicine and leader of the study and his colleagues in 1998, removing problematic antibodies from a patient’s blood prior to transplant, could lead to potentially 3,000 more kidney transplants from living donors each year.  As of right now, this process cannot be used with patients receiving cadaver organs because several days of treatment are needed before the surgery can take place.  The process essentially allows an incompatible kidney to function long term, and in most patients, the harmful antibodies do not return.  Other hospitals have begun to use it, but many others are awaiting data indicating long-term benefits to patients.

In the new study, Montgomery and colleagues transplanted 211 HLA-sensitized patients between February 1998 and December 2009 using plasmapheresis and IVIg before and after surgery.  In order to develop a control group, the research team, on the day each patient received his or her incompatible transplant, identified five patients on the kidney waiting list who most closely matched the characteristics of the person who got the new organ.  The researchers then followed the progress of all transplant candidates, whether they remained on dialysis or eventually received a compatible organ.

After the first year, each group of patients had about the same chance for survival (in the low 90th percentile range), but after eight years, the treatment group had an 80.6 percent survival rate.  The dialysis group on the other hand had a 30.5 percent chance of survival.  The patients who remained on the waitlist with the possibility of receiving a compatible kidney had a 49.1 percent change of eight-year survival.

Montgomery emphasizes that the number of these patients who actually received a compatible transplant was very small because finding compatible organs for HLA-sensitized patients is very challenging.

In 2008, of the 82,000 patients on the waiting list in the United States, 16,520 received kidney transplants and 4,800 died waiting for one.

Although desensitization makes kidney transplants more expensive, Montgomery says the cost savings when compared to dialysis are enormous.  He expects his findings to ease doubts about the ability of HLA-sensitized candidates to have successful transplants; insurers who historically have not covered desensitization should now reconsider.

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Dialysis At Home Improves Sleep Problems From Restless Legs Syndrome

A study earlier this year published in the Clinical Journal of the American Society of Nephrology (CJASN) found that performing daily dialysis at home for dialysis patients can help alleviate sleep problems related to restless legs syndrome (RLS).  RLS is a common problem for dialysis patients, and it affects hemodialysis patients about four times as often as people in the general population.  The study was conducted by lead author Bertrand L. Jaber, MD, of St. Elizabeth’s Medical Center in Boston and colleagues.

The preliminary report was part of the FREEDOM study, which evaluates SDHD as an alternative to dialysis center treatment.  SDHD allows patients to perform dialysis at home for a few hours, six days per week.  This is the largest U.S.-based observational study examining the potential clinical and economic benefits of home SDHD.

Data on 235 patients was analyzed to reveal how SDHD affected symptoms of RLS.  RLS is manifested by a “pins and needles” or crawling sensation that are relieved by moving the legs.  These symptoms may lead to sleep problems.  Although it is not known what causes, RLS, RLS has been linked to increased rates of heart complications and death.

Switching to SDHS led to significant improvement in RLS-related symptoms for patients in the study.  Jaber reports a decline in the percentage of patients reporting RLS and those reporting moderate-to-severe symptoms over twelve months.  Patients also reported continued improvement in sleep disorders even after adjustment for the presence of RLS and for use of anti-anxiety or sedative drugs.  Future results from this study will determine how SDHD affects hospitalization rates and overall non-treatment related costs in dialysis patients.

Important limitations in the study included selection bias from the recruitment of a relatively young patient population and the absence of a control group.

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LDL Lowering Not Found To Slow Progression of Renal Disease

David Lewis, MD, of the Clinical Trial Service Unit at the University of Oxford, presented overall and sub-analyses of the renal results of the Study of Heart and Renal Protection (SHARP) at the European Renal Association – European Dialysis and Transplant Association in Prague in June.

The study found that lowering LDL cholesterol can prevent and reverse atherosclerosis, but it does not do the same for the progression of chronic kidney disease (CKD).  Preclinical and clinical results suggested that elevated LDL is associated with the development and progression of kidney disease and that lowering LDL could impede the loss of kidney function.  The SHARP trial investigators tested whether such an intervention could slow the progression of renal disease in patients with CKD.

The research team randomly assigned CKD patients aged 40 years and older to receive SIM/EZE, SIM 20 mg, or a placebo for one year.  SIM alone was used as a comparison to assess the safety of adding EZE to SIM.  At one year, patients on SIM were randomized to either the SIM/EZE cohort (4,650 patients) or to the placebo (4,620 patients).  The patients were followed for a median of 4.9 years and a minimum of four years.  SIM/EZE was correlated with a mean LDL reduction of 33m/dL at 2.5 years compared with the placebo arm.

In the entire sample of 9,270 patients with a mean age of 63 years, two-thirds were not on dialysis at the beginning of the trial, and the rest were.  Study participants could not have had a myocardial infarction or coronary revascularization.

The researchers observed no significant effect from the administration of the LDL lowering therapy.

Session moderator Johannes Mann, MD, Director of the Department of Nephrology at Munich General Hospitals emphasized the good news.  He stressed that even if the presence of kidney disease is the only cardiovascular risk factor present, doctors should use LDL lowering independent of patients’ baseline LDL cholesterol because many patients who are not receiving this treatment should be receiving it.

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