♦ BACKGROUND: Peritoneal dialysis (PD) is challenging for patients with functional limitations, and assisted PD can support these patients, but previous reports of assisted PD have not examined the role of temporary assisted PD and had difficulty identifying adequate comparator cohorts. ♦ METHODS: Peritoneal Dialysis Assist (PDA), a 12-month pilot of long-term and temporary assisted PD was completed in multiple PD centers in British Columbia, Canada. Continuous cycler PD (CCPD) patients were identified for PDA by standardized criteria, and service could be long-term or temporary/respite. The PDA program provided daily assistance with cycler dismantle and setup, but patients remained responsible for cycler connections and treatment decisions. Outcomes were compared against both the general CCPD population and patients who met PDA criteria but were not enrolled (PDA-eligible). ♦ RESULTS: Fifty-three PDA patients had an 88% 1-year death- and transplant-censored technique survival that was similar to the general CCPD cohort (84%) and PDA-eligible cohort (86%). The PDA cohort had lower peritonitis rates (0.18 episodes/patient-year vs 0.22 and 0.36, respectively), but higher hospitalization (55% vs 34% and 35%, respectively). Long-term PDA cost approximately CDN$15,000/year in addition to existing dialysis costs. A total of 8/11 respite PDA patients (73%) returned to self-care PD after a median PDA use of 29 days, which costs $1,250/patient. ♦ CONCLUSIONS: Peritoneal Dialysis Assist provides effective support to functionally-limited CCPD patients and yields acceptable clinical outcomes. The program costs less than transfer to HD or long-term care, which represents cost minimization for failing self-care PD patients. Respite PDA provides effective temporary support; most patients returned to self-care PD and service was cost-effective compared with alternatives of hospitalization or transfer to HD.
Purpose:The purpose of this article is to update the previously published consensus recommendations from March 2017 discussing the optimal management of adult patients with autosomal dominant polycystic kidney disease (ADPKD). This document focuses on recent developments in genetic testing, renal imaging, assessment of risk regarding disease progression, and pharmacological treatment options for ADPKD.Sources of information:Published literature was searched in PubMed, the Cochrane Library, and Google Scholar to identify the latest evidence related to the treatment and management of ADPKD.Methods:All pertinent articles were reviewed by the authors to determine if a new recommendation was required, or if the previous recommendation needed updating. The consensus recommendations were developed by the authors based on discussion and review of the evidence.Key findings:The genetics of ADPKD are becoming more complex with the identification of new and rarer genetic variants such as GANAB. Magnetic resonance imaging (MRI) and computed tomography (CT) continue to be the main imaging modalities used to evaluate ADPKD. Total kidney volume (TKV) continues to be the most validated and most used measure to assess disease progression. Since the publication of the previous consensus recommendations, the use of the Mayo Clinic Classification for prognostication purposes has been validated in patients with class 1 ADPKD. Recent evidence supports the benefits of a low-osmolar diet and dietary sodium restriction in patients with ADPKD. Evidence from the Replicating Evidence of Preserved Renal Function: an Investigation of Tolvaptan Safety and Efficacy in ADPKD (REPRISE) trial supports the use of ADH (antidiuretic hormone) receptor antagonism in patients with ADPKD 18 to 55 years of age with eGFR (estimated glomerular filtration rate) of 25 to 65 mL/min/1.73 m2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m2 with historical evidence of a decline in eGFR >2.0 mL/min/1.73 m2/year.Limitations:Available literature was limited to English language publications and to publications indexed in PubMed, the Cochrane Library, and Google Scholar.Implications:Advances in the assessment of the risk of disease progression include the validation of the Mayo Clinic Classification for patients with class 1 ADPKD. Advances in the pharmacological management of ADPKD include the expansion of the use of ADH receptor antagonism in patients 18 to 55 years of age with eGFR of 25 to 65 mL/min/1.73 m2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m2 with historical evidence of a decline in eGFR >2.0 mL/min/1.73 m2/year, as per the results of the REPRISE study.
A utosomal dominant polycystic kidney disease (AD-PKD) is the most common inherited renal disease and is the fourth-leading cause of end-stage renal disease (1-3). ADPKD is progressive in nature, but the rate of progression is variable (4); in light of this variability, a readily available tool to determine individualized rate of progression is valuable in ADPKD management (5). Increases in renal cyst number and size leading to observable enlargement of the kidneys (4) precedes renal dysfunction in ADPKD, often by many years to decades (4). Therefore, quantifying renal enlargement emerged as a robust marker of progression in ADPKD (6,7). This concept was extended to imaging-based classifications (6) used to individualize prognosis and make treatment decisions (8-10). It is now recommended that all patients with ADPKD have an assessment of renal size as part of their initial evaluation (8,10,11). Whereas various methods of renal size assessment have been reported (6,7,12), total kidney volume (TKV) has emerged as the most accurate assessment method and is most strongly associated with clinical outcomes (5). MRIderived TKV is accurate and reproducible but the reference standard method of manual planimetry is time consuming (11,13,14), which limits translation into clinical practice. Alternative methods have been developed that estimate TKV on the basis of a more rapidly obtained series of measurements, although familiarity with these methods is limited in many clinical settings (6,14-16). In addition, image acquisition can be a challenge for clinicians who practice in settings where MRI access is limited (17). CT is known to help provide accurate TKV assessment (6,18), but there are concerns regarding radiation exposure; however, this has not been re-evaluated in the context of modern dosereducing imaging techniques (19).
Purpose of review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. Sources of information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. Key findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed.
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