Journal of Nephrology & Therapeutics

Acute kidney injury (AKI) is a frequent and severe complication after cardiovascular surgery. Indications for continuous renal replacement therapy (CRRT) in patients with AKI have been proposed. However, there is often less discussion of when to terminate CRRT as well as what conditions are required for transferring patients to intermittent hemodialysis (HD). In this retrospective study of electronic medical records, we examined the role of a mechanical ventilator support in determining when to terminate CRRT in patients with AKI. When CRRT was stopped, 32 patients were supported with a mechanical ventilator while 41 patients had no support. Although there were no differences in age, sex, and pre levels of cardiopulmonary between the two groups, the levels of eGFR before the cardiovascular surgery were lower in the patients without a ventilator. Increases in body weight after cardiac surgery were higher, sequential organ failure assessment (SOFA) score was higher, and central venous pressures were higher in patients supported with a ventilator (all were p<0.05). The rate of re-introduction to CRRT was higher (p=0.016) in patients supported with a ventilator. After multiple regression analysis, successful cessation of CRRT was dependent on support of mechanical ventilation (odds ratio, 5.20 (CI: 1.15-23.4)). These data suggest that successful termination of CRRT is closely associated with removing the support of a mechanical ventilator.

Background: Though inadequate dialysis is a known risk factor for resistance to erythropoietin (EPO) therapy, there is no consensus about the relationship between hemodialysis (HD) time and EPO requirement. Our study sought to explore the relationship between EPO dosage and dialysis time in HD patients with diabetes. Methods: We report a cross-sectional analysis of the relationship between EPO dosage and dialysis time in HD patients with diabetes. A total of 77 patients with diabetes receiving maintenance HD at three outpatient HD facilities in Japan were included. At one such facility, HD time was 6 hours (n=37), and at the other facilities, HD time was 4 hours (n=40). In 6-hour HD patients and 4-hour HD patients, we studied parameters of weekly EPO requirement, Kt/V, hemoglobin, ferritin, albumin, C-reactive protein and intact parathyroid hormone. These parameters were analyzed with JMP9TM statistical software (SAS Institute). Results: Means for hemoglobin, ferritin, albumin, C-reactive protein and intact parathyroid hormone were not significantly different between the 6-hour and 4-hour HD patient groups. The EPO requirement was significantly lower among 6-hour HD patients (3111.8 ± 2360.8 versus 5682.9 ± 3863.3 U/week. P=0.0007). Kt/V was not significantly different between the two groups. Multiple regression analysis with EPO requirement as the dependent variable showed that dialysis time was the only significant independent variable (P=0.0001). Conclusions: Six-hour HD without a significant increase in dialysis dose, as judged by Kt/V, can reduce the dose of EPO in HD patients with diabetes.

Background: Calcitriol [1,25(OH)2D] plays a central role in endocrine regulation of bone and mineral metabolism. Low 1,25(OH)2D levels in chronic kidney disease (CKD) are associated with increased cardiovascular morbidity and mortality. However, the role of 1,25(OH)2D in acute kidney injury (AKI) is unclear, with very limited data. This pilot study examined the relationship between 1,25(OH)2D levels in critically ill patients with AKI and clinical outcomes. Methods: Plasma 1,25(OH)2D, intact parathyroid hormone (iPTH), 25-OH Vitamin D (VitD), calcium and phosphorus were measured in 34 patients with AKI without pre-existing chronic kidney disease and 12 healthy controls. Results: The mean 1,25(OH)2D levels were significantly lower in patients with AKI compared to controls, (42 ± 5.6 pg/mL vs. 76.1 ± 5.3 pg/mL, P<0.0001). The mortality in patients with AKI was 30%. 1,25(OH)2D levels were higher in non-survivors than survivors (62 ± 41.4 pg/mL vs. 33.7 ± 24.2 pg/mL respectively, P=0.046) and serum phosphorus was also higher in non-survivors (6.2 ± 2.1 mg/dL vs. 4.6 ± 1.6 mg/dL, P=0.019). However, on multivariate regression analysis, accounting for age and APACHE II score, higher levels of 1,25(OH)2D was not associated with mortality in critically ill patients with AKI. Conclusion: Mineral metabolism is dysregulated within days of acute renal injury in critically ill patients. On univariate analysis, high levels of calcitriol were associated with adverse clinical outcome in AKI. This association was not apparent after adjusting for age and APACHE II. Large controlled studies are needed to confirm these results, and determine if higher 1,25(OH)2D mediates worse outcomes in AKI.

In these times of limited financial and human resources, physicians must be cognizant of the rising costs of healthcare. Expensive imaging studies should be reserved for conditions that are particularly challenging to diagnose using traditional laboratory tests. Consequently, we must revisit the use of alternative simple, inexpensive and readily available laboratory tests to help differentiate medical conditions. Therefore, we would like to revisit the use of intact PTH as a discriminatory lab value in evaluating chronic vs. acute kidney injury.

Purpose: Among patients end-stage renal disease who receive peritoneal dialysis, malnutrition is an strong predictor of increased morbidity and mortality rates. In cases with malnutrition, hypoalbuminemia occurs mainly due to the leakage of albumin through peritoneal membrane. Therefore, the current study aimed to investigate and compare the effects of intraperitoneal or oral amino acid supplements in preventing hypoalbuminemia. 1.2 1.2

Method: Our study included 36 patients on continuous ambulatory peritoneal dialysis (CAPD) in our center. In one group, one of the exchanges was replaced with a daily dose of 2000ml of peritoneal dialysis solution with 1.1% amino acids (AAs). The other group was given oral supplementation of keto/amino acids. The group receiving intraperitoneal (IP) AAs was composed of 16 patients, while oral keto/amino acid group included 20 patients. The baseline levels of serum albumin, prealbumin, transferrin, CRP, CO2, cholesterol panels and weights (recorded during PET) were compared with the values measured after 6 months of treatment.

Results: The baseline albumin levels in the IP AA group were lower than the Oral AA group (p=0.008). When we categorized the patients based on their peritoneal membrane permeability, we found no difference between the peritoneal membrane permeability values of the groups and their laboratory variables (p>0.05). At the end of month 6, the BUN levels significantly elevated in the group receiving IP AA solution, whereas their levels of phosphorus and HDL declined (p <0.05). The group receiving oral AAs supplement had lower levels of albumin and HbA1C at the end of month 6 (p <0.05).

Conclusion: Although treatment with AAs supplements administered either intraperitoneally or orally, can be considered a good nutritional support, it should be borne in mind that the important point is to increase the amount of dietary protein intake in individual patients.

Background: Azilsartan is a new angiotensin receptor blocker with more continuous antihypertensive effects. The objective of this study was to demonstrate the efficacy and safety of azilsartan in hemodialysis patients with uncontrolled hypertension.

Methods: Twenty-two hemodialysis patients treated with multiple antihypertensive drugs including olmesartan (20- 40 mg/day) were enrolled in this retrospective observational study. Blood pressure was measured in the morning and evening for a week at baseline and after switching from olmesartan to azilsartan. The patients’ mean blood pressure at baseline was 171/71 mmHg. Olmesartan (20-40 mg/day) was switched to azilsartan with the same dose. An electrocardiogram, an echocardiogram, and measurement of the ankle-brachial index were performed in all patients, and the echocardiogram showed left ventricular hypertrophy in all patients. Home-measured blood pressure, heart rate, and serum potassium were followed for 9 months after switching.

Results: Systolic blood pressure was significantly decreased at 1, 3, 6, and 9 months after switching. Diastolic blood pressure was significantly decreased at 3 and 6 months after switching. Switching did not alter the serum potassium level.

Conclusions: Switching from olmesartan to azilsartan significantly and safely decreased home-measured blood pressure in hemodialysis patients.