Precision Medicine in the Transition to Dialysis and Personalized Renal Replacement Therapy

Rhee, Connie M.; Obi, Yoshitsugu; Mathew, Anna; Kalantar-Zadeh, Kamyar

doi:10.1016/j.semnephrol.2018.05.003

Cited by 22 publications

(13 citation statements)

References 39 publications

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“…An important strategy in preventing the risk of SCD is customizing and unvulgarizing the dialysis procedure to the individual patient according to Precision Medicine, in lieu of a “one-size-fits-all” approach. Indeed, multiple factors should be considered in prescribing and adapting patients’ dialysis prescriptions, including their underlying residual kidney function, 61 comorbidities, symptoms, and lifestyle patterns. As the first month of hemodialysis is the highest-risk period for SCD, 5 incident ESRD patients transitioning to dialysis require particular attention and vigilant modification of their prescription.…”

Section: Future Directions and Conclusionmentioning

confidence: 99%

Dialysis Prescription and Sudden Death

Rhee

Chou

Kalantar-Zadeh

2018

Seminars in Nephrology

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In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day following the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population based observational studies have suggested that lower dialysate potassium concentrations appear associated with heightened risk of post-dialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies suggests that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose to SCD. There is ongoing controversy about an association betweenhigher dialysate bicarbonate concentrations and higher risk of cardiac arrest, which is likely due to confounding by indication. Some observational studies have also shown that large interdialytic weight gains, fluid retention, and high ultrafiltration (UFR) rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper UFR limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this Review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.

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Section: Future Directions and Conclusionmentioning

confidence: 99%

Dialysis Prescription and Sudden Death

Rhee

Chou

Kalantar-Zadeh

2018

Seminars in Nephrology

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“…Furthermore, some individuals, in particular if affected by multiple and severe comorbidity, may not gain any benefit from dialysis, in terms of morbidity and mortality; while the controversy about so-called “palliative” or “conservative” care is behind the scope of this review, the advantage of this open discussion is to point out that the need for dialysis cannot be reduced to a mere series of indexes, each of which is incomplete and potentially misleading [7,8,9,10,11,12,13,51,52,53,54,55,108,109,110,111,112,113,114].…”

Section: One-size-fits-all or Tailor-made Treatments?mentioning

confidence: 99%

“…This was also the starting point for reconsidering incremental dialysis and for realizing that, especially in elderly patients, the advantages of a high dialysis dose are often counterbalanced by the iatrogenicity of treatment [120,121,122,123,124,125]. Increasing the dialysis dose by increasing the number (and/or duration) of sessions may, conversely, be necessary in particular situations, such as pregnancy or high metabolic needs, or be a suitable way to attain tolerance in fragile individuals [49,50,51,52,53,125,126,127].…”

Section: One-size-fits-all or Tailor-made Treatments?mentioning

confidence: 99%

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Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

Piccoli

Cabiddu

Breuer

et al. 2019

JCM

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Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.

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“…The iTrend (Intelligent Technologies for Renal Dialysis) programme is a long-term collaborative project performed by a multidisciplinary research team from the Universities of Derby and Nottingham and the Royal Derby Hospital Renal Unit in the UK. The primary goal of the programme is to develop supporting technologies and real-time analysis of data to enable personalised and precision treatment in ESKD [16] , [17] . Blood pressure monitoring to diagnose hypertension and hypotension [18] , [19] are typically plethorperidialytic and intermittent intradialytic BP measurements.…”

Section: Introductionmentioning

confidence: 99%

A Feasibility Study of Non-Invasive Continuous Estimation of Brachial Pressure Derived From Arterial and Venous Lines During Dialysis

Stewart

Walker

et al. 2021

IEEE J. Transl. Eng. Health Med.

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Objective: Intradialytic haemodynamic instability is a significant clinical problem, leading to end-organ ischaemia and contributing to morbidity and mortality in haemodialysis patients. Non-invasive continuous blood pressure monitoring is not currently part of routine practice but may aid detection and prevention of significant falls in blood pressure during dialysis. Brachial blood pressure is currently recorded intermittently during haemodialysis via a sphygmomanometer. Current methods of continuous non-invasive blood pressure monitoring tend to restrict movement, can be sensitive to external disturbances and patient movement, and can be uncomfortable for the wearer. Additionally, poor patient blood circulation can lead to unreliable measurements. In this feasibility study we performed an initial validation of a novel method and associated technology to continuously estimate blood pressure using pressure sensors in the extra-corporeal dialysis circuit, which does not require any direct contact with the person receiving dialysis treatment. Method: The paper describes the development of the measurement system and subsequent in vivo patient feasibility study with concurrent measurement validation by Finapres Nova physiological measurement device. Real-time physiological data is collected over the entire period of (typically 4-hour) dialysis treatment. Results: We identify a quasi-linear mathematical function to describe the relationship between arterial line pressure and brachial artery BP, which is confirmed in a patient study. The results from this observational study suggest that it is feasible to derive a continuous measurement of brachial pressure from continuous measurements of arterial and venous line pressures via an empirically based and updated mathematical model. Conclusion: The methodology presented requires no interfacing to proprietary dialysis machine systems, no sensors to be attached to the patient directly, and is robust to patient movement during treatment and also to the effects of the cyclical pressure waveforms induced by the hemodialysis peristaltic blood pump. This represents a key enabling factor to the development of a practical continuous blood pressure monitoring device for dialysis patients.

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Precision Medicine in the Transition to Dialysis and Personalized Renal Replacement Therapy

Cited by 22 publications

References 39 publications

Dialysis Prescription and Sudden Death

Dialysis Prescription and Sudden Death

Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

A Feasibility Study of Non-Invasive Continuous Estimation of Brachial Pressure Derived From Arterial and Venous Lines During Dialysis

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