DIALYSIS THERAPIES AND MORE: THINGS THAT YOU SHOULD KNOW
Introduction Common Clinical Quandaries Encountered by Nephrologists: More Questions Answered Roger A. Rodby* and Mark A. Perazella† *Division of Nephrology, Rush University Medical Center, Chicago, Illinois, and †Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
An overwhelmingly positive response to the first “Clinical Quandaries” issue in Seminars in Dialysis (1) prompted the Editor-in-Chief, Richard Sherman, to “go back to the well”. Sequels, while tempting to make, are risky business. Caddyshack 2 was one of the worst movies ever produced, while Godfather 2 consistently ranks high in lists of the top movies ever made. For our sequel, we were asked to coedit another issue in the journal that this time would consist of several questions on various topics in nephrology, primarily in the areas of dialysis that overlapped with acute kidney injury (AKI) and endstage renal disease (ESRD) that would be of interest for practicing nephrologists. As we previously noted, clinicians practicing nephrology, especially dialysis-related care, are commonly confronted with patient issues and clinical care questions that are not easily answered or have little data to support a robust evidence-based approach, what we refer to as “quandaries”. Thus, we once again generated a series of questions that the clinician would like answered in a concise manner. The commentaries would be slighter longer than those in the previous issue; however, still relatively short, approximately 1500 words limited to 15–25 references and a single figure or table if appropriate. A successful sequel has several things in common: (i) a good script: We handpicked questions that addressed various issues primarily focusing on dialysis, AKI, and ESRD topics, (ii) a good cast: We handpicked authors based on specific expertise in the area, and (iii) a good producer: And in that we had our fearless leader and Editor-in-Chief Richard Sherman. Invitations for submission were sent and all authors agreed, making us very happy! We
edited the papers as they arrived. While at times daunting, we both found this task quite enjoyable and highly educational. We hope the readers will appreciate this second “Quandaries” issue and find the authors’ responses insightful and practical. We arbitrarily categorized the papers into acute dialysis- and AKI-related issues and chronic, outpatient-related ESRD issues. As technology advances, clinicians are faced with daunting problems that arise in the acute, hospital (often intensive care unit) setting. Nephrologists must safely dialyze patients who have their life sustained by a left ventricular assist device (LVAD) and decide which cardio-renal patients, if any, would garner benefit from ultrafiltration therapy. A particularly difficult and contentious area for the clinician is deciding on which end-stage liver disease (ESLD) patients with irreversible kidney failure should be offered dialysis and figuring out the utility of various “liver dialysis” extracorporeal devices (MARS, PROMETHEUS) in patients with acute hepatic failure and those with severe porto-systemic encephalopathy (PSE). Other acute dialysis-related issues contemplated in this issue for the clinician include discussing the role of renal replacement therapy in bleeding patients suffering from dabigatran toxicity, comparing high-flux hemodialysis with carboxypeptidase G2 for methotrexate intoxication, and the role of high-cutoff hemodialysis for patients with AKI from myeloma cast nephropathy. While not currently available in clinical practice, the potential for novel biomarkers in predicting recovery from AKI in patients requiring RRT is considered. Nephrologists often have to decide whether dialysis is preferable to conservative management when consulted on the hospitalized patient with advanced CKD and multiple severe comorbidities. They must decide if and when acute peritoneal dialysis (PD) is feasible in patients with hospital-acquired AKI, while also contemplating use of urgent-start PD as a preferable (and feasible) option for initial ESRD therapy in the hospitalized patients (rather than catheter-based HD). In regards
Address correspondence to: Mark A. Perazella, MD, Section of Nephrology, BB 114, 330 Cedar Street, New Haven, CT 06520-8029, Tel.: 203-785-4184, Fax: 203-785-7068, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp. 221–222 DOI: 10.1111/sdi.12234 © 2014 Wiley Periodicals, Inc. 221
222
Rodby and Perazella
to acute dialysis catheter placement, the pros and cons of whether nephrology programs should be required to continue training fellows in catheter placement, despite the majority relinquishing this procedure in subsequent practice, is discussed. Along the same lines, although performance of kidney biopsies is an important procedure for nephrologists, many are giving away this procedure to the interventional radiologists—the wisdom of this is debated in an article. In the outpatient dialysis arena, several quandaries are regularly encountered. Vascular access remains a challenge for the nephrologist. In this issue, our author experts review the data for when a stent is appropriate for the failing access, how to approach symptomatic central vein stenosis, and debate whether placement of a native fistula should always be “first”. A number of hemodialysis issues were considered, including the role of dialyzer reuse in current ESRD care, and whether hemodiafiltration is superior to hemodialysis in regards to ESRD patient outcomes. Nephrologists are faced with rising concerns over the safety low-potassium dialysate and whether a concentration less than 2 mEq/l is ever indicated. Furthermore, the controversial issue of death risk from an increased serum bicarbonate concentration developing during hemodialysis is examined. Along the lines of concern over harm for the ESRD patient, data on “early start” dialysis are reviewed to provide insight on whether it is truly associated with harm. Finally, ESRD topics of
interest in recent times are covered with a thoughtful discussion of a lower hemoglobin target (9–10 g/ dl) for dialysis patients, the utility of bone biopsy in managing renal osteodystrophy, and the question if calcium-based phosphate binders are ever preferable in ESRD patients. These are just a few of the vexing issues that clinicians must deal with on a day-to-day basis. It was our goal that each of these questions be answered in a succinct and evidence-based fashion. As before, “answered” was the operative term; hedging and waffling was not allowed! This was a challenge for many of the authors tackling areas with very little definitive data. However, they capably pulled it off. We are indebted to the authors who contributed the commentaries—thank you for your thoughtful writing. As previously, we found the entire editorial process for this issue to be educational and fun. We are hopeful that the readers find this encore issue helpful in the day-to-day management of patients when they are confronted with these difficult issues, and that it plays more like Godfather 2 than Caddyshack 2. Reference 1. Curbside Consultations: Questions and Answers on Dialysis. Sem Dial 24(4):363–451, 2011
Introduction Common Clinical Quandaries Encountered by Nephrologists: More Questions Answered Roger A. Rodby* and Mark A. Perazella† *Division of Nephrology, Rush University Medical Center, Chicago, Illinois, and †Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
An overwhelmingly positive response to the first “Clinical Quandaries” issue in Seminars in Dialysis (1) prompted the Editor-in-Chief, Richard Sherman, to “go back to the well”. Sequels, while tempting to make, are risky business. Caddyshack 2 was one of the worst movies ever produced, while Godfather 2 consistently ranks high in lists of the top movies ever made. For our sequel, we were asked to coedit another issue in the journal that this time would consist of several questions on various topics in nephrology, primarily in the areas of dialysis that overlapped with acute kidney injury (AKI) and endstage renal disease (ESRD) that would be of interest for practicing nephrologists. As we previously noted, clinicians practicing nephrology, especially dialysis-related care, are commonly confronted with patient issues and clinical care questions that are not easily answered or have little data to support a robust evidence-based approach, what we refer to as “quandaries”. Thus, we once again generated a series of questions that the clinician would like answered in a concise manner. The commentaries would be slighter longer than those in the previous issue; however, still relatively short, approximately 1500 words limited to 15–25 references and a single figure or table if appropriate. A successful sequel has several things in common: (i) a good script: We handpicked questions that addressed various issues primarily focusing on dialysis, AKI, and ESRD topics, (ii) a good cast: We handpicked authors based on specific expertise in the area, and (iii) a good producer: And in that we had our fearless leader and Editor-in-Chief Richard Sherman. Invitations for submission were sent and all authors agreed, making us very happy! We
edited the papers as they arrived. While at times daunting, we both found this task quite enjoyable and highly educational. We hope the readers will appreciate this second “Quandaries” issue and find the authors’ responses insightful and practical. We arbitrarily categorized the papers into acute dialysis- and AKI-related issues and chronic, outpatient-related ESRD issues. As technology advances, clinicians are faced with daunting problems that arise in the acute, hospital (often intensive care unit) setting. Nephrologists must safely dialyze patients who have their life sustained by a left ventricular assist device (LVAD) and decide which cardio-renal patients, if any, would garner benefit from ultrafiltration therapy. A particularly difficult and contentious area for the clinician is deciding on which end-stage liver disease (ESLD) patients with irreversible kidney failure should be offered dialysis and figuring out the utility of various “liver dialysis” extracorporeal devices (MARS, PROMETHEUS) in patients with acute hepatic failure and those with severe porto-systemic encephalopathy (PSE). Other acute dialysis-related issues contemplated in this issue for the clinician include discussing the role of renal replacement therapy in bleeding patients suffering from dabigatran toxicity, comparing high-flux hemodialysis with carboxypeptidase G2 for methotrexate intoxication, and the role of high-cutoff hemodialysis for patients with AKI from myeloma cast nephropathy. While not currently available in clinical practice, the potential for novel biomarkers in predicting recovery from AKI in patients requiring RRT is considered. Nephrologists often have to decide whether dialysis is preferable to conservative management when consulted on the hospitalized patient with advanced CKD and multiple severe comorbidities. They must decide if and when acute peritoneal dialysis (PD) is feasible in patients with hospital-acquired AKI, while also contemplating use of urgent-start PD as a preferable (and feasible) option for initial ESRD therapy in the hospitalized patients (rather than catheter-based HD). In regards
Address correspondence to: Mark A. Perazella, MD, Section of Nephrology, BB 114, 330 Cedar Street, New Haven, CT 06520-8029, Tel.: 203-785-4184, Fax: 203-785-7068, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp. 221–222 DOI: 10.1111/sdi.12234 © 2014 Wiley Periodicals, Inc. 221
222
Rodby and Perazella
to acute dialysis catheter placement, the pros and cons of whether nephrology programs should be required to continue training fellows in catheter placement, despite the majority relinquishing this procedure in subsequent practice, is discussed. Along the same lines, although performance of kidney biopsies is an important procedure for nephrologists, many are giving away this procedure to the interventional radiologists—the wisdom of this is debated in an article. In the outpatient dialysis arena, several quandaries are regularly encountered. Vascular access remains a challenge for the nephrologist. In this issue, our author experts review the data for when a stent is appropriate for the failing access, how to approach symptomatic central vein stenosis, and debate whether placement of a native fistula should always be “first”. A number of hemodialysis issues were considered, including the role of dialyzer reuse in current ESRD care, and whether hemodiafiltration is superior to hemodialysis in regards to ESRD patient outcomes. Nephrologists are faced with rising concerns over the safety low-potassium dialysate and whether a concentration less than 2 mEq/l is ever indicated. Furthermore, the controversial issue of death risk from an increased serum bicarbonate concentration developing during hemodialysis is examined. Along the lines of concern over harm for the ESRD patient, data on “early start” dialysis are reviewed to provide insight on whether it is truly associated with harm. Finally, ESRD topics of
interest in recent times are covered with a thoughtful discussion of a lower hemoglobin target (9–10 g/ dl) for dialysis patients, the utility of bone biopsy in managing renal osteodystrophy, and the question if calcium-based phosphate binders are ever preferable in ESRD patients. These are just a few of the vexing issues that clinicians must deal with on a day-to-day basis. It was our goal that each of these questions be answered in a succinct and evidence-based fashion. As before, “answered” was the operative term; hedging and waffling was not allowed! This was a challenge for many of the authors tackling areas with very little definitive data. However, they capably pulled it off. We are indebted to the authors who contributed the commentaries—thank you for your thoughtful writing. As previously, we found the entire editorial process for this issue to be educational and fun. We are hopeful that the readers find this encore issue helpful in the day-to-day management of patients when they are confronted with these difficult issues, and that it plays more like Godfather 2 than Caddyshack 2. Reference 1. Curbside Consultations: Questions and Answers on Dialysis. Sem Dial 24(4):363–451, 2011
