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Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only due to our changing and aging dialysis population but also to our evolving knowledge base. As nephrologists, we strive to achieve both quality and (often) quantity of life for our patients and we feel reassured when we have a quantifiable marker to show for our efforts. However, we suggest that adequate dialysis reaches far beyond the realms of attaining a particular biochemical result. Dialysis adequacy should encompass a more comprehensive assessment of patient well-being. This metric could comprise quality of life and patient-specified goals, sufficient small solute and middle molecule clearance, optimal blood pressure control, and effective bone-mineral balance, all in the context of minimizing mortality and morbidity, and a livable dialysis regimen for the patient., (© 2018 Wiley Periodicals, Inc.)

Background: Readmissions following hospital discharge among maintenance dialysis patients are common, potentially modifiable, and costly. Compared with patients receiving in-center hemodialysis (HD), patients receiving peritoneal dialysis (PD) have fewer routine dialysis clinic encounters and as a result may be more susceptible to a hospital readmission following discharge., Study Design: Population-based retrospective-cohort observational study., Settings & Participants: Patients treated with maintenance dialysis who were discharged following an acute-care hospitalization during January 1, 2003, to December 31, 2013, across 164 acute-care hospitals in Ontario, Canada. For those with multiple hospitalizations, we randomly selected a single hospitalization as the index hospitalization., Predictor: Dialysis modality PD or in-center HD. Propensity scores were used to match each patient on PD therapy to 2 patients on in-center HD therapy to ensure that baseline indicators of health were similar between the 2 groups., Outcome: All-cause 30-day readmission following the index hospital discharge., Results: 28,026 dialysis patients were included in the study. 4,013 PD patients were matched to 8,026 in-center HD patients. Among the matched cohort, 30-day readmission rates were 7.1 (95% CI, 6.6-7.6) per 1,000 person-days for patients on PD therapy and 6.0 (95% CI, 5.7-6.3) per 1,000 person-days for patients on in-center HD therapy. The risk for a 30-day readmission among patients on PD therapy was higher compared with those on in-center HD therapy (adjusted HR, 1.19; 95% CI, 1.08-1.31). The primary results were consistent across several key prespecified subgroups., Limitations: Lack of information for the frequency of nephrology physician encounters following discharge from the hospital in both the PD and in-center HD cohorts. Limited validation of International Classification of Diseases, Tenth Revision codes., Conclusions: The risk for 30-day readmission is higher for patients on home-based PD compared to in-center HD therapy. Interventions to improve transitions in care between the inpatient and outpatient settings are needed, particularly for patients on PD therapy., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/V urea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to ( 1 ) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and ( 2 ) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures., (Copyright © 2017 by the American Society of Nephrology.)

Treatment for end-stage kidney disease is a major economic challenge and a public health concern worldwide. Renal-replacement therapy poses several practical and ethical dilemmas of global relevance for patients, clinicians, and policy makers. These include how to: promote patients' best interests; increase access to dialysis while maintaining procedural and distributive justice; minimise the influence of financial incentives and competing interests; ensure quality of care in service delivery and access to non-dialytic supportive care when needed; minimise the financial burden on patients and health-care system; and protect the interests of vulnerable groups during crisis situations. These issues have received comparatively little attention, and there is scant ethical analysis and guidance available to decision makers. In this Health Policy, we provide an overview of the major ethical issues related to dialysis provision worldwide, identify priorities for further investigation and management, and present preliminary recommendations to guide practice and policy., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades., (Copyright © 2016 by the American Society of Nephrology.)

Mortality is highest in the first months of maintenance hemodialysis (HD) therapy. In many Western countries, patients who transition to kidney replacement therapy usually begin thrice-weekly HD regardless of their level of residual kidney function (RKF). RKF is a major predictor of survival. RKF may decline more rapidly with thrice-weekly HD treatments, is associated with a reduced need for dialytic solute clearance, and is an important factor in the prescription of peritoneal dialysis. In this article, we review the concept of incremental HD, in which weekly dialysis dose, in particular HD treatment frequency, is based on a variety of clinical factors, such as RKF (including urine output > 0.5 L/d), volume status, cardiovascular symptoms, body size, potassium and phosphorus levels, nutritional status, hemoglobin level, comorbid conditions, hospitalizations, and health-related quality of life. These 10 clinical criteria may identify which patients might benefit from beginning maintenance HD therapy twice weekly. Periodic monitoring of these criteria will determine the timing for increasing dialysis dose and frequency. We recognize that twice-weekly HD represents a major paradigm shift for many clinicians and jurisdictions. Therefore, we propose conducting randomized controlled trials of twice-weekly versus thrice-weekly HD to assess the potential of twice-weekly HD to improve survival and health-related quality of life while simultaneously reducing costs, protecting fragile vascular accesses, and optimizing resource use during the first year of hemodialysis therapy. Such incremental and individualized HD therapy may prove to be the most appropriate approach for transitioning to dialytic therapy., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The National Institute of Diabetes, Digestive, and Kidney Diseases-supported Kidney Research National Dialogue asked the scientific community to formulate and prioritize research objectives that would improve our understanding of kidney function and disease. Kidney Research National Dialogue participants identified the need to improve outcomes in ESRD by decreasing mortality and morbidity and enhancing quality of life as high priority areas in kidney research. To reach these goals, we must identify retained toxins in kidney disease, accelerate technologic advances in dialysate composition and devices to remove these toxins, advance vascular access, and identify measures that decrease the burden of disease in maintenance dialysis patients. Together, these research objectives provide a path forward for improving patient-centered outcomes in ESRD.

Diuretics are commonly prescribed to manage various conditions in the general population. They can continue to play a role in dialysis patients to manage extracellular fluid volume and hypertension and to reduce the tendency to hyperkalemia. Nevertheless, diuretics are often stopped when patients commence dialysis. Several studies have shown that preserved residual renal function in dialysis patients is associated with improved patient survival. Although the association between diuretic use and preserved residual renal function is still controversial, the numerous clinical benefits offered by diuretics render those agents valuable in dialysis patients with urine output. Loop diuretics are generally the agents of choice in end-stage renal disease. They need to be used at higher doses because of pharmacokinetic changes in the context of diminishing renal clearance. Other classes of diuretics can still be used in end-stage renal disease, but usually in conjunction with loop diuretics or for benefits independent of diuresis. Complications can occur with the use of diuretics, but are avoidable with appropriate use. Dose-related ototoxicity, especially with concomitant use of other ototoxic medications, can occur. Hyperkalemia is possible with the use of potassium-sparing diuretics, but studies suggest that these agents can be safely administered with close monitoring.

For individuals living with CKD and those who have been discovered to have ESRD, the decisions facing them can be daunting. Such decisions include having renal replacement therapy (RRT) or conservative care, having a kidney transplant, or selecting a modality of dialysis that would fit their lifestyle and values. Education at this critical time is essential, but it must be tailored to the individual and his or her readiness to learn, and it must be provided with empathy and understanding of the chronicity of the disease and the magnitude of the effect of kidney failure on their life. We present strategies derived from education and psychology that can assist health-care practitioners to provide such education and support to individuals with advanced CKD. We also present an approach to educate and support those who have urgently started dialysis and require chronic RRT. This educational model has its basis in theories of education and decision-making and has been used with success in this population., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Presentation of the Nephrology Quiz and Questionnaire (NQQ) has become an annual "tradition" at the meetings of the American Society of Nephrology. It is a very popular session judged by consistently large attendance. Members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They can also compare their answers in real time, using audience response devices, to those of program directors of nephrology training programs in the United States, acquired through an Internet-based questionnaire. As in the past, the topics covered were transplantation, fluid and electrolyte disorders, end-stage renal disease and dialysis, and glomerular disorders. Two challenging cases representing each of these categories along with single best answer questions were prepared by a panel of experts (Drs. Hricik, Palmer, Bargman, and Fervenza, respectively). The "correct" and "incorrect" answers then were briefly discussed, after the audience responses and the results of the questionnaire were displayed. The 2010 version of the NQQ was exceptionally challenging, and the audience, for the first time, gained a better overall correct answer score than the program directors, but the margin was small. Last month we presented the transplantation and fluid and the electrolyte cases; in this issue we present the remaining end-stage renal disease and dialysis and the glomerular disorder cases. These articles try to recapitulate the session and reproduce its educational value for a larger audience--that of the readers of the Clinical Journal of the American Society of Nephrology. Have fun.

Several comparisons of peritoneal dialysis (PD) and hemodialysis (HD) in incident patients with ESRD demonstrate superior survival in PD-treated patients within the first 1 to 2 years. These survival differences may be due to higher HD-related mortality as a result of high rates of incident central venous catheter (CVC) use or due to an initial survival advantage conferred by PD. We compared the survival of incident PD patients with those who initiated HD with a CVC (HD-CVC) or with a functional arteriovenous fistula or arteriovenous graft (HD-AVF/AVG). We used multivariable piece-wise exponential nonproportional and proportional hazards models to evaluate early (1 year) mortality as well as overall mortality during the period of observation using an intention-to-treat approach. We identified 40,526 incident adult dialysis patients from the Canadian Organ Replacement Register (2001 to 2008). Compared with the 7412 PD patients, 1-year mortality was similar for the 6663 HD-AVF/AVG patients but was 80% higher for the 24,437 HD-CVC patients (adjusted HR, 1.8; 95% confidence intervals [CI], 1.6 to 1.9). During the entire period of follow-up, HD-AVF/AVG patients had a lower risk for death, and HD-CVC patients had a higher risk for death compared with patients on PD. In conclusion, the use of CVCs in incident HD patients largely accounts for the early survival benefit seen with PD.

Insulin resistance and abnormal carbohydrate metabolism is a recognized complication in patients with advanced chronic kidney disease. We describe a rare case of severe hypoglycemia with inappropriate endogenous hyperinsulinemia in a hemodialysis patient following parathyroidectomy for severe secondary hyperparathyroidism. The patient required intravenous dextrose infusions for 3 days to prevent neuroglycopenic symptoms. Extensive workup for hypoglycaemia revealed high C-peptide and insulin levels in the absence of insulinoma. It is postulated that reversal of parathyroid hormone (PTH)-mediated inhibition of insulin secretion, along with large doses of 1,25-dihydroxyvitamin D3 (calcitriol) were responsible for the increase in insulin secretion and consequent hypoglycemia in this patient.

Background and Objectives: An increasing number of patients are returning to dialysis after allograft loss (DAGL). These patients are at a higher mortality risk compared with incident ESRD patients. Among transplant-naïve patients, those treated with peritoneal dialysis (PD) enjoy an early survival advantage compared with those treated with hemodialysis (HD), but this advantage is not sustained over time. Whether a similar time-dependent survival advantage exists for PD-treated patients after allograft loss is unclear and may impact dialysis modality selection in these patients., Design, Setting, Participants, & Measurements: We identified 2110 adult patients who initiated dialysis after renal transplant failure between January 1991 and December 2005 from The Canadian Organ Replacement Register. Multivariable regression analysis was used to evaluate the impact of initial dialysis modality on early (2 years), late (after 2 years), and overall mortality using an intention-to-treat approach., Results: After adjustment, there was no difference in overall survival between HD- and PD-treated patients (hazard ratio((HD:PD)), 1.05; 95% confidence interval, 0.85 to 1.31), with similar results seen for both early and late survival. Superior survival was seen in more contemporary cohorts of patients returning to DAGL., Conclusions: The use of PD compared with HD is associated with similar early and overall survival among patients initiating DAGL. Differences in both patient characteristics and predialysis management between patients returning to DAGL and transplant-naive incident dialysis patients may be responsible for the absence of an early survival advantage with the use of PD in DAGL patients.

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of long-term peritoneal dialysis (PD) therapy. Encapsulating peritoneal sclerosis is characterized by peritoneal membrane inflammation, followed by progressive peritoneal membrane fibrosis and intestinal encapsulation. Clinical manifestations include ascites as well as intermittent and recurrent small bowel obstruction. The prognosis of EPS is poor. The exact cause of EPS remains unknown. While the risk factors for EPS are not well elucidated, EPS is seen with increased frequency after an increased duration of PD therapy. In more than half the patients who develop EPS, the diagnosis is made after transfer to hemodialysis (HD). It is important for the HD practitioner to initiate surveillance in any patient at risk for EPS while maintaining a heightened index of suspicion for EPS in an HD patient with gastrointestinal symptoms and a history of previous PD therapy. Early diagnosis and prompt initiation of treatment is essential. Early in the course of EPS, immunosuppressive therapy remains the mainstay of treatment. Ultimately, parenteral nutritional support may be required along with surgical therapy to relieve intestinal obstruction. We report a case of EPS in an HD patient at our center highlighting the incidence, risk factors, and treatment strategies in the context of available evidence.

Increasing the dialysis dose has failed to have an impact on the mortality of dialysis patients. In contrast, residual kidney function (RKF) has consistently been a potent predictor of improved survival for both hemodialysis and peritoneal dialysis patients. The benefits of RKF preservation challenge historical concepts of dialysis adequacy that have focused principally on achieving small-solute clearance targets. In this review, we highlight the evidence supporting the impact of RKF on survival and quality of life of dialysis patients and provide a mechanistic framework for this relationship. Current strategies to preserve RKF also are reviewed, emphasizing those used in patients treated with peritoneal dialysis.

Background: Increasing numbers of patients on dialysis are undergoing coronary artery bypass grafting (CABG). We undertook this retrospective study to identify risk factors of operative mortality in dialysis patients who underwent CABG., Patients and Methods: We performed retrospective analysis of 105 patients who were on dialysis for at least two months before surgery and who underwent CABG in Toronto General Hospital from 1997 to 2006. Using prospectively collected data from the Division of Cardiovascular Surgery Database of Toronto General Hospital, we collected data on comorbidities, procedures, modality change during hospitalization, and operative outcomes. Logistic regression was used to assess risk factors of operative mortality., Results: One hundred and five maintenance dialysis patients (40 PD and 65 HD) who met the inclusion criteria were studied. Overall in-hospital mortality was 7.6%. Atrial fibrillation and pneumonia occurred in 16.2 and 9.5%, respectively, of all dialysis patients. Among PD patients, rates of post-operative dialysate leak and peritonitis were 10 and 12.5%, respectively. Among HD patients, 4.6% experienced post-operative AV access thrombosis. Logistic regression showed older age (>or=70 years) and peritoneal dialysis are independent risk factors of operative mortality., Conclusion: In this retrospective study, older patients on PD had higher operative mortality than HD patients. These findings suggest extra care should be taken when CABG is considered for PD patients over 70 years old. In this study we could not identify the reason(s) for the high mortality of elderly peritoneal dialysis patients undergoing CABG.

Patients returning to dialysis after graft loss (DAGL) are an increasing segment of the end-stage renal disease (ESRD) population. It is unclear whether patients with previous graft loss have equivalent or reduced survival from the time of restarting dialysis when compared with ESRD patients initiating dialysis for the first time. Moreover, the impact of dialysis modality on the survival of patients returning to DAGL is not known. Studies of patients with transplant graft failure returning to hemodialysis (HD) have suggested decreased survival when compared with transplant-naïve dialysis patients, yet some studies of patients with graft failure returning to peritoneal dialysis (PD) have demonstrated equivalent survival. Based on these data, it is unclear whether survival differences may exist between the dialysis modalities, and if they do, whether they can be attributed to either differences in patient characteristics or to factors related to the dialysis modalities. For patients starting back onto dialysis, in whom preservation of residual renal function is important, it is also unclear how immunosuppression reduction or transplant nephrectomy may affect survival. In this review, we will summarize the available literature on survival rates of patients returning to DAGL; compare and contrast survival after initiation of HD and PD and discuss what is known about the impact of transplant nephrectomy and the different approaches to immunosuppression reduction. Practical considerations will be discussed with a specific emphasis on patients treated by PD.

End stage renal disease is a serious complication in heart or heart-lung transplant recipients and is associated with high morbidity and mortality. The majority of these patients are currently treated with hemodialysis. Since there are no randomized control trials comparing hemodialysis to peritoneal dialysis in this patient population, the potential beneficial effects of peritoneal dialysis remain largely unknown. We compared the clinical outcome of such patients on peritoneal dialysis with another group on hemodialysis. Our results indicate that patients on peritoneal dialysis had fewer episodes of congestive heart failure, fluid overload and a lower overall hospitalization rate, despite having worse cardiac function than patients on hemodialysis.

The publication of the CHOICE study, which compared survival of US hemodialysis and peritoneal dialysis patients, has re-opened the debate about the relative merits of the two dialysis modalities. The principal focus of the research and associated commentary, however, is about which modality is associated with the longest life expectancy. What appears to be missing, however, in the quagmire of propensity scores, comorbidity and confounding factors is that outcomes other than duration of survival must be addressed in discussions of the merits of renal replacement therapies. Home dialysis is very different from in-center hemodialysis, and each therapy has advantages and disadvantages that will have different implications for each patient. Given that overall survival is comparable between home peritoneal dialysis and in-center hemodialysis, we need to stop focusing so much on survival time and let the informed patient choose the modality.

Background: Mineral metabolism has emerged as an important predictor of morbidity and mortality in dialysis patients. Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for bone metabolism and disease in chronic kidney disease (CKD) recommend that, in Stage 5 CKD, the target levels for calcium (Ca) (corrected for serum albumin), phosphate (P), calcium x phosphate (CaxP) product and parathyroid hormone (PTH) levels should be maintained at 8.4-9.5 mg/dl, 3.5-5.5 mg/dl, <55 mg2/dl2 and 150-300 pg/ml, respectively., Objectives: To evaluate our ability to achieve K/DOQI guidelines for bone metabolism and disease targets in our patients and to compare them between patients on hemodialysis (HD) and peritoneal dialysis (PD) and also with those reported in the literature., Methods: We reviewed bone metabolism laboratory parameters in 57 HD patients and 69 PD patients, who had been on dialysis for more than 9 months., Results: The percentage of patients whose serum Ca, P, CaxP product and PTH were within K/DOQI recommended target ranges were 46%, 53%, 77% and 28% in HD patients and 52%, 65%, 77% and 23% in PD patients, respectively. There were no significant differences between HD and PD patients in the percentage of all parameters that were within K/DOQI recommended target ranges. The percentage of our HD patients who had Ca, P, and PTH levels within recommended target range was similar to those in previous reports., Conclusion: In our unit, the management of bone and mineral metabolism in HD and PD patients is still far short of meeting K/DOQI guidelines. These findings appear similar in HD and PD patients. Our findings resemble those reported in the literature.