Advances in chronic kidney disease
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Adv Chronic Kidney Dis · Sep 2020
ReviewTreatment Options for Coronavirus Disease 2019 in Patients With Reduced or Absent Kidney Function.
Coronavirus disease 2019, the disease caused by the severe acute respiratory syndrome coronavirus 2 virus, was first identified in the Hubei Province of China in late 2019. Currently, the only role for therapy is treatment of the disease, as opposed to postexposure prophylaxis, however multiple clinical trials are currently ongoing for both treatment and prophylaxis. Treating coronavirus disease 2019 relies on two components; the first is inhibition of the viral entrance and replication within the body and the second is inhibition of an exacerbated immune response which can be seen in patients with severe disease. ⋯ This review summarizes the current data for the most commonly used drugs for coronavirus disease 2019 and will cover the unique factors that may affect the dosing of these medications in patients with CKD. While clinical trials are ongoing, most are in patients with normal kidney function. During a pandemic, when patients with CKD are at higher risk of both infection and death, it is imperative to include patients these patients in the clinical trials.
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Kidney palliative care is a growing subspecialty of clinical practice, education, and research in nephrology. It is an essential aspect of care for patients across the continuum of advanced kidney disease who have high symptom burden, multidimensional communication needs, and limited life expectancy. ⋯ At this time, a minority of nephrologists pursue formal fellowship training in specialty palliative care. This article will discuss opportunities and challenges in building a skilled workforce that will address the palliative needs of patients living with advanced kidney disease.
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Adv Chronic Kidney Dis · Jul 2019
ReviewHypoxia-Inducible Factor Activators in Renal Anemia: Current Clinical Experience.
Prolyl hydroxylase domain oxygen sensors are dioxygenases that regulate the activity of hypoxia-inducible factor (HIF), which controls renal and hepatic erythropoietin production and coordinates erythropoiesis with iron metabolism. Small molecule inhibitors of prolyl hydroxylase domain dioxygenases (HIF-PHI [prolyl hydroxylase inhibitor]) stimulate the production of endogenous erythropoietin and improve iron metabolism resulting in efficacious anemia management in patients with CKD. Three oral HIF-PHIs-daprodustat, roxadustat, and vadadustat-have now advanced to global phase III clinical development culminating in the recent licensing of roxadustat for oral anemia therapy in China. Here, we survey current clinical experience with HIF-PHIs, discuss potential therapeutic advantages, and deliberate over safety concerns regarding long-term administration in patients with renal anemia.
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The responsibilities of a dialysis unit medical director are specified in the ESRD Conditions for Coverage and encompass multiple quality, safety, and educational domains. Many of these responsibilities require leadership skills that are neither intuitive nor acquired as part of the medical director's training. An effective medical director is able to shape the culture of the dialysis facility such that patients and staff feel free to communicate their concerns regarding suboptimal processes without fear of retribution, and there is a continuous iterative process of quality improvement and safety, which values input from all stakeholders. ⋯ Fundamental to this leadership by the medical director are communications skills, staff empowerment, allocation of resources, mentoring, team building, and strategic vision. The medical director leads by example and must be present in the dialysis unit for extended periods to send a message of accessibility and commitment. Many dialysis medical directors would benefit from leadership training inside or outside their dialysis corporation.
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Although the field of oncology has made significant steps toward individualized precision medicine, cardiology and nephrology still often use a "one size fits all" approach. This applies to the intersection of the heart-kidney interaction and the cardiorenal syndrome as well. ⋯ This review will summarize current cardiac and renal biomarkers and their status in the evaluation of cardiorenal syndrome. Although we have made progress in our understanding of this syndrome, further investigation is needed to bring precision medicine into routine clinical practice for the care of patients with cardiorenal syndrome.