Seminars in dialysis
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Seminars in dialysis · May 2019
EditorialWhen to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines.
There is wide variation in clinical practice regarding timing of discontinuation of renal replacement therapy (RRT) in patients with acute kidney injury (AKI). Prolonged, unnecessary RRT treatment can contribute to length of stay, overall hospital costs, and risk of complications associated with RRT. In addition, prolonged RRT can paradoxically lengthen the time for which the patient remains dialysis-dependent. ⋯ We emphasize the importance of frequent clinical assessment while considering discontinuation of RRT for AKI patients with a creatinine clearance >15 mL/min on a timed urine collection and/or a urine output >400 mL/24 h without diuretics, or >2000 mL/24 h with diuretics. We also discuss newer biomarkers, methods of GFR estimation, and imaging techniques that may play a greater role in the future. Clinical trials objectively comparing the success of RRT discontinuation criteria will be required to provide high-quality evidence for our proposed guidelines.
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While oral diuretics are commonly used in patients with chronic kidney disease for the management of volume and blood pressure, they are often discontinued upon initiation of dialysis. We suggest that diuretics are considerably underutilized in peritoneal dialysis and haemodialysis patients despite numerous potential benefits and few side effects. ⋯ In patients on haemodialysis, diuretics can help lessen interdialytic weight gain, resulting in decreased ultrafiltration rates and fewer episodes of intradialytic hypotension. This paper will review the mechanism of action of diuretics in patients with renal insufficiency, quantify the risk of side effects and elaborate on the potential advantages of diuretic use in peritoneal dialysis and hemodialysis patients with residual kidney function.
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Seminars in dialysis · Sep 2014
EditorialAntibiotic dosing in critically ill patients receiving CRRT: underdosing is overprevalent.
Published CRRT drug dosing algorithms and other dosing guidelines appear to result in underdosed antibiotics, leading to failure to attain pharmacodynamic targets. High mortality rates persist with inadequate antibiotic therapy as the most important risk factor for death. Reasons for unintended antibiotic underdosing in patients receiving CRRT are many. ⋯ Other factors include the variability in body size and fluid composition of patients, the serious consequence of delayed achievement of antibiotic pharmacodynamic targets in septic patients, potential subtherapeutic antibiotic concentrations at the infection site, and the influence of RRT intensity on antibiotic concentrations. Too often, clinicians weigh the benefits of overcautious antibiotic dosing to avoid antibiotic toxicity too heavily against the benefits of rapid attainment of therapeutic antibiotic concentrations in critically ill patients receiving CRRT. We urge clinicians to prescribe antibiotics aggressively for these vulnerable patients.
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Seminars in dialysis · May 2012
Editorial Case ReportsThe new label for erythropoiesis stimulating agents: the FDA'S sentence.
On June 24, 2011, the U. S. ⋯ We believe that the new label language may deprive patients of the full benefits of erythropoiesis-stimulating agent treatment and impair the opportunity to individualize treatment through shared decision making. Diminished discovery and innovation in the treatment of one of the most common and important complications of kidney disease may also be an unintended consequence of the label change.
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Seminars in dialysis · Jan 2011
EditorialCherry picking in ESRD: an ethical challenge in the era of pay for performance.
In poorly designed pay-for-performance schemes in which case mix adjustments are not adequate, self-interest could lead nephrologists toward cherry picking dialysis patients. Cherry picking, however, is morally problematic. ⋯ Second, it involves shifting the burden of caring for sicker (and less financially attractive) patients to other nephrologists and dialysis units that do not practice cherry picking, creating injustices in the health care system. Finally, it treats patients as mere means through which nephrologists achieve reimbursement instead of as persons possessing dignity and deserving of respect.