Renal hyperparathyroidism- a risk factor in the development of encapsulating peritoneal sclerosis.

Background: Encapsulating peritoneal sclerosis (EPS) is a rare complication of prolonged peritoneal dialysis (PD) exposure, characterised by peritoneal thickening, calcification, and fibrosis ultimately presenting with life-threatening bowel obstruction. The presence or role of peritoneal calcification in the pathogenesis of EPS is poorly characterised. We hypothesise that significantly aberrant bone mineral metabolism in patients on PD can cause peritoneal calcification which may trigger the development of EPS.

A randomised controlled trial to examine the effects of cinacalcet on bone and cardiovascular parameters in haemodialysis patients with advanced secondary hyperparathyroidism.

Background: Secondary hyperparathyroidism may lead to increased cardiovascular risk. The use of cinacalcet may improve bone and cardiovascular health with improved parathormone (PTH) and phosphate control.

Methods: This is an open-label prospective randomised controlled trial to compare progression of cardiovascular and chronic kidney disease mineral and bone disorder (CKD-MBD) parameters.

Prescribing high-quality peritoneal dialysis: Moving beyond urea clearance.

Urea removal in peritoneal dialysis (PD) has been a primary measure of dialysis adequacy, but its utility remains limited due to its poor correlation with the clearance of other important uraemic retention solutes and the low certainty of evidence relating peritoneal urea clearance and survival of individuals doing PD. Indeed, clearances of other uraemic solutes, electrolyte imbalances, hypoalbuminaemia and nutritional status, may provide a more holistic measure of dialysis adequacy when evaluating individuals on PD in addition to focusing on person-centred outcomes. Here, we review the history of the urea and creatinine-centric approach to dialysis adequacy and explore the potential importance of other uraemic retention solutes, electrolyte disturbances, phosphorus control, peritoneal protein losses and hypoalbuminaemia, as well as nutritional management to promote a broader multidimensional concept of clearance for PD.

Hyperphosphataemia in 2019: have we made progress?

Purpose Of Review: This review describes recent developments in the management of serum phosphate in dialysis patients, with a focus on the development of recent trials which randomize patients to different levels of control.

Recent Findings: We review the uncertainties around clinical benefits of serum phosphate control and alternative approaches to current management, as well as a multinational attempt to conduct randomized controlled trials in this area. We discuss novel methods of limiting oral phosphate absorption.

A randomized controlled trial of different serum phosphate ranges in subjects on hemodialysis.

Background: Hyperphosphataemia in dialysis subjects is associated with increased mortality. However cause and effect has not been proven, and the ideal phosphate target range is unknown despite KDOQI's call for studies over 12 years ago. The design and conduct of a randomized controlled trial is challenging because maintaining two groups within differing target ranges of serum phosphate has not been achieved over a long follow-up of 1 year, in a trial setting, before.

Long-Term Mortality and Bone Safety in Patients with End-Stage Renal Disease Receiving Lanthanum Carbonate.

Background/aims: This post-marketing observational study assessed the long-term safety of lanthanum carbonate (LaC) in US patients with end-stage renal disease (NCT00567723).

Methods: Patients (≥18 years old) undergoing dialysis, who had Medicare as their primary healthcare payer, and records in the United States Renal Data System were followed-up for 5 years. Patients who had received LaC for at least 12 consecutive weeks formed the exposed cohort.

A Multifaceted Quality Improvement Programme to Improve Acute Kidney Injury Care and Outcomes in a Large Teaching Hospital.

Acute kidney injury (AKI) is now widely recognised as a serious health care issue, occurring in up to 25% of hospital in-patients, often with worsening of outcomes. There have been several reports of substandard care in AKI. This quality improvement (QI) programme aimed to improve AKI care and outcomes in a large teaching hospital.

Lanthanum carbonate: safety data after 10 years.

Despite 10 years of post-marketing safety monitoring of the phosphate binder lanthanum carbonate, concerns about aluminium-like accumulation and toxicity persist. Here, we present a concise overview of the safety profile of lanthanum carbonate and interim results from a 5-year observational database study (SPD405-404; ClinicalTrials.gov identifier: NCT00567723).

Dissolution of extensive urolithiasis: extending the utility of rasburicase can avoid the need for surgical intervention and renal replacement therapy.

A 79-year-old male with chronic myelomonocytic leukaemia and extensive bilateral renal stone disease was treated with intravenous rasburicase for persistent hyperuricaemia. Subsequent imaging revealed a complete dissolution of stone burden, avoiding the need for complex, invasive stone surgery and further renal replacement therapy.

A Study to Inform the Design of a National Multicentre Randomised Controlled Trial to Evaluate If Reducing Serum Phosphate to Normal Levels Improves Clinical Outcomes including Mortality, Cardiovascular Events, Bone Pain, or Fracture in Patients on Dialysis.

Unlabelled: Background. Retrospective, observational studies link high phosphate with mortality in dialysis patients. This generates research hypotheses but does not establish "cause-and-effect.

Acute arteriovenous access failure: long-term outcomes of endovascular salvage and assessment of co-variates affecting patency.

Aims: This study reports long-term outcomes after endovascular salvage (EVS) for acute dialysis fistula/graft dysfunction.

Methods: All patients presenting with acute fistula or graft dysfunction, excluding primary failures, referred for endovascular salvage were included in this single-centre prospective study.

Results: Altogether, 410 procedures were carried out in 232 patients.

Novel phosphate binders: plus ça change, plus c'est la même chose.

Sucroferric oxyhydroxide is a new calcium-free polynuclear iron(III)-oxyhydroxide compound that binds phosphate by ligand exchange. Floege et al. report equivalent phosphate control with a mean dose of three pills daily compared with eight of sevelamer, and suggest that a reduced pill burden may represent an aid to improved adherence.

Profiling patient attitudes to phosphate binding medication: a route to personalising treatment and adherence support.

Objective: Nonadherence to phosphate binding medication (PBM) compromises the efficacy of treatment for chronic kidney disease, but its causes are poorly understood. This study sought to explore patient attitudes towards PBM and to evaluate the utility of the necessity-concerns framework for understanding adherence to PBM.

Design: A sample of 221 dialysis patients currently prescribed PBM were surveyed from eight UK renal units.

Incidence and consequence of acute kidney injury in unselected emergency admissions to a large acute UK hospital trust.

Background: AKI is common among hospital in-patients and places a huge financial burden on the UK National Health Service, causing increased length of hospital stay and use of critical care services, with increased requirement for complex interventions including dialysis. This may account for up to 0.6% of the total Health Service budget.

Outcomes of peritoneal dialysis patients and switching to hemodialysis: a competing risks analysis.

Background: We performed a review of a large incident peritoneal dialysis cohort to establish the impact of current practice and that of switching to hemodialysis.

Methods: Patients starting peritoneal dialysis between 2004 and 2010 were included and clinical data at start of dialysis recorded. Competing risk analysis and Cox proportional hazards model with time-varying covariate (technique failure) were used.

Variability in parathyroid hormone assays confounds clinical practice in chronic kidney disease patients.

Background: Intact parathyroid hormone (iPTH) measurements are used to guide therapy in renal patients, but variability in results can occur depending on the assay used. This study has investigated iPTH assay variation in North West England and paired data with regional audit data to determine clinical relevance of assay variability.

Methods: Thirty-seven haemodialysis patients had blood taken (EDTA plasma, and serum), and samples were processed at 17 laboratories that analyse iPTH for North West dialysis patients.

Lanthanum carbonate versus placebo for management of hyperphosphatemia in patients undergoing peritoneal dialysis: a subgroup analysis of a phase 2 randomized controlled study of dialysis patients.

Background: This short-term study assessed the efficacy and safety of lanthanum carbonate in the treatment of hyperphosphatemia in dialysis patients; here, we report a prespecified subgroup analysis of patients undergoing peritoneal dialysis.

Methods: Men and women (n=39) who had received continuous ambulatory peritoneal dialysis for chronic kidney disease for 6 months or more were enrolled in eight renal medicine departments in the United Kingdom. A 2-week washout period was followed by a 4-week dose-titration phase during which patients received lanthanum carbonate titrated up to 2250 mg/day.

Use of magnesium as a drug in chronic kidney disease.

From chronic kidney disease (CKD) Stage 4 onwards, phosphate binders are needed in many patients to prevent the development of hyperphosphataemia, which can result in disturbed bone and mineral metabolism, cardiovascular disease and secondary hyperparathyroidism. In this review, we re-examine the use of magnesium-containing phosphate binders for patients with CKD, particularly as their use circumvents problems such as calcium loading, aluminum toxicity and the high costs associated with other agents of this class. The use of magnesium hydroxide in the 1980s has been superseded by magnesium carbonate, as the hydroxide salt was associated with poor gastrointestinal tolerability, whereas studies with magnesium carbonate show much better gastrointestinal profiles.

Enabling self-management: selecting patients for home dialysis?

Pre-emptive living donor transplantation should always be promoted as the first-line treatment for kidney failure. Where that is not possible, patients must receive timely information and advice regarding all dialysis options available, including home-based peritoneal dialysis and haemodialysis. Where a dialysis unit enables and actively encourages self-management, patients will tend to select themselves, and if well motivated may overcome significant difficulties to exceed the expectations or predictions of dialysis staff.

Pharmacology, efficacy and safety of oral phosphate binders.

The ideal serum level of phosphate in patients on dialysis, and the benefits of controlling levels of phosphate in serum remain unclear despite observational studies that associate phosphate levels with mortality. In the absence of robust data from trials, current guidelines are necessarily based on opinion. Oral phosphate binders are required by the majority of patients on dialysis, and all of these binders can control serum levels of phosphate to similar degrees.

Update and critical appraisal of sevelamer in the management of chronic renal failure.

Sevelamer (Renagel and Renvela), is an orally administered weakly basic anion exchange resin that binds dietary phosphate in the gastrointestinal tract, and is approved for use in the US, Europe and many other countries for the treatment of hyperphosphatemia in adult patients on hemodialysis or peritoneal dialysis. Clinical evidence shows that sevelamer is at least as effective as calcium-based oral phosphate binders in controlling serum phosphate, but with a lower incidence of hypercalcemia. Whilst sevelamer hydrochloride is associated with mild acidosis, sevelamer carbonate does not have this drawback.

Calcium and magnesium flux in automated peritoneal dialysis.

Background: Calcium and magnesium balance in continuous ambulatory peritoneal dialysis (CAPD) has been extensively studied with several of the different formulations of fluid available. Calcium and magnesium balance in automated PD (APD) is less well studied and the effect on Ca and Mg flux is unknown. Data on glucose polymer solutions are also lacking.

Cardiovascular disease in patients with chronic kidney disease.

Patients with chronic kidney disease have a high burden of cardiovascular morbidity and mortality. The vast majority of patients with chronic kidney disease do not progress to end stage renal failure, but do have a significantly higher incidence of all cardiovascular co-morbidities. Traditional cardiovascular risk factors only partially account for this increased incidence of cardiovascular disease.

Lanthanum carbonate for hyperphosphatemia in patients with advanced CKD and patients receiving dialysis.

Reduced renal excretion of phosphate leads to hyperphosphatemia, which is prevalent in patients with end-stage renal disease, and is associated with increased morbidity and mortality. Dialysis alone is unable to adequately remove the ingested phosphate contained in food. It is therefore usually necessary to supplement food with drugs that reduce the intestinal absorption of dietary phosphate in order to control serum phosphate.