Can Intensive Hemodialysis Prevent Loss of Functionality in the Elderly ESRD Patient?

Initiation of dialysis may be accompanied by decline in physical and cognitive function and independence, especially in the elderly ESRD patient. Here, we postulate the underlying factors, which may contribute to this observation in the elderly dialysis population, such as increased risk of dialysis-induced hypotension and associated cerebral and cardiac events, as well as malnutrition, infections, sleep abnormalities, and psychological complications of dialysis initiation. We describe an elderly dialysis patient who did well on nocturnal home hemodialysis (HD), and we hypothesize how intensive HD (i.e., nocturnal HD and/or short daily HD) may reduce the incidence of these dialysis complications and may therefore be considered as an option to attempt to preserve functional status and quality of life, especially early after the transition from predialysis to dialysis. Before general adoption of this strategy, further studies on the etiology of functional loss at the time of dialysis initiation, as well as on the potential advantageous effects of intensive HD in the elderly ESRD patient as compared with conventional HD, peritoneal dialysis and kidney transplantation, are required.     

Intensive Hemodialysis: Normalizing the “Unphysiology” of Conventional Hemodialysis?

Interest in intensified hemodialysis (HD) regimens is increasing internationally, as there is growing evidence that they are associated with improved outcomes. Appreciation that conventional hemodialysis (CHD), delivered as 4-hour sessions three times a week, is not providing optimal physiological replacement of renal function has led to the development of intensified dialysis therapies. These include long intermittent hemodialysis typically lasting 6-8 hours and delivered three times a week, short daily hemodialysis, providing more frequent sessions 4-7 days a week lasting 2-3.5 hours, and nocturnal hemodialysis, performed 5-7 days a week for 6-8 hours. Studies evaluating outcomes from these programs have indicated superior results to those achieved with CHD, including favorable modifications of cardiovascular risk factors and improvements in a variety of clinical measures. The objective of this review is to present available evidence supporting the hypothesis that in an attempt to provide a "more normal physiology," intensified HD regimens achieve outcomes superior to those historically achieved with CHD.     

Quality of Life After Kidney Transplantation: The Bright Side of Life?

This review describes the state-of-the-art on quality of life (QOL) in kidney transplant (KTx) recipients. More specifically, posttransplant QOL is compared with the pretransplant evaluation, with other chronically ill patient populations, and with healthy subjects. Determinants, consequences, and potential interventions to improve QOL are also summarized. However, because of the methodological diversity of published articles, this review starts with addressing some conceptual and methodological concerns surrounding research on QOL in general and in KTx recipients specifically. The ultimate goal of this review was to identify the gaps in the state-of-the-art evidence and to provide some guidelines for conduct of research in the future.     

Measurement of Health‐Related Quality of Life in the Care of Patients with ESRD: Isn’t This the Metric That Matters?

An outcome can take many forms in the health care of an individual. Common measures in clinical research may include mortality, time to ESRD, or change in glomerular filtration rate. While a patient surely may share an interest with a clinician regarding these endpoints, individual life priorities expectedly vary. Outcomes of great value to a clinician (or their performance quality measures) may not be shared by their patient. While continued education and efforts in effective communication may help each party understand the reasons behind these differences, the time required to foster such dialogues remains a major hurdle for most clinicians. Through the use of contemporary computers such as smartphones, tablets, and laptops, healthcare providers can gain meaningful insight from patient-reported data such as pain, sleep, and sexual function. This review will detail how carefully constructed questionnaires with equivalent reliability as long annual surveys, such as KDQOL, can be more quickly completed by using novel technology, which can be transmitted from the patient to the clinician and back to the bedside in minutes rather than in weeks.     

Editorial: Aminoglycosides in Hemodialysis Patients: Is the Current Practice of Post Dialysis Dosing Appropriate?

Aminoglycosides have been widely used in end-stage renal failure patients for the treatment of infections caused by gram-negative bacilli and Staphylococcus aureus . Traditionally, these agents are administered post dialysis to avoid premature dialytic clearance, although no studies have been performed to confirm that this dosing strategy represents the optimal treatment regimen. In recent years, a more complete understanding of the pharmacokinetics–pharmacodynamics of aminoglycosides has led to a global change in clinical practice from multiple to once-daily dosing in patients with normal renal function with the aim of providing intermittent pulses to maximize the peak concentration relative to overall drug exposure. These same considerations strongly support administration of aminoglycosides before, rather than after, hemodialysis. This study will review the key pharmacokinetic/pharmacodynamic considerations in aminoglycoside dosing, the relationship between serum aminoglycoside concentrations and efficacy/toxicity, the influence of renal function and hemodialysis on aminoglycoside pharmacokinetics/pharmacodynamics, and the mounting population pharmacokinetic and clinical study evidence supporting a paradigm shift in aminoglycoside dosing from post dialysis to predialysis.