Incorporating ethnic and cultural food preferences in the renal diet

Medical nutrition therapy (MNT), nutrition education, and counseling are essential components for effective management of end-stage kidney disease (ESKD). Patients with ESKD have to alter their diets and to implement new eating behaviors, sometimes irrespective of ethnic and cultural food preferences because of their high content of specific nutrients. Ethnic and cultural factors influence dietary adherence. Therefore, assessing cultural issues surrounding food and food preferences may help improve dietary adherence. A large percentage of the ESKD population in the United States is black and Hispanic, with cultural food preferences that are particularly high in potassium, phosphorus, and sodium. This article provides an overview of the role of culture and ethnicity in food habits and dietary adherence, a list of cultural and ethnic foods that should be examined and incorporated in the development of an appropriate renal diet meal plan for black and Hispanic Americans with ESKD, and practical recommendations for cross-cultural nutrition counseling. If MNT is to be effective in the medical management of patients from different cultural and ethnic backgrounds, it must incorporate more traditional and customary foods in the renal diet meal plan.     

When ESKD complicates cancer screening and cancer treatment

End-stage kidney disease (ESKD) affects the recommended screening, incidence, treatment, and mortality of cancer. Cancer occurring in a patient with ESKD can influence candidacy for kidney transplantation as well as dialysis decision-making and cancer treatment. Certain cancers are more common among ESKD patients, notably, viral-mediated cancers that are associated with human papilloma or hepatitis viruses, and urothelial cancers associated with analgesic and Balkan nephropathies. Solid tumors are not believed to occur more frequently in ESKD patients. The presence of ESKD may confer a higher risk of post-surgical complications as well as mortality. The cost-effectiveness of cancer screening depends upon individual cancer risk and estimated overall survival. The high mortality associated with ESKD argues against routine cancer screening in dialysis patients. Cancer treatment in ESKD may be complicated by the need to avoid, adjust doses of and/or coordinate the timing of administration of imaging contrast, chemotherapy, and immunotherapy with dialysis treatments. There is a general dearth of information on the treatment of cancer in ESKD patients. These issues will be discussed, and some general guidelines presented based upon the current literature.     

High prevalence of colon adenomas in end‐stage kidney disease patients on hemodialysis undergoing renal transplant evaluation

The aim of this study was to determine whether patients with end‐stage kidney disease (ESKD) on hemodialysis (HD) undergoing kidney transplant evaluation are at higher risk for colonic neoplasia than the general population. This is a retrospective cohort study of patients with ESKD who underwent a first screening colonoscopy while undergoing kidney transplant evaluation. Data were collected on the prevalence of adenomatous polyps and advanced adenomas in 70 patients with ESKD and 70 controls, undergoing their first screening colonoscopy, matched for age, gender, and endoscopist. At the time of the colonoscopy, an average time on HD was 3.2 ± 2.9 yr. The prevalence of adenomatous polyps was significantly higher in ESKD on HD (54.3% vs. 32.9%, p = 0.008) than in controls. In a multivariate analysis controlling for other factors, ESKD on HD remained a risk factor for the presence of adenomas (OR 3.06, 95% CI 1.21, 7.73). No colonoscopy‐related complications were reported in the patients with ESKD on HD. We demonstrate a significantly higher prevalence of adenomatous polyps in patients with ESKD undergoing a first screening colonoscopy as part of kidney transplant evaluation. In addition, colonoscopy can be safely performed in this population.     

When ESKD complicates disease management: GI bleeding and other GI illnesses

The presentation of gastrointestinal (GI) illnesses is similar in patients with end-stage kidney disease (ESKD) and in the general population. However, there are several instances where kidney failure and renal replacement therapy (RRT) can affect the course of the disease and its management. In this section, we will focus on unique factors of GI illnesses that should be considered in the ESKD population with and without residual kidney function (RKF). We will also discuss the role of RRT modalities in the occurrence and treatment of GI disease.     

Medication management in dialysis: Barriers and strategies

People with end-stage kidney disease (ESKD) who require chronic dialysis are often reliant on complicated medication regimens to manage their health conditions. Due to the complexities of the advanced kidney disease, underlying comorbidities, and special instructions, medication regimens for patients on dialysis put patients at high risk for medication therapy problems related to safety, effectiveness, appropriateness, and adherence. This article explores the factors that affect optimal medication use for people on dialysis, including the broader drug use system, and offers recommendations around medication reconciliation, medication review, deprescribing, and considering social determinants of health to improve medication management among patients with ESKD.     

Neuromuscular Disease in the Dialysis Patient: An Update for the Nephrologist

Neuromuscular disease is an extremely common complication of end-stage kidney disease (ESKD), manifesting in almost all dialysis patients, and leading to weakness, reduced exercise capacity, and disability. Recent studies have suggested that hyperkalemia may underlie the development of neuropathy. As such, maintenance of serum K⁺ within normal limits between periods of dialysis in ESKD patients manifesting early neuropathic symptoms may reduce neuropathy development and progression. For patients with more severe neuropathic syndromes, increased dialysis frequency or a switch to high-flux dialysis may prevent further deterioration, while ultimately, renal transplantation is required to improve and restore nerve function. Exercise training programs are beneficial for ESKD patients with muscle weakness due to neuropathy or myopathy, and are capable of improving exercise tolerance and quality of life. Specific treatments have recently been evaluated for symptoms of autonomic neuropathy, including sildenafil for impotence and midodrine for intra-dialytic hypotension, and have been shown to be effective and well tolerated. Other important management strategies for neuropathy include attention to foot care to prevent callus and ulceration, vitamin supplementation, and erythropoietin. Treatment with membrane-stabilizing agents, such as amitryptiline and gabapentin, are highly effective in patients with painful neuropathy.     

Fragmentation of care as a barrier to optimal ESKD management

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.     

ATTENTION: Workforce shortages as a barrier to optimal dialysis

Providing optimal end-stage kidney disease (ESKD) management requires an adequately trained and sufficiently staffed workforce, including doctors, nurses, and patient care technicians (PCTs). The growing need for ESKD services for a surging population of dialysis-dependent patients has made obvious a workforce crisis affecting nephrology. For a multitude of reasons, the physician workforce supply available to provide dialysis care has failed to expand commensurate with patients need in recent years. Of most importance, fewer US trainees are choosing to enter nephrology, and fewer international medical graduates are available to fill training program rosters. Equally important but less frequently cited are occupational shortages of trained dialysis nurses and PCTs. This article brings attention to this complex workforce shortage and addresses the limited information available regarding how it might constitute a barrier to optimal dialysis care.     

Up-regulation of adiponectin, its isoforms and receptors in end-stage kidney disease.

BACKGROUND: Despite the favourable effects of adiponectin on the vasculature and insulin resistance (IR), levels are increased in patients with end-stage kidney disease (ESKD), in whom both IR and atherosclerosis are prevalent. METHODS: To investigate this paradox, we examined the distribution of adiponectin isoforms, the expression of adiponectin receptor (AdipoR) mRNA on peripheral blood mononuclear cells (PBMC) in 41 patients with ESKD on haemodialysis and 41 matched controls, and its function by adenosine monophosphate-activated protein kinase (AMPK) phosphorylation of AdipoR on PBMC. We also compared the expression of AdipoR on PBMC with that on muscle and subcutaneous and visceral fat in 10 patients undergoing elective cholecystectomy. RESULTS: The proportion of the high molecular weight (HMW) isoform of adiponectin was increased in the dialysis group (P = 0.001), even though these patients were significantly insulin resistant compared with controls (P = 0.006). AdipoR1 and AdipoR2 on PBMC were also increased in patients with ESKD (P < 0.05 and P = 0.007, respectively), but levels did not correlate with IR, the HMW isoform or other anthropometric measurements. There was a strong correlation between AdipoR1 and AdipoR2 on PBMC in ESKD and in subcutaneous and visceral fat in controls. However, there was no relationship between AdipoR in PBMC, muscle or visceral fat. Phosphorylation of AMPK by recombinant adiponectin showed that AdipoR on PBMC, from controls and ESKD patients, were equally functional. CONCLUSIONS: IR in ESKD is not explained by the change in isoformic distribution, or by AdipoR down-regulation or dysfunction. Rather, this receptor-ligand axis is up-regulated and may be a beneficial response to the inflammatory milieu of ESKD.     

Epidemiology of end-stage kidney disease

End-stage kidney disease (ESKD) is a common and morbid disease that affects patients’ quality and length of life, representing a large portion of health care expenditure in the United States. These patients commonly have associated diabetes and cardiovascular disease, with high rates of cardiovascular-related death. Management of ESKD requires renal replacement therapy via dialysis or transplantation. While transplantation provides the greatest improvement in survival and quality of life, the vast majority of patients are treated initially with hemodialysis. However, outcomes differ significantly among patient populations. Barriers in access to care have particularly affected at-risk populations, such as Black and Hispanic patients. These patients receive less pre-ESKD nephrology care, are less likely to initiate dialysis with a fistula, and wait longer for transplants—even in pediatric populations. Priorities for ESKD care moving into the future include increasing access to nephrology care in underprivileged populations, providing patient-centered care based on each patient’s “life plan,” and focusing on team-based approaches to ESKD care. This review explores ESKD from the perspective of epidemiology, costs, vascular access, patient-reported outcomes, racial disparities, and the impact of the COVID-19 crisis.     

Endotoxemia in End‐Stage Kidney Disease

Chronic unexplained inflammation remains a prevalent and clinically significant problem for patients with end‐stage kidney disease (ESKD), especially in the dialysis population. The causes of persistent inflammation are likely to be multifactorial, but the underlying mechanisms remain to be elucidated. Endotoxins are reported to play a significant role in the pathogenesis of inflammation in patients with ESKD. However, blood endotoxin measurement with the Limulus amoebocyte lysate (LAL) assay is difficult with current detection systems. The reported degree and prevalence of endotoxemia varies in the literature. There are questions as to whether endotoxemia is truly present; whether the varied findings are due to methodological issues with the LAL assay and whether any endotoxemia that might be present plays a role in chronic inflammation frequently observed in ESKD patients. This review will discuss the challenges of accurate blood endotoxin detection, the potential source of blood endotoxins, and the significance of endotoxemia to patient with ESKD.     

Familial aggregation of end-stage kidney disease in Brazil

BACKGROUND/AIMS: Familial aggregation of end-stage kidney disease (ESKD) has been reported in several studies, most of them carried out in USA. It is uncertain to what extent these findings can be generalized to other populations. The objective of this study was to assess whether familial aggregation of ESKD occurs in Brazil and whether it is influenced by race. METHODS: Case-control study including 555 ESKD patients and 595 controls without renal disease. Multivariate logistic regression models were used to assess the association between a history of ESKD in a first-degree relative (Fam-ESKD) and the risk of ESKD. Additionally, the association between Fam-ESKD and race among ESKD cases was analyzed. RESULTS: Twenty-seven cases (4.9%) and 5 controls (0.8%) reported Fam-ESKD (p < 0.001). Fam-ESKD was significantly more frequent among cases in a regression model adjusted for all studied covariates (OR = 5.71, 95% CI = 2.13-15.4; p < 0.001). The frequency of Fam-ESKD among dialysis patients belonging to the white, black and 'mixed' racial subgroups was 6.0, 4.3 and 4.0%, respectively (p = 0.62). There was no association between race and Fam-ESKD (p = 0.54) in adjusted regression analyses. CONCLUSION: Fam-ESKD occurs in Brazil but, as opposed to what has been suggested by American studies, it does not appear to be influenced by race.     

Clopidogrel Use in End‐Stage Kidney Disease

Clopidogrel irreversibly binds to the P2Y12 platelet receptor and acts as a potent inhibitor of platelet activation and aggregation. It is currently recommended for the prevention of cardiovascular events in patients with acute coronary syndromes, recent ischemic stroke, and peripheral arterial disease. Clopidogrel is a prodrug requiring hepatic conversion into its active metabolite. In the general population, genetic polymorphisms in the CYP2C19 gene interfering with hepatic conversion and the ABCB1 gene interfering with gut absorption of clopidogrel, account for the large interindividual response to clopidogrel and clopidogrel resistance. Chronic kidney disease (CKD) and ESKD are independent risk factors for clopidogrel resistance; 50–80% of patients with ESKD have high on‐treatment residual platelet reactivity when treated with clopidogrel. This may partially explain the abysmal outcomes for patients with kidney disease post coronary intervention. Several assays are used to determine residual on‐treatment platelet reactivity; however, their use in tailoring the suitability of clopidogrel treatment in patients with ESKD is unclear. Although clopidogrel decreased cardiovascular events in the general population after acute coronary syndromes and percutaneous intervention in the CURE and CREDO trials, a reanalysis of these studies in patients with CKD (eGFR <60 ml/minute) showed either a reduced or no benefit from clopidogrel treatment. ESKD patients were not represented in these two large trials; this is true for most of the trials that established clopidogrel as an integral part of the therapeutic armamentarium for cardiovascular disease. Furthermore, clopidogrel has been associated with an increased risk of death, death from bleeding, and hospitalization for bleeding in patients with ESKD. In conclusion, current evidence suggests that ESKD patients may not derive the same benefits from clopidogrel therapy as the general population and this therapy may be associated with harm. Properly designed observational studies and randomized controlled trials are needed to establish the role of clopidogrel in patients with ESKD, the use of platelet assays to tailor therapy, and the role of other antiplatelet agents such as prasugrel or ticagrelor in patients who exhibit high on‐treatment residual platelet reactivity.     

Barriers to optimal vascular access for hemodialysis

Vascular access is the Achilles heel for hemodialysis (HD). An arteriovenous fistula (AVF), considered the optimal access for HD, rather than a graft or central venous catheter (CVC) caused the “Fistula First” initiative to dominate quality assessment. However, this initiative had the unintended consequence of increasing the proportion of less desirable catheters, leading to “Fistula First, Catheter Last”. But as the end-stage kidney disease (ESKD) population expanded with aging, sicker patients, individual assessment of the appropriate access changed the paradigm to KDOQI’s “Patient First: ESKD Life-Plan” to attain the “right access, in the right patient, at the right time, for the right reasons”. However, such a goal has proved elusive because the optimal vascular access does not currently exist. Thus, ESKD care providers attempting to offer the “right access” must weigh the barriers to achieving the most optimal access to suit each of their HD patients. The barriers are based on shortcomings related specifically to each of the three vascular accesses and to characteristics of each ESKD patient's demographics, physical factors, quality of life, and cost considerations. This article will describe these barriers so that clinicians caring for ESKD patients initiating or receiving HD provide the most optimal vascular access for that specific patient.     

Delayed gastric emptying in nondiabetic patients with end-stage kidney disease

ObjectiveThis study aimed to assess the gastric emptying capacity in nondiabetic patients with end-stage kidney disease (ESKD) by ultrasound.MethodsConsecutive hemodialysis patients with ESKD (n = 37) and healthy controls (n = 37) were enrolled. All ESKD patients underwent ultrasound examinations on the day of hemodialysis (dialysis day) and the day after hemodialysis (nondialysis day). Standard ultrasound examinations were performed after overnight fasting, immediately after a light meal, and at 6 h after a meal. The antral cross-sectional area and gastric emptying according to the Perlas grading system were evaluated.ResultsCompared with the controls, patients with ESKD, on both dialysis and non-dialysis days, had significantly larger antral areas when examined in the supine position (p = 0.002 and p = 0.003, respectively), but not in the right lateral decubitus position (p = 0.452 and p = 0.512, respectively). In the supine position, the antral area of ESKD patients before dialysis (8 a.m. on the dialysis day) was larger than that at the same time on the nondialysis day (p = 0.028). The controls had a Perlas grade of either 0 or 1 at 6 h after a meal, whereas five patients (13.5%) and 11 patients (29.7%) in the ESKD group had Perlas grade 2 on the dialysis and non-dialysis days, respectively. Among patients with or without delayed gastric emptying, no differences were detected in the dialysis duration or levels of biochemical markers, except blood urea nitrogen (p = 0.038) and serum creatinine (p = 0.003).ConclusionNondiabetic patients with ESKD had significantly delayed gastric emptying. Hemodialysis might improve gastric emptying and reduce gastric emptying delay.     

Improving wellbeing in patients undergoing dialysis: Can meditation help?

Coping with the stress and anxiety caused by end stage kidney disease (ESKD ) symptoms, treatment, restrictions, and social, financial and family stressors, consumes many afflicted with kidney disease. Meditation has been shown to decrease anxiety and stress, and improve wellbeing and quality of life of people with chronic disease. However, the clinical uptake of meditation is low in the ESKD dialysis population. This review describes what meditation and mindful meditation are and how they have been used for people with ESKD . Further research, using active control conditions and larger sample size, is required to identify effective meditation interventions that can improve the wellbeing of our patients and their ability to cope with the demands of ESKD .     

Outcome of dialysis in children with human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection accounts for an unknown percentage of children with end-stage kidney disease (ESKD). Our objective was to compare the outcome of renal replacement therapy (RRT) in subjects with ESKD due to HIV and other diagnoses and to examine the prevalence of ESKD due to HIV. We analyzed Kt/V, morbidity, mortality, echocardiography, nutritional, and transplant status in 12 dialysis patients with HIV and 32 without HIV followed at our center between February 2002 and February 2007. Body mass index (BMI) was lower and Kt/V higher in HIV than in non-HIV patients. Shortening fraction was significantly lower in HIV patients. There were six deaths in the HIV group and one in the non-HIV group over the study period. Hemodialysis (HD) is the prevalent mode of RRT in HIV in urban settings, and its adequacy as measured by Kt/V was higher in HIV patients than in non-HIV patients. Decreased BMI and cardiovascular disease may be associated with increased mortality in children with HIV on RRT.     

Chronic kidney disease and bone fracture: a growing concern

Susceptibility to fracture is increased across the spectrum of chronic kidney disease (CKD). Moreover, fracture in patients with end-stage kidney disease (ESKD) results in significant excess mortality. The incidence and prevalence of CKD and ESKD are predicted to increase markedly over the coming decades in conjunction with the aging of the population. Given the high prevalence of both osteoporosis and CKD in older adults, it is of the utmost public health relevance to be able to assess fracture risk in this population. Dual-energy X-ray absorptiometry (DXA), which provides an areal measurement of bone mineral density (aBMD), is the clinical standard to predict fracture in individuals with postmenopausal or age-related osteoporosis. Unfortunately, DXA does not discriminate fracture status in patients with ESKD. This may be, in part, because excess parathyroid hormone (PTH) secretion may accompany declining kidney function. Chronic exposure to high PTH levels preferentially causes cortical bone loss, which may be partially offset by periosteal expansion. DXA can neither reliably detect changes in bone volume nor distinguish between trabecular and cortical bone. In addition, DXA measurements may be low, normal, or high in each of the major forms of renal osteodystrophy (ROD). Moreover, postmenopausal or age-related osteoporosis may also affect patients with CKD and ESKD. Currently, transiliac crest bone biopsy is the gold standard to diagnose ROD and osteoporosis in patients with significant kidney dysfunction. However, bone biopsy is an invasive procedure that requires time-consuming analyses. Therefore, there is great interest in developing non-invasive high-resolution imaging techniques that can improve fracture risk prediction for patients with CKD. In this paper, we review studies of fracture risk in the setting of ESKD and CKD, the pathophysiology of increased fracture risk in patients with kidney dysfunction, the utility of various imaging modalities in predicting fracture across the spectrum of CKD, and studies evaluating the use of bisphosphonates in patients with CKD.     

Exercise and cognitive function in patients with end‐stage kidney disease

In this review we summarize the research pertaining to the role of exercise in preventing cognitive decline in patients with end‐stage kidney disease (ESKD). Impairment in cognitive function, especially in executive function, is common in patients with ESKD, and may worsen with maintenance dialysis as a result of retention of uremic toxins, recurrent cerebral ischemia, and high burden of inactivity. Cognitive impairment may lead to long‐term adverse consequences, including dementia and death. Home‐based and intradialytic exercise training (ET) are among the nonpharmacologic interventions identified to preserve cognitive function in ESKD. Additionally, cognitive training (CT) is an effective approach recently identified in this population. While short‐term benefits of ET and CT on cognitive function were consistently observed in patients undergoing dialysis, more studies are needed to replicate these findings in diverse populations including kidney transplant recipients with long‐term follow‐up to better understand the health and quality of life consequences of these promising interventions. ET as well as CT are feasible interventions that may preserve or even improve cognitive function for patients with ESKD. Whether these interventions translate to improvements in quality of life and long‐term health outcomes, including dementia prevention and better survival, are yet to be determined.