RESUMO
Rationale & Objective: The use of hemodiafiltration (HDF) as a kidney replacement therapy (KRT) in patients with end-stage kidney disease (ESKD) has sparked a debate regarding its advantages over conventional hemodialysis (HD). The present study aims to shed light on this controversy by comparing mortality rates and cause-specific deaths between ESKD patients receiving HDF and those undergoing HD. Study Design: Systematic review and meta-analysis of randomized controlled trials (RCTs). The search was conducted using PubMed, EMBASE, and Cochrane Central on July 1, 2023. Setting & Participants: Adult patients with ESKD on regular KRT. Exposure: Studies with participants undergoing HDF. Outcomes: Primary outcomes were all-cause mortality, cardiovascular (CV) mortality, deaths related to infections, and kidney transplant. We also evaluated the endpoints for deaths related to malignancy, myocardial infarction, stroke, arrhythmias, and sudden death. Analytical Approach: We included RCTs evaluating HDF versus HD. Crossover trials and studies with overlapping populations were excluded. Two authors independently extracted the data following predefined search criteria and quality assessment. The risk of bias was assessed with Cochrane's RoB2 tool. Results: We included 5 RCTs with 4,143 patients, of which 2,078 (50.1%) underwent HDF, whereas 2,065 (49.8%) were receiving HD. Overall, HDF was associated with a lower risk of all-cause mortality (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.73-0.91; P < 0.001; I2 = 7%) and a lower risk of CV-related deaths (RR, 0.75; 95% CI, 0.61-0.92; P = 0.007; I2 = 0%). The incidence of infection-related deaths was also significantly different between therapies (RR, 0.69; 95% CI, 0.50-0.95; P = 0.02; I2 = 26%). Limitations: In individual studies, the HDF groups achieved varying levels of convection volume. Conclusions: Compared with those undergoing HD, patients receiving HDF experienced a reduction in all-cause mortality, CV mortality, and infection-related mortality. These results provide compelling evidence supporting the use of HDF as a beneficial intervention in ESKD patients undergoing KRT. Registration: Registered at PROSPERO: CRD42023438362.
RESUMO
Despite its rare frequency, a pleuroperitoneal communication is a well-documented complication for patients on peritoneal dialysis. It occurs in ~2% of continuous ambulatory peritoneal dialysis, with uncertain incidence for those on automated peritoneal dialysis. We report a case of a 30-year-old female patient with end-stage kidney disease with sudden dyspnea 2 days after starting automated peritoneal dialysis. Her chest x-ray revealed a significant pleural effusion on the right side. A thoracocentesis was performed, with a pleural glucose/plasma glucose of 1.08. Additionally, a computed tomography scan revealed a pleuroperitoneal communication upon dialysate infusion added with media contrast. A pleural-to-serum glucose gradient of greater than 50 mg/dL may indicate the diagnosis of a pleuroperitoneal communication in patients on peritoneal dialysis. Current literature also indicates that a pleural-to-serum glucose ratio above 1.0 may provide a more sensitive analysis. This case highlights the diagnosis process for this complication, with both laboratory and image findings corroborating the clinical hypotheses of a pleuroperitoneal communication in a patient on automated peritoneal dialysis.
Assuntos
Hidrotórax , Falência Renal Crônica , Diálise Peritoneal Ambulatorial Contínua , Diálise Peritoneal , Humanos , Feminino , Adulto , Hidrotórax/etiologia , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal Ambulatorial Contínua/efeitos adversos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/terapia , Falência Renal Crônica/complicações , GlucoseRESUMO
BACKGROUND: Anemia is a common finding among patients with advanced chronic kidney disease, especially those on dialysis. The recent introduction of hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) has raised some concerns about the cardiovascular and thrombotic complications of this class of drugs. OBJECTIVES: This meta-analysis aimed to assess the safety of HIF-PHIs in patients with end-stage kidney disease (ESKD) versus standard therapy with erythropoiesis-stimulating agents (ESAs). METHODS: Databases were searched on April 2022. Studies that reported incidence of all-cause mortality; major cardiovascular adverse events (MACEs); myocardial infarction (MI); stroke and thrombotic events in the use of HIF-PHIs or ESA on ESKD patients in hemodialysis or peritoneal dialysis were evaluated. Data were extracted from published reports, and quality assessment was performed per Cochrane recommendations. RESULTS: 12,821 patients from ten randomized controlled trials were included in this study. Most patients (83%) were on hemodialysis. 6,461 (50.3%) were using HIF-PHIs, and 6,360 (49.6%) were in the ESA group. The pooled estimated incidence of all-cause mortality was 769 in the HIF-PHIs group (relative-risk ratios (RR): 1.04; confidence interval (CI): 0.95-1.14; p = 0.52; I2 = 0%). There was no difference in the groups regarding the outcomes of MACE in the analysis of the three studies that reported this outcome (RR: 0.95; CI: 0.87-1.04; p = 0.69; I2 = 0%). In addition, there was no statistical difference among the outcomes of MI, stroke, or thrombotic events. CONCLUSIONS: Among patients with ESKD on dialysis, the use of HIF-PHIs was non-inferior regarding the safety outcomes when compared to standard of care therapy.