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• W4386143009 abstract "It is well known that some degree of preserved residual kidney function (RKF) in end-stage kidney disease (ESKD) patients is associated with higher rates of survival.1Termorshuizen F, Dekker FW, van Manen JG, Korevaar JC, Boeschoten EW, Krediet RT; NECOSAD Study Group. Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol. 2004 Apr;15(4):1061-1070. doi: 10.1097/01.asn.0000117976.29592.93. PMID: 15034110.Google Scholar,2Vilar E. Wellsted D. Chandna S.M. Greenwood R.N. Farrington K. Residual renal function improves outcome in incremental haemodialysis despite reduced dialysis dose.Nephrol Dial Transplant. 2009 Aug; 24 (Epub 2009 Feb 24. PMID: 19240122): 2502-2510https://doi.org/10.1093/ndt/gfp071Crossref PubMed Scopus (121) Google Scholar Also, it has been demonstrated that loss of residual kidney function is associated with a high mortality rate.3Obi Y, Rhee CM, Mathew AT, Shah G, Streja E, Brunelli SM, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Residual Kidney Function Decline and Mortality in Incident Hemodialysis Patients. J Am Soc Nephrol. 2016 Dec;27(12):3758-3768. doi: 10.1681/ASN.2015101142. Epub 2016 May 11. PMID: 27169576; PMCID: PMC5118484.Google Scholar There are several questions in this area that have remain unanswered: 1) is the reduced mortality with RKF seen with all-cause deaths or is the association limited to deaths due to cardiovascular disease or infection? Is the presence of RKF associated with reduction in sudden cardiac deaths? 2) what is the “dose-response” relationship between the level of RKF and survival benefit? ; 3) what are the possible mechanisms for the higher survival rate when RKF is present? Is there lowering of cardiovascular stress because of the lower ultrafiltration rates typically seen in patients with RKF? Do patients with RKF have a lesser degree of fluid overload than their anuric counterparts? Is the survival benefit of RKF linked to less exposure to very high levels of serum potassium and phosphate, each of which has been associated with mortality, and in the case of potassium, with sudden death? 4) does presence of RKF allow for a more liberal diet, leading to improved nutrition and a lower prevalence of protein-energy wasting?, and 5) does increased removal by RKF of high molecular weight and protein-bound uremic toxins meaningfully lower serum levels and thereby reduce inflammation and mitigate other pathology involved in the uremic syndrome? No one study can answer all of these questions, but the observational study by Okazaki and colleagues4Okazaki M. Obi Y. Shafi T. Rhee C.M. Kovesdy C.P. Kalantar-Zadeh K. Residual kidney function and cause-specific mortality among incident hemodialysis patients.Kidney Int Rep. 2023; (in press)Abstract Full Text Full Text PDF Google Scholar published in this issue of Kidney International Reports provides important and useful new insights. These investigators were able to identify 39,000 incident hemodialysis patients in whom residual kidney clearance of urea and urine volume had been measured approximately 60 days after starting hemodialysis. In one-third, repeat measurements were available, allowing for assessment of associations between the extent of decline in RKF or urine volume (over a 6-month period after enrollment) and mortality . Okazaki et al confirmed multiple previous reports, showing that death rate was lower in patients who had retained some residual kidney clearance of urea at baseline. This survival association was seen with non-cardiovascular deaths as well as with sudden cardiac deaths (SCD) and with non-SCD cardiovascular deaths. With respect to a “dose-response” relationship for these associations, for non-cardiovascular deaths, the data suggested a monotonically higher death rate in subgroups with renal clearance of urea below 6 ml/min per 1.73 m2, with a more pronounced higher death rate when this value was below 1.5. A plethora of adjustments, including case-mix, ultrafiltration rate, and a packet of laboratory values had little affect on the observed “dose-response” association. For SCD and non-SCD cardiovascular deaths, the dose-response relationship between renal urea clearance at baseline and mortality risk depended strongly on whether an adjustment for “laboratory values” was made. These included the normalized protein catabolic rate (nPCR), predialysis blood hemoglobin, and predialysis serum levels of albumin, creatinine, phosphorus, iron saturation, bicarbonate, alkaline phosphatase, and ferritin, as well as the highest predialysis serum potassium level measured during the initial 3-month observation period. Body mass index was included in the “laboratory values” adjustment packet. Adjustment for ultrafiltration rate did not seem to affect any of the renal urea clearance vs. mortality dose-response relationships, whether or not the packet of laboratory values was included. If the “laboratory values” adjustments were excluded, the dose-response relationship between renal clearance of urea and cardiovascular deaths seemed to differ slightly from that observed with non-cardiovascular deaths. Compared to patients with renal urea clearance >6.0 ml/min per 1.73 m2, the non-cardiovascular death rate was already higher when renal urea clearance was less than 6.0, whereas for non-sudden (non-SCD) cardiovascular deaths, the risk of death was higher only in the subgroups with renal urea clearance below 1.5 ml/min per 1.73 m2. For sudden cardiac death (SCD) the death risk was higher in subgroups with renal urea clearances below 3.0 (including those in the 1.5–3.0 ml/min range). The authors then did a similar “dose-response” analysis for the three categories of cause-specific mortality vs. daily urine volume. Here mortality risk seemed to be higher in subgroups in whom daily urine volume was below 900 ml/day. Results were similar for non-cardiovascular death, SCD, and non-SCD cardiovascular death. When examining the effect of a change in urine volume over the 6-month period after enrollment, and increase in urine volume was associated with a reduced death risk for all 3 mortality categories, while a reduction in urine volume was associated with increase in death risk for non-cardiovascular death and for SCD, while for non-SCD cardiovascular death, a reduction in urine volume was not clearly associated with increased risk of death. When trying to analyze mechanistic variables, including ultrafiltration rate, nutrition, potassium, and phosphate, the study made several interesting observations. In their supplemental data table S4, ultrafiltration rate, nPCR, and serum potassium and phosphorus are compared in subgroups based on different levels of daily urine output at baseline. The renal clearances of urea tracked daily urine output, as expected. One of the potential “benefits” of a high daily urine volume is a lower ultrafiltration rate during dialysis. When a given volume of fluid is ingested or generated from food during the week, fluid excreted by the kidneys no longer has to be removed during dialysis and the ultrafiltration rate is proportionately lowered. In this S4 data table, we see that in the subgroup with urine output was < 300 ml/day, ultrafiltration rate averaged 8.0 ml/hr per kg, whereas in the subgroup with urine output was > 1200 ml/day, the average ultrafiltration rate was only 6.5. Similar differences were found among the urine volume subgroups for values of weekday and weekend interdialytic weight gains. With regard to nutrition/ inflammation, serum albumin was slightly higher in the subgroups with higher daily urine output. The normalized protein catabolic rate was substantially higher in the subgroups with higher urine volume, averaging 0.80 g/kg per day when urine volume was < 300 ml/day, vs. 1.11 when urine volume was > 1200, with relatively monotonically increased catabolic rate value for the urine volume subgroups in between. One might have expected the predialysis serum potassium and phosphate values to be lower in the subgroups with higher urine volume, but they were not. Also, the incidences of high predialysis serum potassium levels (>6.0 or > 6.5 mmol/L) during the 3-month baseline period were similar in the different urine volume subgroups. The most logical explanation for this is, that patients in the subgroups with higher urine volume were eating more, and the increased food intake overrode any increased removal of potassium and phosphate due to residual kidney function. So, were the benefits of increased renal clearance of urea at baseline on subsequent survival mediated by ultrafiltration, nutrition, potassium, or phosphate? Adjusting the mortality analyses for baseline ultrafiltration rate or incidence of high baseline serum potassium levels did not meaningfully change the associations between baseline renal urea clearance and the 3 categories of mortality. In summary, the results of the study by Okazaki et al are primarily confirmatory and suggest a broad-based benefit of increased residual kidney function on survival. The association was not limited to a reduced rate of sudden cardiac deaths or of non-SCD cardiovascular deaths, but was as or more prominent with non-cardiovascular mortality. Slightly higher nPCR and serum albumin levels suggest that patients with higher RKF may have been somewhat healthier at the outset. The exact mechanism whereby residual kidney function reduces death risk remains incompletely defined, but most likely is related to reduced serum levels of potential uremic toxins as opposed to reduced need for ultrafiltration or reductions in incidence of hyperkalemia. Even small amounts of residual kidney function can substantially lower serum levels of higher molecular weight toxins such as beta-2-microglobulin5Vilar E, Boltiador C, Wong J, Viljoen A, Machado A, Uthayakumar A, Farrington K. Plasma Levels of Middle Molecules to Estimate Residual Kidney Function in Haemodialysis without Urine Collection. PLoS One. 2015 Dec 2;10(12):e0143813. doi: 10.1371/journal.pone.0143813. PMID: 26629900; PMCID: PMC4668015.Google Scholar as well as protein-bound uremic toxins, which are not well removed by hemodialysis. Future exploration of the role of RKF and urine volume on hard outcomes should ideally include measurement of serum levels such uremic toxins. Residual Kidney Function and Cause-Specific Mortality Among Incident Hemodialysis PatientsKidney International ReportsPreviewThe survival benefit of residual kidney function (RKF) in patients on hemodialysis is presumably due to enhanced fluid management and solute clearance. However, data are lacking on the association of renal urea clearance (CLurea) with specific causes of death. Full-Text PDF Open Access" @default.
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