journal club: residual renal function
DESCRIPTION
Here is a nice presentation by Dr.Peter Schrier on Residual renal function in hemodialysis patientsTRANSCRIPT
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Association of Residual Urine Output with Mortality, Quality of Life, and Inflammation in
Incident Hemodialysis
The Choices for Healthy Outcomes in caring for End-Stage Renal Disease (CHOICE) Study
Peter Schrier, MDJournal Club
Hofstra North Shore LIJ School of Medicine2011
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Outline
• Residual Renal Function– What it is– Why it matters
• Peritoneal Dialysis Data• Hemodialysis Data• CHOICE Study
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Residual Renal Function
• Small Solute Clearance (measured GFR)
• Volume Clearance (Urine output/volume)
• Endocrine Kidney (ESA usage, hemoglobin)
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Residual Renal Function
AY-M Wang & K-N Lai, Kidney International (2006) 69, 1726–1732
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Residual Renal Function
• Mortality– All-cause mortality– Cardiovascular
• Quality of Life– Overall QoL– Fewer diet restrictions– Less volume restriction– Others (sleep, pain,
perceived disease burden, etc.)
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RKF and Morality in PD
• Effects of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis: ADEMEX, a Prospective, Randomized, Controlled Trial– 965 person, multicenter, prospective, randomized
controlled trial– Follow-up at least 2 years– RCT was to measure mortality with standard PD dose vs.
more intense PD dose with greater pCrCl (peritoneal creatinine clearance)
– Looked at other factors that correlated with mortality, including rCrCl (renal creatinine clearance)
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RKF and Mortality in PD
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RKF and Morality in PD
• The relative importance of residual renal function compared with peritoneal clearance for patient survival and quality of life: An analysis of the Netherlands cooperative study on the adequacy of dialysis (Necosad)-2– 413 person, multicenter, prospective,
observational, cohort study of incident PD patients– Mortality with increased rGFR (renal GFR = RKF) vs.
increased pCrCl (peritoneal creatinine clearance)
NECOSAD-2- Am J Kidney Dis. 2003;41(6):1293- 1302.
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RKF and Mortality in PD
NECOSAD-2- Am J Kidney Dis. 2003;41(6):1293- 1302.
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RKF and Morality in PD
• Relative Contribution of Residual Renal Function and Peritoneal Clearance to Adequacy of Dialysis: A Reanalysis of the CANUSA Study– 680 person, multicenter, prospective cohort study – 2-year follow-up– Reanalysis of data– Mortality with increased rGFR (renal GFR = RKF) vs.
increased pCrCl (peritoneal creatinine clearance) vs. urine output
CANUSA- J Am Soc Nephrol 12: 2158–2162, 2001
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RKF and Morality in PD
CANUSA- J Am Soc Nephrol 12: 2158–2162, 2001
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RKF and Morality in PD
CANUSA- J Am Soc Nephrol 12: 2158–2162, 2001
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RKF and Mortality in HD
• Residual renal function and mortality in hemodialysis patients– 114 person, single center, prospective cohort
study– 2-year follow-up– Mortality in patients with vs without RKF– Residual renal function defined as producing
> 100cc urine / 24 hour urine collection– Patients included all current patients at the
single hemodialysis center who agreed to participate and RFK was assessed at study initiation only Shemin- Am J
Kidney Dis. 2001;38(1):85-90.
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RKF and Mortality in HD
Shemin- Am J Kidney Dis. 2001;38(1):85-90.
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RKF and Mortality in HD
Shemin- Am J Kidney Dis. 2001;38(1):85-90.
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RKF and Mortality in HD
• 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– 740-person, prospective, observational
multicenter cohort study– Incident ESRD patients– Median follow-up 1.7 years
J Am Soc Nephrol 15: 1061–1070, 2004
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RKF and Mortality in HD
Figure 1. The effect of single-pool Kt/Vurea (sp-dKt/Vurea) on mortality by presence of residual renal function (rKt/Vurea = 0 [“anurics’” versus rKt/Vurea >0). The rKt/Vurea and sp-dKt/Vurea were included as time-dependent variables. The relative risks are adjusted for age, Davies’ comorbidity score, primary kidney disease, subjective global assessment, and body mass index.
J Am Soc Nephrol 15: 1061–1070, 2004
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RKF and Mortality in HD
J Am Soc Nephrol 15: 1061–1070, 2004
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RKD and Mortality in Dialysis
Pearl and Bargman, Am J Kidney Dis 53:1068-1081
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Quality of Life (QoL) in PD
NECOSAD-2- Am J Kidney Dis. 2003;41(6):1293- 1302.
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CHOICE STUDY
• 734 patients from 81 clinics nationally• Prospective, observational cohort study• Incident dialysis patients– New onset of long-term dialysis– Baseline at within after initiation of therapy
• Goal: Determine association of urine output with mortality, quality of life, and inflammation in incident HD patients
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Assessment of RKF
• Urine output used as a surrogate for RKF• Questionnaire at baseline and one year– “Do you produce at least one full cup (250cc) of
urine daily?”– Urine output was measured in 42% of patients
and was found to correlate well with reported production of 250cc/day
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Baseline Characteristics of Study
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Baseline Characteristics of Study
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Baseline Characteristics of Study
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All-Cause Mortality
e Clinical and treatment factors in addition to demographic characteristics: smoking history (ever smoked), pulse pressure, body mass index, primary cause of kidney failure (diabetes, hypertension, glomerulonephritis, or other), Index of Coexistent Disease score (0-3), cardiovascular disease, congestive heart failure, left ventricular hypertrophy, diabetes, and serum albumin level (at baseline or year 1).
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All-Cause Mortality
All-cause Mortality by baseline urine output
All-cause Mortality by one-year urine output
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Cardiovascular Mortality
e Clinical and treatment factors in addition to demographic characteristics: smoking history (ever smoked), pulse pressure, body mass index, primary cause of kidney failure (diabetes, hypertension, glomerulonephritis, or other), Index of Coexistent Disease score (0-3), cardiovascular disease, congestive heart failure, left ventricular hypertrophy, diabetes, and serum albumin level (at baseline or year 1).
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Cardiovascular Mortality
Cardiovascular Disease mortality by baseline urine
output
Cardiovascular Disease mortality by one-year urine
output
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Mortality and Change in Urine Output
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Quality of Life (QoL)
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EPO Dose Requirements
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Improvements
• CVD Mortality– Not enough power? Many variables were very
close to statistical significance
• Definition of Residual Renal Function– Subjective urine output of >250cc rather arbitrary.
Maybe we are mislabeling those with ~100 cc urine output/day as not having RKF when they do enjoy its protective effects
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Improvements
• More nit-picking than real concerns– Diuretics shouldn’t increase RKF even though they
do increase urine output (unless volume is the issue!)
– EPO usage was only calculated at baseline and 6 months, much earlier than the study stopped follow-up. Maybe not the best measure of residual endocrine kidney function
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Conclusions
• Residual Renal Function, especially the maintenance of existing residual renal function, has important prognostic value
• Future studies may be useful to assess interventions aimed at preserving residual renal function
• As nephrologists, it is our responsibility to be advocates for the last few cc’s of GFR; they may be the difference between life and death…
• …or certainly a keg-stand and a picnic