Personal Daily Dialysis: The Evolution of the Artificial Kidney

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Abstract

To improve hemodialysis (HD) patients' clinical tolerance and quality of life, a new paradigm of technological evolution of the artificial kidney needs to be addressed at this point. Compared to the second law of thermodynamics, if HD is a barrier against entropy increase, personal daily dialysis (PDD), taking account of multidimensional treatment parameters specific to the patient, can be a new treatment option. Here, we review currently used HD equipment and competing technologies of the wearable artificial kidney (WAK) for future application to PDD. Biofeedback control during HD personalizes treatment parameters such as blood volume changes, thermal energy balance and biochemical variables in well-defined ranges and tries to deliver the targeted treatment dose without intradialytic hypotension. Miniaturized devices such as WAK could also meet the needs of patients by providing mobility, the possibility of normal social activities and flexibility of treatment schedule. So far, many studies have shown the future direction of renal replacement therapy for chronic patients: personalization and daily treatment. PDD might require a new index including a biological plan for recovery of homeostasis and a strategy toward long-term rehabilitation of the patient. The concept of entropy includes these multidimensional factors, and the artificial kidney should be evolved to minimize the increase in entropy of the patient.

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Most cited references 13

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A wearable haemodialysis device for patients with end-stage renal failure: a pilot study.

Masoud Beizai, Andrew Davenport, Claudio Ronco … (2007)

More frequent haemodialysis can improve both survival and quality of life of patients with chronic kidney disease. However, there is little capacity in the UK to allow patients to have more frequent haemodialysis treatments in hospital and satellite haemodialysis units. New means of delivering haemodialysis are therefore required. Our aim was to assess the safety and efficiency of a wearable haemodialysis device. Eight patients with end-stage kidney failure (five men, three women, mean age 51.7 [SD 13.8] years) who were established on regular haemodialysis were fitted with a wearable haemodialysis device for 4-8 h. Patients were given unfractionated heparin for anticoagulation, as they would be for standard haemodialysis. There were no important cardiovascular changes and no adverse changes in serum electrolytes or acid-base balance. There was no evidence of clinically significant haemolysis in any patient. Mean blood flow was 58.6 (SD 11.7) mL/min, with a dialysate flow of 47.1 (7.8) mL/min. The mean plasma urea clearance rate was 22.7 (5.2) mL/min and the mean plasma creatinine clearance rate was 20.7 (4.8) mL/min. Clotting of the vascular access occurred in two patients when the dose of heparin was decreased and the partial thromboplastin time returned towards the normal reference range in both of these patients. The fistula needle became dislodged in one patient, but safety mechanisms prevented blood loss, the needle was replaced, and treatment continued. This wearable haemodialysis device shows promising safety and efficacy results, although further studies will be necessary to confirm these results.

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The effects of control of thermal balance on vascular stability in hemodialysis patients: results of the European randomized clinical trial.

Pedro Ponce, G Panzetta-Dutari, Antonio Santoro … (2002)

Many reports note that the use of cool dialysate has a protective effect on blood pressure during hemodialysis (HD) treatments. However, formal clinical trials in which dialysate temperature is tailored to the body temperature of appropriately selected hypotension-prone patients are lacking. We investigated the effect of thermal control of dialysate on hemodynamic stability in hypotension-prone patients selected from 27 centers in nine European countries. Patients were eligible for the study if they had symptomatic hypotensive episodes in 25% or more of their HD sessions, assessed during a prospective screening phase over 1 month. The study is designed as a randomized crossover trial with two phases and two treatment arms, each phase lasting 4 weeks. We used a device allowing the regulation of thermal balance (Blood Temperature Monitor; Fresenius Medical Care, Bad Homberg, Germany), by which we compared a procedure aimed at preventing any transfer of thermal energy between dialysate and extracorporeal blood (thermoneutral dialysis) with a procedure aimed at keeping body temperature unchanged (isothermic dialysis). One hundred sixteen HD patients were enrolled, and 95 patients completed the study. During thermoneutral dialysis (energy flow rate: DeltaE = -0.22 +/- 0.29 kJ/kg x h), 6 of 12 treatments (median) were complicated by hypotension, whereas during isothermic dialysis (energy flow rate: DeltaE = -0.90 +/- 0.35 kJ/kg x h), the median decreased to 3 of 12 treatments (P < 0.001). Systolic and diastolic blood pressures and heart rate were more stable during the latter procedure. Isothermic dialysis was well tolerated by patients. Results show that active control of body temperature can significantly improve intradialytic tolerance in hypotension-prone patients. Copyright 2002 by the National Kidney Foundation, Inc.

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Daily hemodialysis: a systematic review.

Gihad E Nesrallah, Rajesh R Mainra, Timothy Lindsay … (2005)

Several studies have reported improved outcomes with daily hemodialysis (DHD), but the strength of this evidence has not been evaluated. The published evidence on DHD was synthesized and its quality rated to inform need and sample size calculations for a randomized trial. Citations were identified in MEDLINE and EMBASE using validated search strategies. Dialysis journals that were not indexed and bibliographies of relevant articles were hand-searched. Two authors reviewed all citations. Articles that reported original data on five or more adults who were receiving DHD (1.5 to 3 h, 5 to 7 d/wk) for > or = 3 mo were included. Twenty-five articles reporting 14 unique populations with 268 patients (five to 72 per study) met inclusion criteria. Of the 14 cohorts, 13 were studied with an observational design, 10 were studied prospectively, and four had parallel control groups. Mean age ranged form 41 to 64 yr, mean time on dialysis was 2 to 11 yr, 0 to 28% of patients had diabetes, > 90% had arteriovenous fistulae, and > 50% were dialyzed at home. Most data were described at < or = 12 mo of follow-up. Outcomes included quality of life, cardiovascular disease, erythropoiesis, nutritional status, hospitalizations, and vascular access failures. Reporting was too heterogeneous to allow pooling of data. Ten of 11 studies suggested improvements in blood pressure; findings for other outcomes varied. Discontinuation of DHD occurred in 0 to 57% in-center and 0 to 15% home patients. Studies of DHD are limited by small sample size, nonideal control groups, selection and dropout biases, and paucity of data on potential risks. Randomized trials with adequate statistical power are required to establish the efficacy and the safety of DHD.

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Author and article information

Journal

Journal ID (publisher-id): BPU

Journal ID (nlm-ta): Blood Purif

Journal ID (doi): 10.1159/issn.0253-5068

Title: Blood Purification

Publisher: S. Karger AG

ISBN: 978-3-318-02428-9

ISBN: 978-3-318-02429-6

ISSN (Print): 0253-5068

ISSN (Electronic): 1421-9735

Publication date Subscription-year: 2013

Publication date (Print): June 2013

Publication date (Electronic): 25 May 2013

Volume: 36

Issue: 1

Pages: 47-51

Affiliations

Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute, St. Bortolo Hospital, Vicenza, Italy

Author notes

*Claudio Ronco, MD, Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute, St. Bortolo Hospital, Viale Rodolfi 37, IT-36100 Vicenza (Italy), E-Mail cronco@goldnet.it

Article

Publisher ID: 350586 Other ID: Blood Purif 2013;36:47-51

DOI: 10.1159/000350586

PubMed ID: 23735654

SO-VID: 5a6dcf5e-388d-4be2-93cc-263c30b7e44a

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

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Personal Daily Dialysis: The Evolution of the Artificial Kidney

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Abstract

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Karger: Nephrology

Most cited references 13

A wearable haemodialysis device for patients with end-stage renal failure: a pilot study.

The effects of control of thermal balance on vascular stability in hemodialysis patients: results of the European randomized clinical trial.

Daily hemodialysis: a systematic review.

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