Kidney Dial., Volume 4, Issue 1 (March 2024) – 5 articles

Pregnancy in the dialysing population is an infrequent but increasing event. There is a lack of contemporary guidance regarding the nutritional management of this complex patient group. The aim of this scoping review was to identify, evaluate and summarise the evidence base describing nutritional recommendations for pregnant women receiving dialysis. A systematic search strategy of four databases and the grey literature was conducted. Eligible publications contained reference to recommendations regarding nutrition, supplements, breastfeeding, dietary patterns, and/or weight recommendations for pregnant dialysing women. A total of 136 eligible records were included for synthesis including 66 case reports/case series, 46 reviews, 15 book chapters, 5 editorials, and 4 consensus guidelines/position papers. Recommendations regarding energy, protein, dietary patterns, weight, and vitamin and mineral supplementation were common. However, significant discrepancy across these recommendations was evident. There were limited recommendations regarding other nutrients and breastfeeding. A summary of nutritional recommendations to guide clinical practice was constructed. Pregnancy planning, pre-conception dietetic counselling, interprofessional education, and the guidance synthesised in this review could be utilised by clinicians to improve clinical management and optimise outcomes in these patients. Future research should explore the experiences and perspectives of pregnant dialysing women, investigate nutrient losses during intensive dialysis, and evaluate postpartum follow-up. Full article

A perturbation in the water balance rather than any change in salt content is the main cause of hyponatremia, the most frequent electrolyte abnormality, defined as a serum sodium concentration <135 mEq/L. Hyponatremia may be divided between mild (Na > 120 mEq/L) or severe (Na < 120 mEq/L) hyponatremia, and is most frequently observed in elderly ICU hospitalized patients. Based on tonicity, hyponatremia may be hypotonic (a decreased concentration of the solute), isotonic, and hypertonic (falsely low sodium). According to the volume of extracellular fluid (ECF), hyponatremia is further divided among hypovolemic, euvolemic, or hypervolemic hyponatremia. Finally, hyponatremia may develop rapidly as acute (<48 h), usually with severe symptoms, or slowly as chronic hyponatremia, usually being asymptomatic or with mild symptoms. Acute severe hyponatremia presents with severe CNS problems, increased hospitalization rates, and mortality. The treatment with 3% sodium chloride and a 100 mL IV bolus based on severity and persistence of symptoms needs careful monitoring. A non-severe hyponatremia may be treated with oral urea. In asymptomatic mild hyponatremia, an adequate solute intake with an initial fluid restriction of 500 mL/d adjusted according to the serum sodium levels is preferred. Vaptans could be considered in patients with high ADH activity regardless of whether they are euvolemic or hypervolemic. In general, the treatment of hyponatremia should be based on the underlying cause, the duration and degree of hyponatremia, the observed symptoms, and volume status of patient. Full article

Conventional hemodialysis (HD) (a 4 h session three times a week) is not appropriate for everyone and is excessive in the presence of substantial residual kidney function (RKF). However, it can be safely replaced by a softer incremental approach guided by the urea kinetic model (UKM), starting with one or two sessions a week. Observational data suggest that RKF may be lost less quickly if dialysis is initiated less frequently than 3 times a week. Incremental HD means that, in the presence of substantial RKF, kidney replacement therapy can begin with low doses and/or frequencies, which, however, must be adequately increased to compensate for any subsequent losses of RKF, keeping the total clearance level (kidney + dialysis) always above the minimum levels of adequacy. In HD, there are complexities in combining the dialysis dose with RKF, but tools have been developed to facilitate this issue. The literature findings lend support to the safety of incremental HD and highlight the potential for this method to be implemented as a new standard of care in dialysis patients with substantial RKF. Ongoing and future trials will likely generate further evidence of the clinical and healthcare benefits of incremental HD in routine practice. Full article

Urgent-start peritoneal dialysis (USPD) is defined as peritoneal dialysis initiated within 14 days of catheter insertion. In this review, the authors describe the most recent data on USPD, including outcomes, complications, barriers to implementation, and areas for future research. Outcomes appear similar between catheter insertion techniques, so patient factors and institutional workflow should guide practice. Mechanical complications may occur at a higher rate in USPD, but it does not impact technique survival or mortality. Infectious complications appear unchanged in USPD, and there may be fewer complications compared to urgent-start hemodialysis. Barriers to implementation are multifactorial, including physician and staff unfamiliarity and lack of institutional support. A significant limitation within the field includes lack of uniform terminology and definitions. Full article

Magnesium is an essential element with a pleiotropic role in human biology. Despite tight intestinal and renal regulation of its balance, insufficient intake can finally result in hypomagnesemia, which is a proxy of intracellular deficiency. Conditions such as diabetes, cancer, and infections are often associated with hypomagnesemia, which mostly predicts an unfavorable outcome. The effects of hypomagnesemia can either be direct and include neurological and cardiovascular symptoms or indirect, taking a mechanistic role in inflammation, endothelial dysfunction, and oxidative stress. The indication for intravenous magnesium as a treatment of torsades de pointes and pre-eclampsia is unrefuted, but new indications of peroral or intravenous supplementation, albeit with less supporting evidence, have emerged suggesting, respectively, an attenuation of vascular calcification in chronic kidney disease and improved rate control in atrial fibrillation. Other potential beneficial properties of magnesium, which were claimed by observational data, such as lipid lowering and renal protection, were not, or only partially, investigated in randomized controlled trials. Thus, the role of peroral supplementation of mild chronic asymptomatic hypomagnesemia should be separated from the more targeted prescription of magnesium in specific study populations. (Severe) hypermagnesemia is potentially life-threatening and occurs almost uniformly in subjects with severe renal failure exposed to either supplements or to magnesium-containing cathartics or antacids. Moderate hypermagnesemia is very common in pre-eclamptic women treated with intravenous magnesium. For most (but not all) studied endpoints, mild hypermagnesemia yields a survival benefit. Long-lasting concerns about the potential negative effects of mild hypermagnesemia on bone physiology and structure have so far not been unequivocally demonstrated to be troublesome. Full article