In the Thursday November 13th session “Are We Missing the Achilles Heel in Hemodialysis Survival?”, Dr. Anthony Bleyer presented an interesting discussion of the measures that can used to preserve residual kidney function (RKF) in a talk entitled “It is Good to the Last Drop: How to Preserve Residual Kidney Function in ESRD Patients”.  Dr. Bleyer began by reinforcing the idea that the rates of RKF decline are slower with PD in comparison with HD, a frequently observed phenomena that, in part, has led to suggestions that PD First should be a more widely adopted approach with patients who require renal replacement therapy.

Dr. Bleyer, however, goes further in suggesting that the more rapid decline in RKF observed in HD patients may not be inevitable and that a number of therapeutic interventions could slow the rate of this decline.  Specifically, he argued that avoidance of intradialytic (and post-dialytic) hypotension might be an effective measure to prevent this decline, particularly in incident HD patients during the first 3 months of HD during which the most rapid decline in RKF is observed.

Secondly, he advocated for more regular use of loop diuretics (with augmentation by thiazide diuretics as needed) to increase urine output between HD sessions and thus lessen intra-dialytic weight gain and accordingly the rate of ultrafiltration.  He highlighted data from DOPPS that the USA has one of the lowest rates of diuretic use in HD patients when compared with the other nations included in DOPPS, suggesting there is room for improvement.

Dr. Bleyer also highlighted the evidence for the use of angiotensin blockade to preserve RKF, a practice which is done for most PD patients but probably not as universally in HD patients, as well as possibly for calcium channel blockade.  He similarly advocates for avoidance of nephrotoxic agents such as aminoglycosides and IV contrast in HD patients with RKF in a manner analogous to the caution utilized in PD patients with RKF.

Overall the talk heightened awareness of the numerous benefits of RKF and emphasized for the nephrology community the importance of preserving this with equal fervor in HD patients as with PD patients.

Post written by Dr. Craig Gordon, eAJKD Contributor.

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