RESUMEN
Residual kidney function (RKF) has been associated with better survival, less morbidity, and improved quality of life in peritoneal dialysis (PD) patients. Since higher peritoneal clearance does not lead to better outcomes, more emphasis should be put on preserving kidney function. Many other benefits have been reported, including better volume and blood pressure control, better nutritional status, lower rates of PD peritonitis, preserved erythropoietin and vitamin D production, middle molecule clearance, lower Left Ventricular Hypertrophy, and better serum phosphate level. The most practical method of assessing RKF is the mean of 24-h urinary urea and creatinine clearance. Incremental PD prescription is an ideal option to supplement RKF in PD patients, which also offers more flexibility to the patient and, possibly, improved adherence. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be used when possible in PD patients to preserve RKF. Loop diuretics are underutilized in PD patients despite providing an additional means of maintaining fluid balance and reducing the need for higher glucose-containing PD solutions. In this paper, we outline the importance of RKF in PD patients and the different strategies for its preservation.
RESUMEN
SGLT2 inhibitors have emerged as a key disease-modifying therapy to prevent the progression of chronic kidney disease (CKD). These agents prevent decline in kidney function through reduction in glomerular hypertension mediated through tubuloglomerular feedback independent of their effect on glycemic control. The proliferation of clinical trials on SGLT2 inhibitors has rapidly expanded the approved clinical indications for these agents beyond patients with diabetes mellitus (DM). We review the current indications for SGLT2 inhibitors in patients with and without diabetic kidney disease, including new evidence for use in patients with heart failure with or without reduced ejection fraction, stage 4 CKD, and chronic glomerulonephritis. The EMPA-KIDNEY trial was recently stopped early for efficacy suggesting that SGLT2 inhibitors may soon be indicated for patients with CKD without albuminuria. We review practical considerations for prescription of SGLT2 inhibitors, including the anticipated acute decline in estimated glomerular filtration rate (eGFR) on initiation, initiating the lowest dosage used in clinical trials, volume status considerations, and adverse event mitigation. Combination therapy in patients with DM may be considered with agents, including glucagon-like peptide-1 receptor agonists (GLP-1-RAs), novel mineralocorticoid receptor antagonists, and selective endothelin receptor antagonists to reduce residual albuminuria and cardiovascular risk.