How can we advance in renal replacement therapy techniques? / ¿Cómo podemos progresar en las técnicas de sustitución de la función renal?

End-Stage Renal Disease (ESRD) is one of the major causes of morbidity and mortality worldwide. Although the incidence of ESRD is relatively stable, the prevalence of maintenance dialysis is increasing, and it is expected to reach a staggering 5439 million patients worldwide by 2030. Despite the great technological evolution that has taken place in recent years, most patients are still treated with in-centre haemodialysis and their prognosis remains far from desirable. Since 1980, there has been an increasing interest in the development of a portable device for renal replacement therapy (RRT), which ultimately led to the creation of the Wearable Artificial Kidney (WAK) and the Wearable Ultrafiltration (WUF) system. Portable RRT devices may be acceptable alternatives that deal with several unmet clinical needs of ESRD patients. So far, 3 important human studies with WAK and WUF have been carried out and, although these devices require considerable technological improvement, their safety and efficacy in solute clearance and fluid removal is undeniable. In this article, we review the evolution of the WAK and the WUF and the main clinical trials performed, highlighting some of their technical features. Some of the main possible clinical advantages that could be achieved with these devices, as well as some economic aspects, are also pointed out. In the future, all renal replacement therapy techniques should evolve to perfectly match the clinical and personal needs of each patient, allowing for an improved health-related quality of life

La enfermedad renal crónica terminal (ERCT) es una de las principales causas de morbimortalidad mundial. Aunque la incidencia de esta enfermedad es relativamente estable, la prevalencia en diálisis está aumentando, y se espera que llegue a la cifra de 5.439 millones de pacientes en todo el mundo en el año 2030. A pesar de la gran evolución tecnológica ocurrida en los últimos años, la mayoría de los pacientes continúan siendo tratados con hemodiálisis, y su pronóstico queda lejos de lo deseable. Desde 1980, existe un interés creciente en el desarrollo de dispositivos portátiles para la terapia de sustitución de la función renal (TSFR), y que llevaron a la creación del Wearable Artificial Kidney (WAK) y del Wearable Ultrafiltration (WUF) system. Estos pueden ser alternativas aceptables que permiten alcanzar las necesidades de los pacientes con ERCT, que hasta ahora no se han alcanzado. A pesar de que estos dispositivos necesitan mejoras tecnológicas, su seguridad y eficacia en el aclaramiento de solutos y la eliminación de fluidos es innegable. Revisamos la evolución del WAK y del WUF, y los principales ensayos clínicos desarrollados, destacando algunas de sus particularidades tecnológicas. Adicionalmente, señalamos algunas de las posibles ventajas clínicas que podrían ser alcanzadas con estos dispositivos, así como algunos aspectos económicos. En el futuro, todas las TSFR deben evolucionar para satisfacer todas las necesidades clínicas y personales de cada paciente, permitiendo una mejor calidad de vida relacionada con la salud

Wearable artificial kidney and wearable ultrafiltration device vascular access-future directions.

BACKGROUND: Since 2005, three human clinical trials have been performed with the Wearable Artificial Kidney (WAK) and Wearable Ultrafiltration (WUF) device. The lack of an adequate vascular access (VA) has been pointed out as the main limitation to their implementation. Based on the current level of understanding, we will make the first conceptual proposal of an adequate VA suitable for the WAK and the WUF. METHODS: All the literature related to WAK and WUF was reviewed. Based on eight main publications the VA major characteristics were defined: a mean blood flow of 100 mL/min; the capability to allow prolonged and frequent dialysis treatments, without interfering in activities of daily living (ADL); safe and convenient connection/disconnection systems; reduced risk of biofilm formation and coagulation; high biocompatibility. A research was done in order to answer to each necessary technological prerequisites. RESULTS: The use of a device similar to a CVC with a 5Fr lumen, seems to be the most feasible option. Totally subcutaneous port devices, like the LifeSite(R) or Dialock (R) systems can be a solution to allow WAK or WUF to operate continuously while patients carry out their ADL. Recently, macromolecules that reduce the risk of thrombosis and infection and are integrated into a CVC have been developed and have the capability of overcoming these major limitations. CONCLUSION: With an adequate VA, portable HD devices can be acceptable options to address several unmet clinical needs of HD patients.

Healthcare systems and chronic kidney disease: putting the patient in control.

Today, health policy seems to be on the top of governments' agendas around the world. Healthcare systems are challenged by a number of phenomena happening on a global scale; these trends include demographic change in terms of an ageing population, an increase in chronic disease, patients having higher expectations on healthcare delivery and above all a major pressure on public finances to slow increasing healthcare expenditures. Such developments are forcing policy-makers to reform healthcare systems. First, there is a tendency towards decentralization of responsibilities. Second, governments are moving towards reimbursement schemes rewarding good outcomes and performance. Third, great importance is being attributed to transparency and accountability, and to introduce competition in healthcare. Fourth, attention is being shifted from simple treatment of a disease towards preventive initiatives, in a more holistic approach to health. Finally, healthcare policy-makers are recognizing the importance of empowering patients to give them control over decisions regarding their own health. These dynamics can be observed in chronic kidney disease, the management of which is a huge economic burden to healthcare systems globally, and which represents a good example of a field where important changes can be witnessed in therapy, technology, delivery and financing.