© 2010 Revista Nefrología. Official Publication of the Spanish Nephrology Society
Future directions in therapy for chronic kidney disease
ALM de Francisco
Nephrology Department. Valdecilla University Hospital. Santander, Spain
he increasing prevalence of chronic kidney disease is well known, as it is a factthat recorded data in all countries show continuing growth in the number of patients that need substitutive treatment for their renal function. The consequences from the social and economic viewpoint are very significant and we cannot be happy with morbidity and mortality rates in terminal stage renal patients that continue to be unacceptably high.1,2 There are different reasons for such highmortality rates, amongst them significant increase in the age of patients undergoing treatment, restoration with haemodialysis and peritoneal dialysis of only 15 to 20ml/min of kidney function, and a significant associated co-morbidity. Despite the progress made in haemodialysis (membrane biocompatibility, highflow membranes, increase frequency in sessions, water quality control, among others) and inperitoneal dialysis (infection risk reduction, introduction of a dialysis machine, etc.) no clear improvement has been shown in the evolution of patients. Therefore, if so little improvement has been made after so many years, what is in store for the future for renal function replacement? This article aims at highlighting which are the future possibilities to face renal insufficiency, bysubstitutive techniques such as haemodialysis, peritoneal dialysis or kidney transplant (or creation of new organs), as well as the possibility of regression of chronic kidney disease before total loss of renal function.
patients themselves and their families, especially because of their bad quality of life and the need to move over to the dialysis centre three or more times per week. Furthermore, a highmortality rate (similar to metastatic breast cancer, colon or prostate cancer) forces to move on toward applying different techniques. The fact that there is evidence of improvement with frequent and prolonged dialysis in quality of life and anaemia control, hypertension control, hospitalisations, medication reduction (i.e. anti-hypertensive or phosphate binders), appetite improvement, volumecontrol improvement, morbidity and mortality reduction, etc., it all leads research toward types of techniques with continous treatment. It is true that continuous ambulatory peritoneal technique could somehow come closer, as in fact it does, to continous treatment. It has been used for many years in many centres. However, the percentage of patients does not extend beyond 10-15% of those undergoingdialysis and, besides, there is a significant decline as time passes due to loss of ultrafiltration capacity or peritoneum diffusion, which is insufficient in many cases when the residual renal function disappears. The requirements for new technologies in dialysis are, therefore, based on the following objectives: 1. Continuous function. 2. Elimination of molecular weight solutes similar to kidneyfunction. 3. Elimination of water and solutes according to patient’s needs. 4. Biocompatibility. 5. Portable, or even better, implantable. 6. Low cost. 7. Safety. There are currently four possible models that could reach these objectives in the future: HNF (Human Nephron Filter), micro-fluid techniques, WAK (Wearable Artificial Kidney) and RAD (Bioartificial Renal Assist Device).
1HAEMODIALYSIS: PORTABLE OR IMPLANTABLE KIDNEYS As it has been expressed, the situation of patients undergoing haemodialysis means a great sacrifice, overall, both for the
Correspondence: ÁLM de Francisco Servicio de Nefrología. Hospital Universitario Valdecilla. Santander. Spain. email@example.com
Human Nephron Filter (HNF) Nisenson et al.3,4 have proposed this model as an innovation in...