1
|
Usui N, Nakata J, Uehata A, Kojima S, Saitoh M, Chiba Y, Ando S, Inatsu A, Hisadome H, Ota S, Suzuki Y. Comparison of intradialytic continuous and interval training on hemodynamics and dialysis adequacy: A crossover randomized controlled trial. Nephrology (Carlton) 2024; 29:214-221. [PMID: 37986674 DOI: 10.1111/nep.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/17/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
AIM Circulating blood volume (BV) during exercise changes depending on the intensity and duration, and post-exercise hypotension is observed after continuous exercise. We investigated the safety and efficacy of both interval and continuous IDE at anaerobic threshold (AT) levels with respect to hemodynamic stability and dialysis efficiency. METHODS In this crossover randomized controlled trial, 16 patients on haemodialysis were subjected to three trial arms, including non-IDE, interval-IDE, and continuous-IDE arms. Systolic blood pressure (SBP), BV, and ultraviolet absorbance - an indicator of dialysis efficiency - were continuously measured, and each change was compared between the three arms by two-way analysis of variance. RESULTS Continuous IDE decreased SBP from post-exercise to the end of dialysis compared with baseline (pre 142.8 ± 19.0 vs. post 127.5 ± 24.5 mmHg, p = .02), whereas interval IDE maintained better SBP levels post-exercise (pre 139.9 ± 17.1 vs. post 140.1 ± 15.8 mmHg, p = 1.0) than continuous IDE (non-IDE 133.2 ± 19.9 vs. interval 140.1 ± 15.8 vs. continuous 127.5 ± 24.5 mmHg, p = .04). Moreover, interval IDE caused less tiredness and few symptoms (p < .05), despite reaching higher intensity than continuous IDE (p = .001). The BV of each IDE arm decreased during exercise and recovered post-exercise to the same level as non-IDE. Ultraviolet absorbance was not different between each arm (p = .16). CONCLUSION AT-level interval IDE maintains better hemodynamic stability from post-exercise to the end of dialysis and may represent a novel approach that can be effectively performed with fewer symptoms.
Collapse
Affiliation(s)
- Naoto Usui
- Department of Rehabilitation, Kisen Hospital, Tokyo, Japan
- Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Junichiro Nakata
- Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Akimi Uehata
- Division of Cardiology, Kisen Hospital, Tokyo, Japan
| | - Sho Kojima
- Department of Rehabilitation, Kisen Hospital, Tokyo, Japan
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Masakazu Saitoh
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Yasuo Chiba
- Department of Clinical Engineering, Kisen Hospital, Tokyo, Japan
| | - Shuji Ando
- Department of Information Sciences, Tokyo University of Science, Chiba, Japan
| | | | | | | | - Yusuke Suzuki
- Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| |
Collapse
|
2
|
Lima CM, Goldenstein PT, dos Reis LM, Jorgetti V, Elias RM, Moysés RM. Factors Associated with Intradialytic Phosphate Removal in Hemodialysis Patients before and after Parathyroidectomy. Clin J Am Soc Nephrol 2023; 18:1346-1348. [PMID: 37227935 PMCID: PMC10578619 DOI: 10.2215/cjn.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Carolina M. Lima
- Laboratório de Fisiopatologia Renal, LIM 16, Nephrology Division, Faculdade de Medicina da USP, São Paulo, Brazil
| | - Patrícia T. Goldenstein
- Laboratório de Fisiopatologia Renal, LIM 16, Nephrology Division, Faculdade de Medicina da USP, São Paulo, Brazil
| | - Luciene M. dos Reis
- Laboratório de Fisiopatologia Renal, LIM 16, Nephrology Division, Faculdade de Medicina da USP, São Paulo, Brazil
| | - Vanda Jorgetti
- Laboratório de Fisiopatologia Renal, LIM 16, Nephrology Division, Faculdade de Medicina da USP, São Paulo, Brazil
| | - Rosilene M. Elias
- Laboratório de Fisiopatologia Renal, LIM 16, Nephrology Division, Faculdade de Medicina da USP, São Paulo, Brazil
- Universidade Nove de Julho, São Paulo, Brazil
| | - Rosa M.A. Moysés
- Laboratório de Fisiopatologia Renal, LIM 16, Nephrology Division, Faculdade de Medicina da USP, São Paulo, Brazil
| |
Collapse
|
3
|
Barreto J, Borges C, Rodrigues TB, Jesus DC, Campos-Staffico AM, Nadruz W, Luiz da Costa J, Bueno de Oliveira R, Sposito AC. Pharmacokinetic Properties of Dapagliflozin in Hemodialysis and Peritoneal Dialysis Patients. Clin J Am Soc Nephrol 2023; 18:1051-1058. [PMID: 37227937 PMCID: PMC10564347 DOI: 10.2215/cjn.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors attenuate incident cardiovascular outcomes, irrespective of baseline GFR, in conservatively managed CKD. As this condition inexorably progresses to demanding KRT, drug withdrawal is supported by the current lack of evidence of safety of SGLT2 inhibitors in dialysis. METHODS This study was a prospective, single-center, open-label trial ( ClinicalTrials.gov identifier: NCT05343078 ) aimed at assessing the pharmacokinetic properties and safety of dapagliflozin in patients with kidney failure on regular dialysis regimens compared with those with type 2 diabetes and age- and sex-matched controls with normal kidney function. Peripheral blood samples were collected from both groups every 30 minutes for 4 hours and again after 48 hours after ingestion of dapagliflozin 10 mg, which occurred immediately before dialysis session initiation in the kidney failure group. This protocol occurred in drug-naïve patients and again after six daily doses of dapagliflozin to assess whether the drug had accumulated. The plasma and dialysate levels of dapagliflozin at each time point were determined by liquid chromatography and used to calculate pharmacokinetics parameters (peak concentration [C max ] and area under the plasma concentration-versus-time curve) for each participant. RESULTS Dapagliflozin C max was 117 and 97.6 ng/ml in the kidney failure and control groups, respectively, whereas the corresponding accumulation ratios were 26.7% and 9.5%. No serious adverse events were reported for either group. Dapagliflozin recovered from dialysate corresponded to 0.10% of the administered dose. CONCLUSIONS In patients with kidney failure on dialysis, dapagliflozin was well tolerated, was slightly dialyzable, and had nonaccumulating pharmacokinetic properties. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Pharmacokinetics and Dialyzability of Dapagliflozin in Dialysis Patients (DARE-ESKD 1), NCT05343078.
Collapse
Affiliation(s)
- Joaquim Barreto
- Laboratory of Atherosclerosis and Vascular Biology (Aterolab), Cardiology Division, University of Campinas (Unicamp), Campinas, Brazil
| | - Cynthia Borges
- Laboratory for Evaluation of Mineral and Bone Disorders in Nephrology (LEMON), Nephrology Division, University of Campinas (Unicamp), Campinas, Brazil
| | - Tais Betoni Rodrigues
- Campinas Poison Control Center (CIATOX), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Daniel C. Jesus
- Laboratory of Atherosclerosis and Vascular Biology (Aterolab), Cardiology Division, University of Campinas (Unicamp), Campinas, Brazil
| | | | - Wilson Nadruz
- Cardiology Division, Clinics Hospital, University of Campinas (Unicamp), Campinas, Brazil
| | - Jose Luiz da Costa
- Campinas Poison Control Center (CIATOX), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
- Faculty of Pharmaceutical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Rodrigo Bueno de Oliveira
- Laboratory for Evaluation of Mineral and Bone Disorders in Nephrology (LEMON), Nephrology Division, University of Campinas (Unicamp), Campinas, Brazil
| | - Andrei C. Sposito
- Laboratory of Atherosclerosis and Vascular Biology (Aterolab), Cardiology Division, University of Campinas (Unicamp), Campinas, Brazil
| |
Collapse
|
4
|
Kameshwar K, Damasiewicz MJ, Polkinghorne KR, Kerr PG. A pilot study comparing the efficiency of a novel asymmetric cellulose triacetate (ATA) dialyser membrane (Solacea-190H) to a standard high flux polysulfone dialyser membrane (FX-80) in the setting of extended hours haemodialysis. Nephrology (Carlton) 2022; 27:494-500. [PMID: 35195932 PMCID: PMC9314010 DOI: 10.1111/nep.14030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 11/29/2022]
Abstract
Aim To compare small, middle and large‐middle molecule clearance; and expression of markers of inflammation, between Solacea‐190H (asymmetric cellulose triacetate [ATA]) and FX‐80 dialysers in long‐hour haemodialysis patients. Methods This pilot, randomized cross‐over trial recruited 10 home haemodialysis patients. The total study duration was 8 weeks, using each dialyser for 4 weeks. Removal of small (urea, phosphate, creatinine and indoxyl sulfate [IS]), middle and large‐middle molecules (beta‐2 microglobulin [β2M], albumin), markers of inflammation (interleukin‐6 [IL‐6], malondialdehyde‐modified low density lipoprotein [MDA‐LDL] and alpha‐1 microglobulin [α1M]), was evaluated in serum and dialysate samples. Results Reduction ratios [RR] were calculated for variables at the fourth week of each dialyzer sequence and results expressed as difference in mean RR between dialyzers. There was no difference in clearance of small molecules, with difference in mean RR for urea −2.43 (95% CI ‐6.44, 1.57; p = .19), creatinine −1.82 (95% CI ‐5.50, 1.85; p = .28) and phosphate −2.61 (95% CI −12.45, 7.23; p = .55); clearance of middle and large‐middle molecules with difference in mean RR (range) for β2M 2.2 (95% CI −3.2, 7.7; p = .35), IS 1.8 (95% CI −9.5, 13; p = .72) and albumin −0.6 (95% CI −5.5, 4.2; p = .77). There was lack of induction of markers of inflammation, including IL‐6 15.2 (95% CI −31.9, 62.2; p = .47), MDA‐LDL −8.1 (95% CI ‐22.1, 5.8; p = .21) and α1M −3.50 (95% CI −29.2, 22.2; p = .76). Dialysate removal results were concurrent. Conclusion This study showed no difference in clearance of small, middle and large‐middle molecules, nor expression of markers of inflammation between dialysers. This pilot cross‐over randomized controlled trial compares small, middle and large‐middle molecule clearance between Solacea‐190H (asymmetric cellulose triacetate [ATA]) and FX‐80 dialysers in 10 patients using long‐hour haemodialysis over an 8‐week period, and showed no difference in clearance between the two dialysers.
Collapse
Affiliation(s)
- Kamya Kameshwar
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Matthew J Damasiewicz
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
5
|
Effect of blood volume change related to intensity of intradialytic aerobic exercise on hemodialysis adequacy: a pilot study. Int Urol Nephrol 2021; 54:1427-1434. [PMID: 34665412 DOI: 10.1007/s11255-021-03038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intradialytic exercise may improve dialysis efficiency; however, the association between changes in blood volume (BV) related to exercise intensity and solute removal kinetics remains unknown. We herein investigated the relationship between changes in BV with exercise and removal of solute molecules during hemodialysis. METHODS Each of the 21 hemodialysis patients underwent cardiopulmonary exercise test to measure anaerobic threshold (AT). According to the exercise intensity, patients were classified into two groups, the low group (n = 12), whose intensity was below the AT, and the high group (n = 9), whose intensity was at the AT level. Each patient completed two trial arms of resting and discontinuous exercise dialysis sessions in a randomized manner. RESULTS The change in BV with the exercise dialysis session in the high group decreased during exercise (p = 0.028) and remained decreased after exercise (p = 0.016), compared with the low group. In the low group, compared with routine sessions, the removal of potassium (p = 0.030), phosphate (p = 0.024), and urea nitrogen (p = 0.065) increased during exercise, but the total removal of these solutes did not change. In the high group, the removal of phosphate (p < 0.001) and urea nitrogen (p = 0.018) after exercise and even total phosphate (p = 0.027) decreased. CONCLUSION These findings suggest that the removal of small solute molecules is improved during exercise in intradialytic low-intensity exercise with no change in BV, and decreased after exercise in high-intensity exercise with a decrease in BV. CLINICAL TRIALS REGISTRY Trial retrospectively registered at the UMIN Clinical Trials Registry: study number UMIN000038629 (Registration date: September 7, 2019).
Collapse
|
6
|
Bi X, Zhang Q, Zhuang F, Lu W, Wang Y, Ding F. An Observational Cohort Study of the 2-Month Use of Regional Citrate Anticoagulation in Maintenance Hemodialysis Patients with Cerebral Hemorrhage. Med Sci Monit 2021; 27:e930513. [PMID: 33859156 PMCID: PMC8056873 DOI: 10.12659/msm.930513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Regional citrate anticoagulation (RCA) is a recommended anticoagulation alternative for patients at high risk of bleeding while undergoing intermittent hemodialysis. Previous reports implied the risk of citrate application on bone metabolism. It is unclear whether long-term use of RCA is safe for maintenance hemodialysis patients in terms of bone metabolism. Material/Methods Seven patients with cerebral hemorrhage were included in the study. Blood samples were collected at baseline and 4 and 8 weeks after treatment. Spent dialysate samples were collected during each mid-week dialysis session, using the partial dialysate collection method. All patients were treated with RCA for 4 to 8 weeks, according to their clinical condition. We assessed bone metabolism-associated parameters, bone turnover markers, and magnesium loss at each dialysis session. Results Serum magnesium levels were 1.24±0.13 mmol/L at baseline and significantly decreased to 1.16±0.14 mmol/L after 4 weeks of RCA treatment (P=0.025). Most patients had negative magnesium balance during citrate hemodialysis. Serum total calcium levels did not change significantly after treatment. One bone marker, N-terminal propeptide of type I procollagen (PINP), significantly decreased from 146.07±130.12 mmol/L to 92.42±79.01 mmol/L after citrate treatment (P=0.018). No significant changes were detected in other bone turnover markers. Conclusions Relatively long-term RCA treatment may decrease serum magnesium levels due to negative magnesium balance. Bone formation marker PINP seemed to decrease after treatment, while other bone turnover markers did not change significantly. Further investigation is needed to verify the effect of RCA on bone remodeling.
Collapse
Affiliation(s)
- Xiao Bi
- Division of Nephrology and Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China (mainland)
| | - Qi Zhang
- Division of Nephrology and Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China (mainland)
| | - Feng Zhuang
- Division of Nephrology and Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China (mainland)
| | - Wei Lu
- Division of Nephrology and Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China (mainland)
| | - Yingdeng Wang
- Division of Nephrology and Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China (mainland)
| | - Feng Ding
- Division of Nephrology and Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China (mainland)
| |
Collapse
|
7
|
Schwotzer N, Kanemitsu M, Kissling S, Darioli R, Benghezal M, Rezzi S, Burnier M, Pruijm M. Water-Soluble Vitamin Levels and Supplementation in Chronic Online Hemodiafiltration Patients. Kidney Int Rep 2020; 5:2160-2167. [PMID: 33305108 PMCID: PMC7710883 DOI: 10.1016/j.ekir.2020.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Supplementation of water-soluble vitamins is a common practice in hemodialysis patients, but dosages are largely based on conventional hemodialysis techniques. The aim of this study was to assess the status of water-soluble vitamins in patients on hemodiafiltration (HDF), and attempt to determine optimal dose of vitamin supplements. Methods This monocentric study included 40 patients on thrice-weekly chronic HDF. At baseline, all patients received 2 tablets of Dialvit containing B and C vitamins after each dialysis session. Predialysis samples of B and C vitamins were measured in both blood (n = 40) and a subgroup of dialysate (n = 6) samples. A second blood sample was obtained in 24 patients 3 months after dose adjustment of the vitamin supplement. Results At baseline, B-vitamin levels were high with, respectively, 0.4%, 10.0%, and 89.6% of patients in the low, normal, and high reference range. For vitamin C, most patients were in the normal range (5.0%, 82.5%, and 12.5% in low, normal, and high reference range). Three months after dose reduction, B vitamin levels decreased but stayed mostly at or above the normal range (1.4%, 25.7%, 72.9% in low, normal, and high reference range). Three patients (12.5%) developed vitamin C deficiency on low-dose substititon. Conclusion This study shows that the levels of most vitamins are above the normal range in patients on HDF receiving a classic dose of vitamin supplements, vitamin C excepted. Our study suggests that the classic dose of postdialysis vitamin B supplements may be reduced.
Collapse
Affiliation(s)
- Nora Schwotzer
- Service of Nephrology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michiko Kanemitsu
- Service of Nephrology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sebastien Kissling
- Service of Nephrology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | | | - Serge Rezzi
- Swiss Vitamin Institute, Epalinges, Switzerland
| | - Michel Burnier
- Service of Nephrology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Menno Pruijm
- Service of Nephrology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
8
|
Doripenem Pharmacokinetics in Hemodialysis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Randomised trial on clinical performances and biocompatibility of four high-flux hemodialyzers in two mode treatments: hemodialysis vs post dilution hemodiafiltration. Sci Rep 2019; 9:18265. [PMID: 31797880 PMCID: PMC6892817 DOI: 10.1038/s41598-019-54404-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/20/2019] [Indexed: 12/29/2022] Open
Abstract
This prospective multicenter randomized comparative cross-over trial aimed at evaluating the influence of hemodialysis vs post-dilution hemodiafiltration with high-flux dialyzers in solute clearance and biocompatibility profile. 32 patients were sequentially dialyzed with Leoceed-21HX, Polypure-22S+, Rexsys-27H and VIE-21A. Primary outcome was β2-microglobulin removal. Secondary outcomes were (i) extraction of other uremic solutes (ii) parameters of inflammation and nutrition and (iii) comparative quantification of perdialytic albumin losses (using total ‘TDC’ vs partial ‘PDC’ collection of dialysate). Significant increases in removal rates of β2-microglobulin (84.7 ± 0.8 vs 71.6 ± 0.8 mg/L), myoglobin (65.9 ± 1.3 vs 38.6 ± 1.3 µg/L), free immunoglobulin light chains Kappa (74.9 ± 0.8 vs 55.6 ± 0.8 mg/L), β-trace protein (54.8 ± 1.3 vs 26.8 ± 1.4 mg/L) and orosomucoid (11.0 ± 1.1 vs 6.0 ± 1.1 g/L) but not myostatin (14.8 ± 1.5 vs 13.0 ± 1.5 ng/mL) were observed in HDF compared to HD when pooling all dialyzers. Rexsys and VIE-A use in both HD and HDF subgroups was associated to a better removal of middle/large-size molecules compared to Leoceed and Polypure, except β2-microglobulin for Rexsys. Inflammatory parameters were unchanged between dialyzers without any interaction with dialysis modality. Mean dialysate albumin loss was comparable between TDC and PDC (1.855 vs 1.826 g/session for TDC and PDC respectively). In addition, a significant difference in albumin loss was observed between dialyzers with the highest value (4.5 g/session) observed using Rexsys. Use of all dialyzers was associated with good removals of the large spectrum of uremic toxins tested and good biocompatibility profiles, with an additional gain in removal performances with HDF. Larger surface area, thinner wall and resultant very high ultrafiltration coefficient of Rexsys should be taken into account in its clear performance advantages.
Collapse
|
10
|
Choo SZ, Polkinghorne KR, Kerr PG. Biochemical comparison of 8 h haemodialysis and 4 h haemodiafiltration, and two dialysis membranes, in a randomized cross-over trial. Nephrology (Carlton) 2019; 24:542-549. [PMID: 29722110 DOI: 10.1111/nep.13397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 11/28/2022]
Abstract
AIM Extended-hours haemodialysis has long been regarded as the optimal form of dialysis for solute clearance. With emerging benefits of haemodiafiltration, we wanted to compare these two head-to-head. METHODS In this randomized cross-over trial, we recruited existing nocturnal haemodialysis patients, who had not been hospitalized in the prior 3 months. After a baseline 8 h haemodialysis session, subjects were randomized to either 2 weeks of 8 h haemodialysis or 4 h haemodiafiltration with cross-over to the alternative treatment after a 2-week washout period. Subjects were additionally randomized to the Fresenius FX80 or Nipro Elisio in a parallel design. Blood and dialysate samples were collected at baseline and at the end of both study periods. RESULTS Twelve patients completed the study. Mean (SD) age and body mass index were 55.1 ± 11.5 years and 36.4 ± 10.8, respectively. Urea and creatinine reduction ratios were higher with extended-hours haemodialysis compared to haemodiafiltration (difference 14.0%, 95% CI = 10.6, 17.3; P < 0.001 and 9.1%, 95% CI = 11.0, 7.2; P < 0.001). Fibroblast growth factor 23 (FGF23) clearance was superior with haemodiafiltration (difference 20.1%, 95% CI = 8.7, 31.6; P = 0.001). No difference was seen in reduction ratios for phosphate, retinol binding protein, alpha-1-microglobulin, beta-2-microglobulin and fetuin with both modalities. Compared to Nipro Elisio, Fresenius FX80 dialyser achieved higher beta-2-microglobulin clearance (Period 1: difference 7.8%, 95% CI = 1.3, 14.4; P = 0.02, Period 2:7.5%, 95% CI = 1.0, 14.1; P = 0.02). CONCLUSIONS Small solute clearance was superior with extended-hours haemodialysis while haemodiafiltration enhanced FGF23 clearance. Beta-2-microglobulin clearance was improved with Fresenius FX80 dialyser, but this difference is unlikely to be clinically significant.
Collapse
Affiliation(s)
- Shi Z Choo
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
11
|
Silva VB, Macedo TA, Braga TMS, Silva BC, Graciolli FG, Dominguez WV, Drager LF, Moysés RM, Elias RM. High Dialysate Calcium Concentration is Associated with Worsening Left Ventricular Function. Sci Rep 2019; 9:2386. [PMID: 30787343 PMCID: PMC6382760 DOI: 10.1038/s41598-019-38887-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/11/2019] [Indexed: 12/05/2022] Open
Abstract
Dialysate calcium concentration (d[Ca]) might have a cardiovascular impact in patients on haemodialysis (HD) since a higher d[Ca] determines better hemodynamic tolerability. We have assessed the influence of d[Ca] on global longitudinal strain (GLS) by two-dimensional echocardiography using speckle-tracking imaging before and in the last hour of HD. This is an observational crossover study using d[Ca] 1.75 mmol/L and 1.25 mmol/L. Ultrafiltration was the same between interventions; patients aged 44 ± 13 years (N = 19). The 1.75 mmol/L d[Ca] was associated with lighter drop of blood pressure. Post HD serum total calcium was higher with d[Ca] 1.75 than with 1.25 mmol/L (11.5 ± 0.8 vs. 9.1 ± 0.5 mg/dL, respectively, p < 0.01). In almost all segments strain values were significantly worse in the peak HD with 1.75 mmol/L d[Ca] than with 1.25 mmol/L d[Ca]. GLS decreased from −19.8 ± 3.7% at baseline to −17.3 ± 2.9% and −16.1 ± 2.6% with 1.25 d[Ca] and 1.75 d[Ca] mmol/L, respectively (p < 0.05 for both d[Ca] vs. baseline and 1.25 d[Ca] vs. 1.75 d[Ca] mmol/L). Factors associated with a worse GLS included transferrin, C-reactive protein, weight lost, and post dialysis serum total calcium. We concluded that d[Ca] of 1.75 mmol/L was associated with higher post dialysis serum calcium, which contributed to a worse ventricular performance. Whether this finding would lead to myocardial stunning needs further investigation.
Collapse
Affiliation(s)
- V B Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - T A Macedo
- Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - T M S Braga
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - B C Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - F G Graciolli
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - W V Dominguez
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - L F Drager
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - R M Moysés
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - R M Elias
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil. .,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil.
| |
Collapse
|
12
|
A new technique for low-volume continuous sampling of spent dialysate: a validation study. J Artif Organs 2019; 22:134-140. [PMID: 30737599 DOI: 10.1007/s10047-019-01091-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 05/28/2018] [Indexed: 10/27/2022]
Abstract
The measure of hemodialysis (HD) adequacy recommended nowadays by most guidelines, Kt/V-urea, presents significant drawbacks. Direct dialysis quantification (DDQ) through total dialysate collection (TDC), considered the gold standard measure of HD adequacy, is cumbersome, which precludes its widespread use in clinical practice. The present study aims to validate a low-volume continuous sampling of spent dialysate (CSSD). Cross-sectional study carried out at a university hospital. Throughout 4-h hemodialysis sessions, urea removal was measured by three DDQ methods: TDC, CSSD, and fractional sampling of dialysate (FSD). The primary outcome was the comparison between the total mass of urea removed measured by TDC and the dialysate sampling techniques. The comparison between urea distribution volume (UDV) estimated by anthropometric method and through DDQ was a secondary outcome. The analysis was done through linear regression and Bland-Altman concordance method. Twenty HD sessions were studied. The mean amount of urea collected in TDC and calculated from the 40-mL sample of CSSD were 33.70 ± 11.70 g and 33.90 ± 11.70 g, respectively [r 0.96, p < 0.0001; bias - 0.2 (95% CI - 1.8 to 1.4); limits of agreement - 6.8 to 6.4]. The anthropometric measure, when compared with DDQ method, underestimated UDV in patients with smaller body size. This new simple, inexpensive, and small volume CSSD technique can provide accurate information about the total amount of solutes removed by hemodialysis.
Collapse
|
13
|
Goldenstein PT, Graciolli FG, Antunes GL, Dominguez WV, dos Reis LM, Moe S, Elias RM, Jorgetti V, Moysés RMA. A prospective study of the influence of the skeleton on calcium mass transfer during hemodialysis. PLoS One 2018; 13:e0198946. [PMID: 30059531 PMCID: PMC6066217 DOI: 10.1371/journal.pone.0198946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/29/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Calcium gradient, the difference between serum calcium and dialysate calcium d[Ca], is the main contributor factor influencing calcium transfer during hemodialysis. The impact, however, of bone turnover, on calcium mass transfer during hemodialysis is still uncertain. METHODS This prospective cross-sectional study included 10 patients on hemodialysis for a 57.6±16.8 months, with severe hyperparathyroidism. Patients were submitted to 3 hemodialysis sessions using d[Ca] of 1.25, 1.5 and 1.75 mmol/l in three situations: pre-parathyroidectomy (pre-PTX), during hungry bone (early post-PTX), and after stabilization of clinical status (late post-PTX). Biochemical analysis and calcium mass transfer were evaluated and serum bone-related proteins were quantified. RESULTS Calcium mass transfer varied widely among patients in each study phase with a median of -89.5, -76.8 and -3 mmol using d[Ca] 1.25 mmol/L, -106, -26.8 and 29.7 mmol using d[Ca] 1.50 mmol/L, and 12.8, -14.5 and 38 mmol using d[Ca] 1.75 mmol/L during pre-PTX, early post-PTX and late post-PTX, respectively, which was significantly different among d[Ca] (p = 0.0001) and among phases (p = 0.040). Ca gradient and delta of Ca also differed among d[Ca] and phases (p<0.05 for all comparisons), whether ultrafiltration was similar. Serum Osteocalcin decreased significantly in late post-PTX, whereas Sclerostin increased earlier, in early post-PTX. CONCLUSIONS The skeleton plays a key role in Ca mass transfer during dialysis, either by determining pre-dialysis serum Ca or by controlling the exchangeable Ca pool. Knowing that could help us to decide which d[Ca] should be chosen in a given patient.
Collapse
Affiliation(s)
| | | | | | | | | | - Sharon Moe
- Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, United States of America
| | - Rosilene Motta Elias
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
- Medicine Master Degree Program, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - Vanda Jorgetti
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa Maria Affonso Moysés
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
- Medicine Master Degree Program, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
- * E-mail:
| |
Collapse
|
14
|
Salame C, Eaton S, Grimble G, Davenport A. Protein Losses and Urea Nitrogen Underestimate Total Nitrogen Losses in Peritoneal Dialysis and Hemodialysis Patients. J Ren Nutr 2018; 28:317-323. [PMID: 29709365 DOI: 10.1053/j.jrn.2018.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/02/2017] [Accepted: 01/29/2018] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Muscle wasting is associated with increased mortality and is commonly reported in dialysis patients. Hemodialysis (HD) and peritoneal dialysis (PD) treatments lead to protein losses in effluent dialysate. We wished to determine whether changes in current dialysis practice had increased therapy-associated nitrogen losses. DESIGN Cross-sectional cohort study. METHODS Measurement of total protein, urea and total nitrogen in effluent dialysate from 24-hour collections from PD patients, and during haemodiafiltration (HDF) and haemodialysis (HD) sessions. SUBJECTS One hundred eight adult dialysis patients. INTERVENTION Peritoneal dialysis, high-flux haemodialysis and haemodiafiltration. MAIN OUTCOME MEASURE Total nitrogen and protein losses. RESULTS Dialysate protein losses were measured in 68 PD and 40 HD patients. Sessional losses of urea (13.9 [9.2-21.1] vs. 4.8 [2.8-7.8] g); protein (8.6 [7.2-11.1] vs. 6.7 [3.9-11.1] g); and nitrogen (11.5 [8.7-17.7] vs. 4.9 [2.6-9.5] g) were all greater for HD than PD, P < .001. Protein-derived nitrogen was 71.9 (54.4-110.4) g for HD and 30.8 (16.1-59.6) g for PD. Weekly protein losses were lower with HD 25.9 (21.5-33.4) versus 46.6 (27-77.6) g/week, but nitrogen losses were similar. We found no difference between high-flux HD and HDF: urea (13.5 [8.8-20.6] vs. 15.3 [10.5-25.5] g); protein (8.8 [7.3-12.2] vs. 7.6 [5.8-9.0] g); and total nitrogen (11.6 [8.3-17.3] vs. 10.8 [8.9-22.5] g). Urea nitrogen (UN) only accounted for 45.1 (38.3-51.0)% PD and 63.0 (55.3-62.4)% HD of total nitrogen losses. CONCLUSION Although sessional losses of protein and UN were greater with HD, weekly losses were similar between modalities. We found no differences between HD and HDF. However, total nitrogen losses were much greater than the combination of protein and UN, suggesting greater nutritional losses with dialysis than previously reported.
Collapse
Affiliation(s)
- Clara Salame
- UCL Division of Medicine, University College London, London, United Kingdom
| | - Simon Eaton
- Development Biology and Cancer Programme, Great Ormond Street Institute of Child Health London, University College London, London, United Kingdom
| | - George Grimble
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, United Kingdom
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, United Kingdom.
| |
Collapse
|
15
|
Cheng Y, Shek C, Tsang D, Li C, Lentino J, Daugirdas J, Kjellstrand C, Ing TS. Stability of Urea and Creatinine in Spent Hemodialysate. Int J Artif Organs 2018. [DOI: 10.1177/039139880002301003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Urea and creatinine levels in spent hemodialysates showed only small declines in spite of incubation at 37° C for 36 hours. In the determination of dialysate-side solute removal, it would seem prudent to keep spent dialysate cold during collection to retard bacterial breakdown of these waste products.
Collapse
Affiliation(s)
- Y.L. Cheng
- Departments of Medicine and Pathology, Queen Elizabeth Hospital, Hong Kong - China
| | - C.C. Shek
- Departments of Medicine and Pathology, Queen Elizabeth Hospital, Hong Kong - China
| | - D.N.C. Tsang
- Departments of Medicine and Pathology, Queen Elizabeth Hospital, Hong Kong - China
| | - C.S. Li
- Departments of Medicine and Pathology, Queen Elizabeth Hospital, Hong Kong - China
| | - J.R. Lentino
- Departments of Medicine, Veterans Affairs Hospital, Hines, IL - USA
| | - J.T. Daugirdas
- Departments of Medicine, Veterans Affairs Hospital, Hines, IL - USA
| | - C.M. Kjellstrand
- Loyola University Chicago, Stritch School of Medicine, Maywood, IL - USA
| | - T. S. Ing
- Departments of Medicine, Veterans Affairs Hospital, Hines, IL - USA
| |
Collapse
|
16
|
Elias RM, Alvares VRC, Moysés RMA. Phosphate Removal During Conventional Hemodialysis: a Decades-Old Misconception. Kidney Blood Press Res 2018; 43:110-114. [PMID: 29414834 DOI: 10.1159/000487108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/25/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Hyperphosphatemia is associated with high mortality rate in patients on dialysis. Conventional hemodialysis (HD) is a limit technique in removing phosphate (P). There is a widespread belief that P is removed mainly in the first hour of HD. The aim of this study was to certify the percentage of 1-hour removal of P as compared to the entire procedure. METHODS data from the first dialysis of the week of 21 patients (13 men, age 44±15 years), for 3 consecutive dialysis sessions were evaluated. Fresh dialysate samples were collected at 1 hour and at the end of the session from a partial spent dialysate collection method. RESULTS Pre dialysis serum P was 4.7±1.7 mg/dl. Reduction rate of serum P was 47.4 ± 14.3 and 45.1 ± 10.8% in 1- and 4-hour of HD, respectively (p=0.322). P removal was 194 (145, 242) mg in 1-hour (p<0.0001), which represents 25.0 ± 0.2% of the total removed during the entire HD. Patients with pre dialysis P ≥ 5.5mg/dl had higher P removal during HD than those with P < 5.5mg/dl [975 (587, 1354) vs. 776 (580, 784) mg, p=0.025], although the percentage of removal in 1 hour was not different from those with P < 5.5mg/d (24.9 ± 0.3 vs. 25.0 ± 0.1%, p=0.918). P removal during dialysis correlated with pre dialysis serum P (r=0.455, p=0.001), parathormone (r=0.264, p=0.037) and ultrafiltration volume (r=0.343, p=0.019). CONCLUSION despite the P serum concentration normalizing in the first hour of hemodialysis, the removal in the same period reaches only 25% of the entire session.
Collapse
Affiliation(s)
- Rosilene M Elias
- Department of Medicine, Renal Division, Universidade de São Paulo, São Paulo, Brazil
| | - Valeria R C Alvares
- Department of Medicine, Renal Division, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa M A Moysés
- Department of Medicine, Renal Division, Universidade de São Paulo, São Paulo, Brazil.,Universidade Nove de Julho, UNINOVE, São Paulo, Brazil
| |
Collapse
|
17
|
Álvares VRC, Ramos CD, Pereira BJ, Pinto AL, Moysés RMA, Gualano B, Elias RM. Pneumatic Compression, But Not Exercise, Can Avoid Intradialytic Hypotension: A Randomized Trial. Am J Nephrol 2017; 45:409-416. [PMID: 28407637 DOI: 10.1159/000471513] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Conventional hemodialysis (HD) is associated with dialysis-induced hypotension (DIH) and ineffective phosphate removal. As the main source of extracellular fluid removed during HD are the legs, we sought to reduce DIH and increase phosphate removal by using cycling and pneumatic compression, which would potentially provide higher venous return, preserving central blood flow and also offering more phosphate to the dialyzer. METHODS We evaluated 21 patients in a randomized crossover fashion in which each patient underwent 3 different HD: control; cycling exercise during the first 60 min; and pneumatic compression during the first 60 min. Data obtained included bioelectrical impedance, hourly blood pressure measurement, biochemical parameters, and direct quantification of phosphate through the dialysate. DIH was defined as a drop in mean arterial pressure (MAP) ≥20 mm Hg. RESULTS There was no difference in the ultrafiltration rate (p = 0.628), delta weight (p = 0.415), delta of total, intra and extracellular body water among the control, cycling, and pneumatic compression (p = 0.209, p = 0.348, and p = 0.467 respectively). Delta MAP was less changed by pneumatic compression when compared to control, cycling, and pneumatic compression respectively (-4.7 [-17.2, 8.2], -4.7 [-20.5, -0.2], and -2.3 [-8.1, 9.0] mm Hg; p = 0.021). DIH occurred in 43, 38, and 24% of patients in control, cycling, and pneumatic compression respectively (p = 0.014). Phosphate removal did not increase in any intervention (p = 0.486). Higher phosphate removal was dependent on ultrafiltration, pre dialysis serum phosphate, and higher parathyroid hormone. CONCLUSION Pneumatic compression during the first hour of dialysis was associated with less DIH, albeit there was no effect on fluid parameters. Neither exercise nor pneumatic compression increased phosphate removal.
Collapse
|
18
|
Gayrard N, Ficheux A, Duranton F, Guzman C, Szwarc I, Vetromile F, Cazevieille C, Brunet P, Servel MF, Argilés À, Le Quintrec M. Consequences of increasing convection onto patient care and protein removal in hemodialysis. PLoS One 2017; 12:e0171179. [PMID: 28166268 PMCID: PMC5293266 DOI: 10.1371/journal.pone.0171179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Recent randomised controlled trials suggest that on-line hemodiafiltration (OL-HDF) improves survival, provided that it reaches high convective volumes. However, there is scant information on the feasibility and the consequences of modifying convection volumes in clinics. METHODS Twelve stable dialysis patients were treated with high-flux 1.8 m2 polysulphone dialyzers and 4 levels of convection flows (QUF) based on GKD-UF monitoring of the system, for 1 week each. The consequences on dialysis delivery (transmembrane pressure (TMP), number of alarms, % of achieved prescribed convection) and efficacy (mass removal of low and high molecular weight compounds) were analysed. RESULTS TMP increased exponentially with QUF (p<0.001 for N >56,000 monitoring values). Beyond 21 L/session, this resulted into frequent TMP alarms requiring nursing staff interventions (mean ± SEM: 10.3 ± 2.2 alarms per session, p<0.001 compared to lower convection volumes). Optimal convection volumes as assessed by GKD-UF-max were 20.6 ± 0.4 L/session, whilst 4 supplementary litres were obtained in the maximum situation (24.5 ± 0.6 L/session) but the proportion of sessions achieving the prescribed convection volume decreased from 94% to only 33% (p<0.001). Convection increased high molecular weight compound removal and shifted the membrane cut-off towards the higher molecular weight range. CONCLUSIONS Reaching high convection volumes as recommended by the recent RCTs (> 20L) is feasible by setting an HDF system at its optimal conditions based upon the GKD-UF monitoring. Prescribing higher convection volumes resulted in instability of the system, provoked alarms, was bothersome for the nursing staff and the patients, rarely achieved the prescribed convection volumes and increased removal of high molecular weight compounds, notably albumin.
Collapse
Affiliation(s)
- Nathalie Gayrard
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Alain Ficheux
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Flore Duranton
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Caroline Guzman
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Ilan Szwarc
- Centre de dialyse Néphrologie Dialyse St Guilhem, Sète, France
| | | | | | - Philippe Brunet
- Service de Néphrologie, Hôpital de La Conception–Université Aix-Marseille, Marseille, France
- European Uraemic Toxin Working Group of ESAO, endorsed by ERA-EDTA (EUTox), Krems, Austria
| | | | - Àngel Argilés
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
- Centre de dialyse Néphrologie Dialyse St Guilhem, Sète, France
- European Uraemic Toxin Working Group of ESAO, endorsed by ERA-EDTA (EUTox), Krems, Austria
| | - Moglie Le Quintrec
- Service de Néphrologie et Transplantation, Hôpital Lapeyronie CHU Montpellier, Montpellier, France
| |
Collapse
|
19
|
Gubensek J, Orsag A, Ponikvar R, Buturovic-Ponikvar J. Calcium Mass Balance during Citrate Hemodialysis: A Randomized Controlled Trial Comparing Normal and Low Ionized Calcium Target Ranges. PLoS One 2016; 11:e0168593. [PMID: 28030601 PMCID: PMC5193410 DOI: 10.1371/journal.pone.0168593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/30/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) during hemodialysis interferes with calcium homeostasis. Optimal ionized calcium (iCa) target range during RCA and consequent calcium balance are unknown. METHODS In a randomized controlled trial (ACTRN12613001029785) 30 chronic hemodialysis patients were assigned to normal (1.1-1.2 mmol/) or low (0.95-1.05 mmol/l) iCa target range during a single hemodialysis with RCA. The primary outcome was calcium mass balance during the procedure, using a partial spent dialysate collection method; magnesium mass balance was also measured. Intact parathormone (iPTH), total calcium (tCa) and magnesium were measured before and after procedures. RESULTS Mean iCa during procedures was significantly different in the two groups (1.12±0.06 in normal and 1.06±0.07 mmol/l in low iCa group, p <0.001), resulting in different tCa (2.18±0.22 vs. 1.95±0.17, p = 0.003) after the procedure. Mean delivered calcium during the procedure was 58.3±4.8 mmol in the normal and 51.5±8.2 mmol in the low iCa group (p = 0.010), which resulted in a significantly higher mean positive calcium mass balance of 14.6±8.3 mmol (584±333 mg) per procedure in normal as compared to 7.2±8.5 mmol (290±341 mg) in low iCa group (p = 0.024). Linear mixed effects model showed a significant interaction effect of time and iCa target range group on iPTH, i.e. a significant increase in iPTH in the low as compared to normal iCa target group (p = 0.008). Magnesium mass balance was mildly negative and comparable in both groups. CONCLUSIONS Low iCa target range resulted in a significantly less positive calcium mass balance, but in a significant increase in iPTH. To achieve a more neutral calcium balance, we recommend allowing a mild hypocalcemia during hemodialysis with RCA, especially when it is used for prolonged periods.
Collapse
Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- * E-mail:
| | - Alesa Orsag
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rafael Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jadranka Buturovic-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
20
|
Orcy R, Antunes MF, Schiller T, Seus T, Böhlke M. Aerobic exercise increases phosphate removal during hemodialysis: A controlled trial. Hemodial Int 2014; 18:450-8. [DOI: 10.1111/hdi.12123] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rafael Orcy
- School of Physiotherapy; Universidade Católica de Pelotas; Pelotas Brazil
- School of Medicine; Universidade Federal de Pelotas; Pelotas Brazil
| | - Maria Fernanda Antunes
- School of Physiotherapy; Universidade Católica de Pelotas; Pelotas Brazil
- Hospital Universitário São Francisco de Paula; Dialysis and Transplantation Unit; Universidade Católica de Pelotas; Pelotas Brazil
| | - Tamires Schiller
- School of Physiotherapy; Universidade Católica de Pelotas; Pelotas Brazil
- Hospital Universitário São Francisco de Paula; Dialysis and Transplantation Unit; Universidade Católica de Pelotas; Pelotas Brazil
| | - Thamires Seus
- School of Physiotherapy; Universidade Católica de Pelotas; Pelotas Brazil
- School of Medicine; Universidade Federal de Pelotas; Pelotas Brazil
| | - Maristela Böhlke
- Hospital Universitário São Francisco de Paula; Dialysis and Transplantation Unit; Universidade Católica de Pelotas; Pelotas Brazil
| |
Collapse
|
21
|
Kraemer M. Physiological monitoring and control in hemodialysis: state of the art and outlook. Expert Rev Med Devices 2014; 3:617-34. [PMID: 17064247 DOI: 10.1586/17434440.3.5.617] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Medical devices for monitoring and feedback control of physiological parameters of the dialysis patient were introduced in the early 1990s. They have a wide range of applications, aiming at increasing the safety and ensuring the efficiency of the treatment, and at an improved restoration of physiological conditions, leading to an overall reduction in morbidity and mortality. Such devices include sensors for the measurement of temperature, optical parameters and sound speed in blood, and electrical characteristics of the human body, and other parameters. Essential for the development of these devices is a detailed understanding of the pathophysiological background of a therapeutical problem. There is still a large potential to introduce new devices for further therapy improvement and automation. Also, the size of the hemodialysis market appears attractive; however, a new product has to meet several specific requirements in order to also become commercially successful. This review describes the therapeutic and technical principles of several available devices, reports on concepts for possible future devices, and presents a short overview on the market environment.
Collapse
Affiliation(s)
- Matthias Kraemer
- Fresenius Biotech GmbH, Borkenberg 14, 61440 Oberursel, Germany.
| |
Collapse
|
22
|
Melo NCV, Moyses RMA, Elias RM, Castro MCM. Reprocessing high-flux polysulfone dialyzers does not negatively impact solute removal in short-daily online hemodiafiltration. Hemodial Int 2014; 18:473-80. [DOI: 10.1111/hdi.12126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Natalia C. V. Melo
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
- HRT-SES/DF; Brasilia Brazil
| | - Rosa M. A. Moyses
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| | - Rosilene M. Elias
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| | - Manuel C. M. Castro
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| |
Collapse
|
23
|
Kirkman DL, Roberts LD, Kelm M, Wagner J, Jibani MM, Macdonald JH. Interaction between intradialytic exercise and hemodialysis adequacy. Am J Nephrol 2013; 38:475-82. [PMID: 24296748 DOI: 10.1159/000356340] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 10/10/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS According to mathematical modeling, intradialytic exercise of sufficient intensity and duration implemented in the second half of dialysis should be as efficacious as increasing dialysis time for dialysis adequacy. This assumption has not been tested in vivo. METHODS In this controlled trial, 11 hemodialysis (HD) patients (mean (SD) age 56 (13) years) were recruited. Each patient completed three trial arms in a randomized order: routine care (CONT), increased HD time of 30 min (TIME), and intradialytic exercise (EXER), 60 min of cycling at 90% of the lactate threshold in the last 90 min of HD. The primary outcome was eKt/Vurea. Secondary outcomes included reduction and rebound ratios of urea, creatinine, phosphate and β2-microglobulin. Outcomes were calculated from blood sampling collected pre-, post- and 30 min post-HD and confirmed with dialysate sampling. RESULTS Exercise was not as efficacious as increased HD time for eKt/Vurea (EXER vs. CONT, mean change (95% CI): 0.03 (-0.05 to 0.12); TIME vs. CONT: 0.15 (0.05-0.26)). Exercise was less efficacious at improving reduction ratios of urea and creatinine. However, exercise was more efficacious than increased dialysis time for phosphate reduction ratio (EXER vs. CONT: 8.6% (0.5-16.7); TIME vs. CONT: 5.0% (-1.0 to 11.1)). CONCLUSION This study utilized a rigorously controlled in vivo design to test mathematical models and assumptions regarding dialysis adequacy. Intradialytic exercise towards the end of HD cannot replace the prescription of increased HD time for dialysis adequacy, but may be an adjunctive therapy for serum phosphate control.
Collapse
Affiliation(s)
- Danielle L Kirkman
- College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | | | | | | | | | | |
Collapse
|
24
|
Sampaio MS, Ruzany F, Dorigo DM, Suassuna JHR. Phosphate mass removal during hemodialysis: a comparison between eKT/V-matched conventional and extended dialysis. Am J Nephrol 2012; 36:121-6. [PMID: 22776782 DOI: 10.1159/000338675] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 04/05/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES The control of hyperphosphatemia is an unmet need in dialysis care. Compared to conventional hemodialysis (cHD), extended hemodialysis (eHD) appears to more easily control blood phosphate levels in chronically dialyzed patients. Here, we sought to compare eKT/V-matched cHD and eHD procedures in order to quantify the contribution of dialysis prescription and time in the mass removal of phosphate. METHODS Eight stable hemodialysis patients with negligible residual renal function underwent cHD and eHD sessions adjusted to provide the same eKT/V(urea). Total dialysate, total and hourly partial dialysate and blood samples were collected for comparison of mass extraction of urea, creatinine, and phosphate. RESULTS Mean eKT/V(urea) was similar in eHD and cHD (1.30 vs. 1.28, p = nonsignificant). Likewise, mass removal of urea and creatinine during cHD and eHD were not significantly different. Conversely, phosphate mass removal was 40% higher with eHD as compared to cHD (1,219 ± 262 vs. 858 ± 186 mg, p = 0.015). Although hourly mass removal of phosphate was higher during cHD, the prolonged period of lesser but continuous removal was responsible for higher total phosphate elimination during eHD. CONCLUSION In dialysis sessions matched to provide a similar eKT/V(urea), removal of phosphate increases by 40% when time is extended from 4 to 8 h. Urea-based adequacy models cannot be used to predict the amount of phosphorus removal during hemodialysis.
Collapse
Affiliation(s)
- M S Sampaio
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | | | | | | |
Collapse
|
25
|
Wang M, Li H, Liao H, Yu Y, You L, Zhu J, Huang B, Yuan L, Hao C, Chen J. Phosphate removal model: an observational study of low-flux dialyzers in conventional hemodialysis therapy. Hemodial Int 2012; 16:363-76. [PMID: 22360645 DOI: 10.1111/j.1542-4758.2012.00678.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Precise assessing phosphate removal by hemodialysis (HD) is important to improve phosphate control in patients on maintenance HD. We reported a simple noninvasive model to estimate phosphate removal within a 4-hour HD. One hundred sixty-five patients who underwent HD 4 hours per session using low-flux dialyzers made of polysulfone (1.2 m(2)) or triacetate (1.3 m(2)) were enrolled. Blood flows varied from 180 to 300 mL/min. Effluent dialysate samples were collected during the 4-hour HD treatment to measure the total phosphate removal. Predialysis levels of serum phosphate, potassium, hematocrit, intact parathyroid hormone, total carbon dioxide (TCO(2)), alkaline phosphatase, clinical and dialysis characteristics were obtained. One hundred thirty-five observations were randomly selected for model building and the remaining 30 for model validation. Total amount of phosphate removal within the 4-hour HD was mostly 15-30 mmol. A primary model (model 1) predicting total phosphate removal was Tpo(4) = 79.6 × C(45) (mmol/L) - 0.023 × age (years) + 0.065 × weight (kg) - 0.12 × TCO(2) (mmol/L) + 0.05 × clearance (mL/min) - 3.44, where C(45) was phosphate concentration in spent dialysate measured at the 45 minute of HD and clearance was phosphate clearance of dialyzer in vitro conditions offered by manufacturer's data sheet. Since the parameter TCO(2) needed serum sample for measurement, we further derived a noninvasive model (model 2):Tpo(4) = 80.3 × C(45) - 0.024 × age + 0.07 × weight + 0.06 × clearance - 8.14. Coefficient of determination, root mean square error, and residual plots showed the appropriateness of two models. Model validation further suggested good and similar predictive ability of them. This study derived a noninvasive model to predict phosphate removal. It applies to patients treated by 4-hour HD under similar conditions.
Collapse
Affiliation(s)
- Mengjing Wang
- Division of Nephrology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Meijers B, Toussaint ND, Meyer T, Bammens B, Verbeke K, Vanrenterghem Y, Kerr PG, Evenepoel P. Reduction in protein-bound solutes unacceptable as marker of dialysis efficacy during alternate-night nocturnal hemodialysis. Am J Nephrol 2011; 34:226-32. [PMID: 21791919 DOI: 10.1159/000330176] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 06/17/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND The uremic retention solutes indoxyl sulfate and p-cresyl sulfate are linked to cardiovascular disease and overall survival. Dialytic clearances are limited, which is principally attributed to tight protein binding. Extending dialysis duration would be expected to substantially increase protein-bound uremic solute removal. The aim of the current study was to study protein-bound uremic retention solute clearances and kinetics during longer-hours nocturnal hemodialysis. METHODS In a prospective cohort study of 32 maintenance alternate-night nocturnal hemodialysis patients, we followed serum concentrations, solute removals and solute clearances of p-cresyl sulfate and indoxyl sulfate. Spent dialysate sampling was fractionated to compare solute removals between the first 4 h and next 4 h of nocturnal dialysis. Single-compartment variable volume kinetics were calculated. RESULTS Dialytic clearances of protein-bound uremic retention solutes are maintained during nocturnal (longer-hours) dialysis. Clearances of indoxyl sulfate exceed those of p-cresyl sulfate, presumably due to less tight protein-binding. Apparent distribution volumes increase substantially during nocturnal dialysis, indicative of multi-compartmental behavior of the protein-bound uremic retention solutes indoxyl sulfate and p-cresyl sulfate. CONCLUSIONS During nocturnal hemodialysis, serum concentrations of protein-bound solute concentrations are reduced less than predicted. Reduction ratios are not a valid tool to estimate total solute removal of protein-bound uremic retention solutes.
Collapse
Affiliation(s)
- Bjorn Meijers
- Division of Nephrology, Department of Medicine, University Hospital Leuven, Belgium
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Ficheux A, Gayrard N, Szwarc I, Andress D, Soullier S, Duny Y, Goubert G, Thomas M, Bismuth-Mondolfo J, Daurès JP, Brunet P, Servel MF, Argilés A. The use of SDS-PAGE scanning of spent dialysate to assess uraemic toxin removal by dialysis. Nephrol Dial Transplant 2010; 26:2281-9. [PMID: 21148683 PMCID: PMC3124329 DOI: 10.1093/ndt/gfq709] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background. Uraemic toxins in the 8 to 60 kDa molecular weight range have been attracting increasing attention in dialysis therapy. However, there are no available standardized methods to evaluate their removal. Using new filtering membranes, we evaluated SDS–PAGE of spent dialysate to assess cut-off ranges and removal capacities into dialysate, while also measuring classical markers of dialyser function. Methods. Eighteen dialysis patients were washed out for 2 weeks with FX 100 (Helixone®), followed by randomization to Xevonta Hi 23 (Amembris®) or FX dialysers for 2 weeks, then crossed over for an additional 2 weeks, and finally placed on Xenium 210 (Purema®) for 2 weeks. SDS–PAGE scanning of the removed proteins contained in the spent dialysate was performed during all dialysis sessions. Total mass of urea, creatinine, total proteins, beta 2 microglobulin (β2m), retinol-binding protein (RBP) and albumin were measured. The reduction rates of serum urea, creatinine, β2m, leptin, RBP, alpha 1-antitrypsin, albumin and total proteins were also determined. Results. SDS–PAGE scanning identified four major protein peaks (10–18, 20–22.5, 23–30 and 60–80 kDa molecular weight) and showed clear differences in the amounts of removed proteins between the dialysers, particularly in the 20–22.5, 23–30 and 60–80 kDa ranges. Total mass of removed β2m, RBP and albumin were in agreement with SDS–PAGE, while serum assays showed differing results. Conclusions. SDS–PAGE scanning provided a good characterization of protein patterns in the spent dialysate; it extended and agreed with protein determinations and allowed a better assessment of dialyser performance in removing 10 to 80 kDa molecular weight substances. It also identified differences between the three mainly filtrating polysulfone dialysers that were not detected with blood measurements.
Collapse
Affiliation(s)
- Alain Ficheux
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Ficheux A, Brunet P, Argilés À. Quantification de la dialyse : est-elle précise et pouvons-nous la rendre simple ? Nephrol Ther 2010; 6:491-3. [DOI: 10.1016/j.nephro.2010.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 01/06/2010] [Indexed: 10/19/2022]
|
29
|
Al Saran K, Sabry A, Abdulghafour M, Yehia A. Online conductivity monitoring of dialysis adequacy versus Kt/V derived from urea reduction ratio: a prospective study from a Saudi Center. Ren Fail 2010; 32:36-40. [PMID: 20113264 DOI: 10.3109/08860220903367486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Adequate delivered dose of solute removal (as assessed by urea reduction and calculation of Kt/V) is an important determinant of clinical outcome in chronic hemodialysis (HD) patients. This requires both prescription of an adequate dose of HD and regular assessment that the delivered treatments are also adequate. Online conductivity monitoring (OCM) using sodium flux as a surrogate for urea allows for the repeated non-invasive measurement of Kt/V on each HD treatment. METHODS We prospectively studied 17 (9 males, 8 females) established chronic HD patients over an eight-week period (408 treatments). A pre- and post-dialyzer measurement of the conductivity is performed by two mutually independent temperature-compensated conductivity cells equipped with Fresenius 4008 S(R) dialysis machines. Urea reduction was measured once a week by a single-pool calculation using immediate post-treatment sampling. No changes were made to any of the dialysis prescriptions over the study period. Values of calculated Kt/V and simultaneously obtained online Kt/V were compared. RESULTS There was a statistically significant difference between calculated Kt/V and online Kt/V over the study period. The mean calculated Kt/V was 1.37 +/- 0.09, and mean online Kt/V 1.02 +/- 0.15 (p = 0.000). Calculated Kt/V >or= 1.2 was achieved in all our patients, while online Kt/V >or= 1.2 was achieved in only 17.64%. Yet there was moderate correlation between calculated Kt/V and online Kt/V (r(2) = 0.48). CONCLUSIONS Online conductivity monitoring (OCM) results underestimates dialysis efficiency compared to calculated Kt/V readings. This difference has to be considered when applying Kt/V to clinical practice.
Collapse
Affiliation(s)
- Khalid Al Saran
- Prince Salman Center for Kidney Disease, Riyadh, Kingdom of Saudi Arabia.
| | | | | | | |
Collapse
|
30
|
Ficheux A, Gayrard N, Szwarc I, Soullier S, Bismuth-Mondolfo J, Brunet P, Servel MF, Argiles A. Use of spent dialysate analysis to estimate blood levels of uraemic solutes without blood sampling: urea. Nephrol Dial Transplant 2009; 25:873-9. [DOI: 10.1093/ndt/gfp539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
31
|
Al Saran K, Sabry A, Abdulghafour M, Yehia A. Online conductivity monitoring of dialysis adequacy versus Kt/V derived from urea reduction ratio: A prospective study from a Saudi center. Int J Nephrol Renovasc Dis 2009; 2:27-31. [PMID: 21694918 PMCID: PMC3108763 DOI: 10.2147/ijnrd.s7316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Ad equate delivered dose of solute removal (as assessed by urea reduction and calculation of Kt/V) is an important determinant of clinical outcome in chronic hemodialysis (HD) patients. This requires both prescription of an adequate dose of HD and regular assessment that the delivered treatments are also adequate. Online conductivity monitoring using sodium flux as a surrogate for urea allows the repeated noninvasive measurement of Kt/V on each HD treatment. METHODS We prospectively studied 17 (9 males, 8 females) established chronic HD patients over an eight-week period (408 treatments). A pre- and post-dialyzer measurement of the conductivity is performed by two mutually independent temperature-compensated conductivity cells equipped with Fresenius 4008 S(®) dialysis machines. Urea reduction was measured (once a week) by a single pool calculation using immediate post-treatment sampling. No changes were made to any of the dialysis prescriptions over the study period. Values of calculated Kt/V and simultaneously obtained online Kt/V were compared. RESULTS There was a statistically significant difference between calculated Kt/V and online Kt/V over the study period. The mean calculated Kt/V was 1.37 ± 0.09, and mean online Kt/V 1.02 ± 0.15 (P = 0.000), calculated Kt/V ≥ 1.2 was achieved in all our patients while online Kt/V ≥ 1.2 was achieved in only 17.64 %. Yet there was moderate correlation between calculated Kt/V and online Kt/V (r(2) = 0.48). CONCLUSIONS Online conductivity monitoring results underestimates dialysis efficiency compared to calculated Kt/V readings. This difference has to be considered when applying Kt/V to clinical practice.
Collapse
Affiliation(s)
- Khalid Al Saran
- Prince Salman Center for Kidney Disease, Riyadh, Kingdom of Saudi Arabia
| | - Alaa Sabry
- Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | | | - Ahmed Yehia
- Prince Salman Center for Kidney Disease, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
32
|
Farese S, Budmiger R, Aregger F, Bergmann I, Frey FJ, Uehlinger DE. Effect of Transcutaneous Electrical Muscle Stimulation and Passive Cycling Movements on Blood Pressure and Removal of Urea and Phosphate During Hemodialysis. Am J Kidney Dis 2008; 52:745-52. [DOI: 10.1053/j.ajkd.2008.03.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 03/10/2008] [Indexed: 11/11/2022]
|
33
|
Grzegorzewska AE, Banachowicz W. Evaluation of hemodialysis adequacy using online Kt/V and single-pool variable-volume urea Kt/V. Int Urol Nephrol 2008; 40:771-8. [PMID: 18592391 DOI: 10.1007/s11255-008-9378-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 03/26/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The hemodialysis (HD) team should deliver single-pool variable-volume (SPVV) urea Kt/V>or=1.2. At present dialysis machines provide online assessment of Kt/V. The aim of our study is to assess if online Kt/V and SPVV urea Kt/V yield similar values and if it may be replaced in evaluation of HD adequacy. PATIENTS AND METHODS Studies were carried out two times (evaluation I and evaluation II) in 40 patients dialyzed using machines with online Kt/V monitoring by the conductivity method. During the middle HD session in the week, SPVV Kt/V was estimated from urea measurements in serum at the beginning and at the end of the HD session using the second generation formula of Daugirdas. Values of SPVV urea Kt/V and simultaneously obtained online Kt/V were compared. RESULTS In I, SPVV Kt/V was 1.37+/-0.16, and online Kt/V was 1.16+/-0.14 (P=0.000), r=0.559 (P=0.000); a regression equation indicated SPVV Kt/V as 0.62457+0.64048 * online Kt/V. In II, estimated SPVV Kt/V was 1.37+/-0.20, online Kt/V-1.16+/-0.15 (P=0.000), r=0.493 (P=0.001), and calculated SPVV Kt/V was 1.37+/-0.10. In I, SPVV urea Kt/V>1.20 was shown in 87.5% of patients, whereas online Kt/V>1.20 was observed in 37.5% of cases (P=0.000). In II, respective values were 82.5% and 40.0% of patients (P=0.000). CONCLUSIONS SPVV urea Kt/V indicates a more adequate HD session than online Kt/V. This difference has to be considered when applying Kt/V to clinical practice.
Collapse
Affiliation(s)
- Alicja E Grzegorzewska
- Department of Nephrology, Transplantology and Internal Diseases, Karol Marcinkowski University of Medical Sciences, Al. Przybyszewskiego 49, 60-355 Poznan, Poland.
| | | |
Collapse
|
34
|
Pellicano R, Polkinghorne KR, Kerr PG. Reduction in β2-Microglobulin With Super-flux Versus High-flux Dialysis Membranes: Results of a 6-Week, Randomized, Double-blind, Crossover Trial. Am J Kidney Dis 2008; 52:93-101. [DOI: 10.1053/j.ajkd.2008.02.296] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Accepted: 02/12/2008] [Indexed: 11/11/2022]
|
35
|
Kanagasundaram NS, Greene T, Larive AB, Daugirdas JT, Depner TA, Paganini EP. Dosing intermittent haemodialysis in the intensive care unit patient with acute renal failure--estimation of urea removal and evidence for the regional blood flow model. Nephrol Dial Transplant 2008; 23:2286-98. [PMID: 18272777 DOI: 10.1093/ndt/gfm938] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Blood-side dosing methods may overestimate urea removal in comparison to dialysate-side measurements during intermittent HD (IHD) for acute renal failure (ARF). The present study sought to quantify this mass balance error (MBE) and explore potential explanatory factors. METHODS Prospective, formal, blood-side urea kinetic modelling was performed in serial sessions (n = 42) in 18 intensive care unit ARF patients. Three blood-side estimates of urea removal were calculated and these were compared to urea removal derived from fractional dialysate sampling and use of an on-line urea monitor. We also examined urea rebound in these patients, as expressed by the intercompartmental urea clearance (Kc), and in a subset of patients examined the relation of Kc to cardiac output and systemic vascular resistance (SVR). RESULTS The mean % MBE (MBE = blood - dialysate-estimated urea removal) was about 9% using conventional two-pool modelling based on a 60-min post-dialysis blood urea nitrogen (BUN) with or without the use of one or more intra-dialytic BUN values. The extent of MBE could not be explained by the clinical or dialytic variables that were measured. Part of the MBE error was due to overestimation of the intradialytic BUN profile, because model-independent profiling of intra-dialytic BUN values to compute urea removal reduced the MBE to approximately 6%. The log Kc was correlated with cardiac output and showed trends towards an inverse correlation with SVR. CONCLUSIONS Classical, two-pool, blood-side UKM produces a modest overestimate of urea removal in IHD for critically ill ARF patients. The source of this small, residual MBE is unknown. The amount of urea rebound, as reflected by Kc, varied among patients and associated with cardiac output and SVR, as predicted by the regional blood flow model.
Collapse
Affiliation(s)
- Nigel S Kanagasundaram
- Section of Dialysis and Extracorporeal Therapy, Department of Hypertension/Nephrology, OH, USA.
| | | | | | | | | | | | | |
Collapse
|
36
|
Prado M, Roa LM, Palma A, Milán JA. Double target comparison of blood-side methods for measuring the hemodialysis dose. Kidney Int 2006; 68:2863-76. [PMID: 16316364 DOI: 10.1111/j.1523-1755.2005.00760.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the fact that urea kinetic modelling has been successfully applied to quantify the hemodialysis since the beginning of the 1980s, there is not a consensus yet concerning which is the most proper dialysis dose index and the method for calculating it. In this work, we propose that a combined measurement of the dialysis dose from two complementary perspectives of the removal process should provide a more complete description of dialysis than a measurement alone. This hypothesis is reviewed and the measuring methods are compared. METHODS A cross-sectional randomized clinical study over 98 stable ESRD patients submitted to thrice-weekly hemodialysis was carried out with the aim of comparing 16 blood-side methods for measuring the hemodialysis dose from patient and dialyzer perspectives. The availability of urea rebound measurements and computational resources have been taken into account. RESULTS The outcomes point to four novel blood-side methods as the most accurate for measuring the effective dialysis system Kt/V (mKt/V) in clinical conditions. Their limits of agreement (mean +/- 2.SD) range from 1.93 +/- 2.09% for a non-iterative method without the urea rebound measurement (BUN3) to -0.08 +/- 0.58% for an iterative method with BUN3. The best non-iterative blood-side method for measuring the equilibrated Kt/V (eKt/V) is the second generation formula of Daugirdas (-2.42 +/- 1.05%) when BUN3 is available and the rate equation of Daugirdas and Schneditz (-1.74 +/- 7.91%) when BUN3 is not available. The difference mKt/V-eKt/V is significant and positive, and increases with the dialysis dose in a personalized manner. CONCLUSION We have confirmed the arguments that support the hypothesis of the study. The best blood-side methods for the combined measurement of dialysis dose as a function of the available resources have been determined.
Collapse
Affiliation(s)
- Manuel Prado
- Biomedical Engineering Group, University of Seville, Seville, Spain.
| | | | | | | |
Collapse
|
37
|
Franssen CFM. Oxalate clearance by haemodialysis--a comparison of seven dialysers. Nephrol Dial Transplant 2005; 20:1916-21. [PMID: 15998647 DOI: 10.1093/ndt/gfh971] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In patients with primary hyperoxaluria (PH) and oliguric end-stage renal disease, oxalate removal is largely dependent on the clearance by dialysis. Data on the oxalate clearance of newer dialyser types are scarce or absent. Therefore, we measured oxalate clearances of seven dialysers in a single 52-year-old female patient with PH. Since haemodiafiltration (HDF) has been advocated to increase oxalate clearance, we also assessed the effect of different pre-dilution flows. The goal of the study was to select the dialyser and pre-dilution flow combination with the highest oxalate clearance. METHODS Oxalate clearances were assessed by simultaneously taking afferent blood and efferent dialysate samples at 30, 60, 120 and 180 min after the start of haemodialysis. Blood flow and dialysate flow were 350 and 500 ml/min, respectively. All dialysers were tested at a pre-dilution flow of 2 l/h. Six dialysers were also tested at either a pre-dilution flow of 4.5 l/h or without HDF, depending on the ultrafiltration coefficient of the dialyser. RESULTS Oxalate clearances differed markedly between the tested dialysers, ranging from 144+/-10 to 220+/-12 ml/min. The highest oxalate clearances were achieved with HdF100S (219+/-10 ml/min) and Sureflux FB-210U (220+/-12 ml/min) at a pre-dilution flow of 2 l/h. Higher pre-dilution flows (2 l/h vs no HDF or 4.5 vs 2.0 l/h) yielded similar oxalate clearances. CONCLUSION The highest oxalate clearances were achieved with a high-flux polysulfone and a cellulose triacetate dialyser with a large surface area. Higher pre-dilution flows did not augment oxalate clearance.
Collapse
|
38
|
Mercadal L, Ridel C, Petitclerc T. Ionic dialysance: Principle and review of its clinical relevance for quantification of hemodialysis efficiency. Hemodial Int 2005; 9:111-9. [PMID: 16191058 DOI: 10.1111/j.1492-7535.2005.01122.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ionic dialysance (D) is an online measured variable now available on several dialysis monitors to evaluate small-solute clearance. Based on conductivity measurements in the inlet and outlet dialysate, the principle of the measurement and the different measurement methods are described. Studies that have evaluated the reliability of ionic dialysance to assess dialysis efficiency are discussed. These studies are divided into two groups: the first comparing ionic dialysance to urea clearance and the second comparing Dt/V to Kt/V(urea), in which the uncertainties of the measurement of V(urea) could have misrepresented the relationship between Dt/V and Kt/V(urea). When Kt/V(urea) via the Daugirdas second-generation equation taking the rebound into account is considered, slight-even nonsignificant-differences are evidenced between Kt/V(urea) and Dt/V. Therefore, ionic dialysance should be considered as a valid measure in future guidelines for dialysis efficiency.
Collapse
Affiliation(s)
- Lucile Mercadal
- Department of Nephrology, Pitié-Salpétrière Hospital, Paris, France.
| | | | | |
Collapse
|
39
|
Locatelli F, Buoncristiani U, Canaud B, Köhler H, Petitclerc T, Zucchelli P. Haemodialysis with on-line monitoring equipment: tools or toys? Nephrol Dial Transplant 2005; 20:22-33. [PMID: 15632348 DOI: 10.1093/ndt/gfh555] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND On-line monitoring of chemical/physical signals during haemodialysis (HD) and bio-feedback represents the first step towards a 'physiological' HD system incorporating adaptive and logic controls in order to achieve pre-set treatment targets. METHODS Discussions took place to achieve a consensus on key points relating to on-line monitoring and bio-feedback, focusing on the clinical applications. RESULTS The relative blood volume (BV) reduction during HD can be monitored by optic devices detecting the variations in concentration of haemoglobin/haematocrit. BV changes result from an equilibrium between ultrafiltration and the refilling capacity. However, BV reduction has little power in predicting intra-HD hypotensive episodes, while the combination of the patient-dialysate sodium gradient, the relative BV reduction between the 20th and 40th minute of HD, the irregularity of the profile of BV reduction over time and the heart rate decrease from the start to the 20th minute of HD predict intra-HD hypotension with a sensitivity of 82%, a specificity of 73% and an accuracy of 80%. A bio-feedback system drives the relative BV reduction according to desired values by instantaneously changing the ultrafiltration rate and the dialysate conductivity. This system has proved to reduce the incidence of intra-HD hypotension episodes significantly. Ionic dialysance and the patient's plasma conductivity can be calculated easily from on-line inlet and outlet dialysate conductivity measurements at two different steps of dialysate conductivity. Ionic dialysance is equivalent to urea clearance corrected for recirculation and is a tool for continuously monitoring the dialysis efficiency and detecting early problems with the delivery of the prescribed dose of dialysis. Given the strict and linear relationship between conductivity and sodium content, the conductivity values replace the sodium concentration values and this permits the development of a conductivity kinetic model, by means of which sodium balance can be achieved at each dialysis session. The conductivity kinetic model has been demonstrated to improve intra-HD cardiovascular stability in hypotension-prone patients significantly. Ionic dialysance is also a useful tool to monitor vascular access function, as it can be used to obtain serial measurements of vascular access blood flow. On-line urea monitors provide detailed information on intra-HD urea kinetics and delivered dialysis dose, but they are not in widespread use because of the costs related to the disposable materials (e.g. urease cartridge). The body temperature monitor measures the blood temperature at the arterial and venous lines of the extra-corporeal circuit and, thanks to a bio-feedback system, is able to modulate the dialysate temperature in order to influence the patient's core body temperature, which can be kept at constant values. This is associated with improved intra-HD cardiovascular stability. The module can also be used to quantify total recirculation. CONCLUSIONS On-line monitoring devices and bio-feedback systems have evolved from toys for research use to tools for routine clinical application, particularly in patients with clinical complications. Conductivity monitoring appears the most versatile tool, as it permits quantification of delivered dialysis dose, achievement of sodium balance and surveillance of vascular access function, potentially at each dialysis session and without extra cost.
Collapse
|
40
|
Lowrie EG, Li Z, Ofsthun N, Lazarus JM. Measurement of dialyzer clearance, dialysis time, and body size: Death risk relationships among patients. Kidney Int 2004; 66:2077-84. [PMID: 15496182 DOI: 10.1111/j.1523-1755.2004.00987.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Urea pharmacokinetic equation systems have contributed to better understanding of treatment dose among hemodialysis patients. The methods are indirect, however, and require the measurement of blood urea nitrogen (BUN) concentration before and after a dialysis session to estimate the total treatment dose that clinicians prescribe [urea clearance x dialysis time (Kt)] indexed to an estimate of body size [the volume of urea distribution in the body (V)] yielding the ratio, Kt/V. New technology permits direct on-line measurement of average small molecule clearance (Kecn) during each dialysis treatment that can be multiplied by time (t) to give a direct measurement of total treatment dose (Kt). This study evaluated the relationship of measured Kt with death risk. It also evaluated the relationship of simple body size measures to risk and also the combination of one such measure [body surface area (BSA)] with Kt to death risk. METHODS The data were taken from the Fresenius Medical Care (NA) (FMCNA) clinical database that included patients who had outcome data, height and weight measurements, and at least one average Kecn and t measurement during April 2002. Kecn, t, and the body size measures [body weight, body mass index (BMI), and BSA)] were averaged during the month. Those values were used as predictors of survival during the next 1 year in unadjusted and case mix adjusted proportional hazards (Cox) models. RESULTS Increasing values of Kecn, t, Kt and all of the body size measures were associated with lower death risk. The body size measure most closely associated with risk was the BSA that was used in subsequent models. Kt and BSA were independent risk predictors. There was a significant interaction between Kt and BSA in the case mix but not the unadjusted model indicating that the risk burden of lower total dialysis dose, Kt, may be greater among small than large patients. CONCLUSION The direct measurement of dialysis dose during each treatment is practical and the values reported by it are clinically relevant. Higher dose was associated with better survival in both small and large patients treated three times weekly. Furthermore, smaller patients may require proportionately greater total dose than larger patients to achieve comparable survival.
Collapse
Affiliation(s)
- Edmund G Lowrie
- Fresenius Medical Care (North America), Lexington, Massachusetts 02420-9192, USA.
| | | | | | | |
Collapse
|
41
|
Vaithilingam I, Polkinghorne KR, Atkins RC, Kerr PG. Time and exercise improve phosphate removal in hemodialysis patients. Am J Kidney Dis 2004; 43:85-9. [PMID: 14712431 DOI: 10.1053/j.ajkd.2003.09.016] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Control of serum phosphate remains a difficult clinical issue in most hemodialysis (HD) patients. This study examines 2 nonpharmacological approaches to improving phosphate control in HD patients. METHODS First, 9 stable HD patients underwent dialysis in random fashion for either 4 hours 3 times weekly or 5 hours 3 times weekly. Adjustments were made to blood flow rates such that Kt/V was the same for all sessions, thus allowing independent assessment of the influence of time. The primary end point was weekly dialysate phosphate removal. In the second study, 12 different patients underwent an exercise program in which they pedaled a bicycle ergometer either immediately before or during dialysis. Again, weekly dialysate phosphate removal was measured. RESULTS In the time study, urea reduction ratio (69% +/- 0.02% versus 68% +/- 0.07, 4 versus 5 hours) and weekly urea removal were no different between the 2 groups. However, weekly phosphate removal (3,007 +/- 641 versus 3,400 +/- 647 mg; P < 0.02) significantly improved with longer dialysis duration. Serum phosphate levels improved, but did not reach statistical significance in this short-term study. In the exercise study, weekly phosphate removal improved with exercise, but did not reach significance (2,741 +/- 715 [no exercise] versus 2,917 +/- 833 [exercise predialysis] versus 2,992 +/- 852 mg [exercise during dialysis]; P = 0.055), although comparing only exercise during dialysis with no exercise reached significance (P = 0.02). There was no significant difference in serum phosphate levels. CONCLUSION Both increased dialysis time and exercise result in increased dialytic removal of phosphate and could be expected in the long term to improve phosphate control.
Collapse
|
42
|
Daugirdas JT, Greene T, Depner TA, Chumlea C, Rocco MJ, Chertow GM. Anthropometrically estimated total body water volumes are larger than modeled urea volume in chronic hemodialysis patients: effects of age, race, and gender. Kidney Int 2003; 64:1108-19. [PMID: 12911564 DOI: 10.1046/j.1523-1755.2003.00179.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The modeled volume of urea distribution (Vm) in intermittently hemodialyzed patients is often compared with total body water (TBW) volume predicted from population studies of patient anthropometrics (Vant). METHODS Using data from the HEMO Study, we compared Vm determined by both blood-side and dialysate-side urea kinetic models with Vant as calculated by the Watson, Hume-Weyers, and Chertow anthropometric equations. RESULTS Median levels of dialysate-based Vm and blood-based Vm agreed (43% and 44% of body weight, respectively). These volumes were lower than anthropometric estimates of TBW, which had median values of 52% to 55% of body weight for the three formulas evaluated. The difference between the Watson equation for TBW and modeled urea volume was greater in Caucasians (19%) than in African Americans (13%). Correlations between Vm and Vant determined by each of the three anthropometric estimation equations were similar; but Vant derived from the Watson formula had a slightly higher correlation with Vm. The difference between Vm and the anthropometric formulas was greatest with the Chertow equation, less with the Hume-Weyers formula, and least with the Watson estimate. The age term in the Watson equation for men that adjusts Vant downward with increasing age reduced an age effect on the difference between Vant and Vm in men. CONCLUSION The findings show that kinetically derived values for V from blood-side and dialysate-side modeling are similar, and that these modeled urea volumes are lower by a substantial amount than anthropometric estimates of TBW. The higher values for anthropometry-derived TBW in hemodialyzed patients could be due to measurement errors. However, the possibility exists that TBW space is contracted in patients with end-stage renal disease (ESRD) or that the TBW space and the urea distribution space are not identical.
Collapse
|
43
|
Canaud B, Bosc JY, Vaussenat F, Leray‐Moragues H, Leblanc M, Garred LJ, Mion C. Quantitation in Hemodialysis: Adequacy Measurement Revisited. Semin Dial 2002. [DOI: 10.1046/j.1525-139x.1999.99061.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Bernard Canaud
- Nephrology Department, Lapeyronie University Hospital, and
| | - Jean yves Bosc
- Nephrology Department, Lapeyronie University Hospital, and
| | | | | | - Martine Leblanc
- Nephrology Department, Maisonneuve‐Rosemont Hospital, Montréal, Québec, and
| | - Laurie J. Garred
- Biochemical Engineering, Lakehead University, Thunder Bay, Ontario, Canada
| | | |
Collapse
|
44
|
Koncki R, Radomska A, Głąb S. Bioanalytical flow-injection system for control of hemodialysis adequacy. Anal Chim Acta 2000. [DOI: 10.1016/s0003-2670(00)00961-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
45
|
Noiri E, Masaki I, Fujino K, Tsuchiya M. Efficacy of a continuous syringe extraction method for monitoring hemodialysis ultrafiltrate. ASAIO J 2000; 46:461-3. [PMID: 10926147 DOI: 10.1097/00002480-200007000-00019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The evaluation of hemodialysis ultrafiltrate is essential for the assessment of uremic toxins, dialyzer net performance, protein catabolic rate, and safety and environmental protection. Total dialysate collection (TDC), however, is technically far from the daily procedure used. In the present study, use of a continuous syringe extraction method (CSEM) as a substitute for TDC was tested to determine its comparative effectiveness. Measurements of urea nitrogen, creatinine, phosphate, beta2-microglobulin, and albumin were simultaneously obtained by both TDC and CSEM in 20 dialysis sessions. CSEM showed an extremely significant correlation with TDC for these values. The correlation coefficients were >0.97 for these indicators and the value of Fisher's r to z were all <0.001. Taken together, these data indicate that CSEM is an effective substitute for TDC. With use of CSEM, the evaluation of spent dialysate could become as a daily procedure.
Collapse
Affiliation(s)
- E Noiri
- First Department of Medicine, The University of Tokyo, Japan
| | | | | | | |
Collapse
|
46
|
ING TS, CHENG YL, SHEK CC, WONG KM, YANG VL, KJELLSTRAND CM, LI CS. Observations on urea kinetic modeling and adequacy of hemodialysis. Int J Organ Transplant Med 2000. [DOI: 10.1016/s1561-5413(09)60026-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
47
|
Kerr PG, Lo A, Chin MM, Atkins RC. Dialyzer performance in the clinic: comparison of six low-flux membranes. Artif Organs 1999; 23:817-21. [PMID: 10491028 DOI: 10.1046/j.1525-1594.1999.06297.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study is to assess the clinical performance of 6 different low-flux dialysis membranes under steady-state conditions in terms of urea and phosphate clearances. Ten stable hemodialysis patients were examined. The following dialyzers were studied, all in 1.5- to 1.6-m2 format: cuprammonium, cellulose acetate, cellulose diacetate, hemophane, polysulfone (low-flux), and polysynthane. The following parameters were examined: urea reduction ratio, phosphate reduction ratio, "instantaneous dialyzer clearance" for urea and phosphate, and total amount of urea and phosphate removed in the dialysate over a 1-week (three dialyses) period. Although there were differences between the membranes, all produced results within a narrow range. There was no one membrane that produced superior clearances in all categories. The cellulose acetate membrane was the least satisfactory membrane. Phosphate clearances were at best one third that of urea clearances. When choosing a low-flux dialysis membrane, urea and phosphate clearances are so similar amongst different membranes that other criteria are likely to have a greater influence on the choice of membrane.
Collapse
Affiliation(s)
- P G Kerr
- Department of Medicine, Monash University, Clayton, Victoria, Australia.
| | | | | | | |
Collapse
|
48
|
Depner TA, Greene T, Gotch FA, Daugirdas JT, Keshaviah PR, Star RA. Imprecision of the hemodialysis dose when measured directly from urea removal. Hemodialysis Study Group. Kidney Int 1999; 55:635-47. [PMID: 9987088 DOI: 10.1046/j.1523-1755.1999.00269.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The postdialysis blood urea nitrogen (BUN; Ct) is a pivotal parameter for assessing hemodialysis adequacy by conventional blood-side methods, but Ct is relatively unstable because of hemodialysis-induced disequilibrium. The uncertainty associated with this method is potentially reduced or eliminated by measuring urea removed on the dialysate side, a more direct approach that can determine adequacy from the fraction of urea removed and by substituting an estimate of the equilibrated postdialysis BUN (Ceq) for Ct. For a patient with a known urea volume (V), Ceq, the equilibrated Kt/V (eKt/V), and the solute removal index (SRI) can be calculated from the predialysis BUN (C0), total urea nitrogen removed (A), and V from simple mass balance calculations (dialysate/volume method). However, a theoretical error analysis showed that relatively small errors in A, C0, or V are magnified when SRI or eKt/V is calculated using this method, especially at higher eKt/V values (for example, if eKt/V = 1.4 per dialysis, a 7% dialysate collection error causes a 20% error in eKt/V). METHODS During three to four baseline dialyses in each of 39 patients enrolled in the pilot phase of the HEMO Study, "A" was measured using an instrument that sampled dialysate frequently (Biostat), and V was calculated from A, C0, and Ceq (median CV for V = 5.6%). The mean V was then applied to the dialysate/volume method to estimate eKt/V and SRI during two to five subsequent dialyses per patient (comparison dialyses). The accuracy and precision of these estimates were assessed by comparing them with eKt/V and SRI derived from a direct measurement of Ceq drawn 30 minutes after dialysis (reference method), from mathematical curve-fitting of sequential dialysate urea concentrations (dialysate curve-fit method), and from another blood-side method that estimates eKt/V from single pool Kt/V and the fractional rate of solute removal (rate method): eKt/V = spKt/V - 0.6.K/V + 0.03. RESULTS During 128 comparison dialyses, median absolute errors for calculated eKt/V compared with the reference method were 0.169, 0.061, and 0.071 for the dialysate/volume method, the rate method, and the dialysate curve-fitting method, respectively. The corresponding correlation coefficients were 0.47, 0.88, and 0.81. For SRI, median absolute errors were 0.044, 0.018, and 0.027, and the correlation coefficients were 0.54, 0.85, and 0.74 for the three methods. CONCLUSIONS The precision of eKt/V and SRI measurements was significantly lower for the dialysate/volume method compared with the blood-side methods. Inclusion of the dialysate curve analysis provided by the Biostat restored precision to the dialysate method to a level comparable to that of the blood-side methods. New techniques employing dialysate urea analysis should include a concentration profile to avoid these inherent methodological errors and assure the accuracy of eKt/V and SRI.
Collapse
Affiliation(s)
- T A Depner
- Division of Nephrology, University of California, Davis, Sacramento, USA.
| | | | | | | | | | | |
Collapse
|