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Zhai L, Wang S, Xue F, Yao Y. Ultrasound findings of the sternoclavicular and shoulder joints in patients on maintenance hemodialysis. Ther Apher Dial 2024; 28:371-379. [PMID: 38084611 DOI: 10.1111/1744-9987.14093] [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: 07/07/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 04/30/2024]
Abstract
INTRODUCTION Ultrasonographic examination of joints is a non-invasive method to detect and monitor Dialysis-associated amyloidosis (DRA). METHODS An ultrasonographic examination of the sternoclavicular (SC) and shoulder joints was performed in patients on maintenance hemodialysis (MHD) and those with normal renal function in the control group. The maximum distance (D) of SC, the rotator cuff thickness (RCs), and the echogenic pads (EPs) of the shoulder were evaluated. RESULTS Compared with the control group, the MHD group had a higher D of SC, a higher proportion of RCs ≥8 mm, and a higher proportion of EPs positive. Adjust for age and Kt/V, the D of SC was positively related to dialysis vintage, standardized coefficients β = 0.329, p = 0.004. A significant positive correlation existed between the D of SC and the RCs. CONCLUSION In addition to the shoulder joint, the sternoclavicular is a suitable site for ultrasonographic detection of DRA.
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Affiliation(s)
- Lin Zhai
- Department of Ultrasonography, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Siyu Wang
- Department of Nephrology, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Fei Xue
- Department of Nephrology, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Ying Yao
- Department of Nephrology, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
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Ok E, Demirci C, Asci G, Yuksel K, Kircelli F, Koc SK, Erten S, Mahsereci E, Odabas AR, Stuard S, Maddux FW, Raimann JG, Kotanko P, Kerr PG, Chan CT. Patient Survival With Extended Home Hemodialysis Compared to In-Center Conventional Hemodialysis. Kidney Int Rep 2023; 8:2603-2615. [PMID: 38106580 PMCID: PMC10719649 DOI: 10.1016/j.ekir.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up. Methods We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters. Results The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR] = 0.60; 95% confidence interval [CI] 0.45 to 0.80; P < 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement. Conclusion These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.
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3
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Portales-Castillo I, Yee J, Tanaka H, Fenves AZ. Beta-2 Microglobulin Amyloidosis: Past, Present, and Future. KIDNEY360 2020; 1:1447-1455. [PMID: 35372889 DOI: 10.34067/kid.0004922020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022]
Abstract
Almost half a century has elapsed since the first description of dialysis-related amyloidosis (DRA), a disorder caused by excessive accumulation of β-2 microglobulin (B2M). Within that period, substantial advances in RRT occurred. These improvements have led to a decrease in the incidence of DRA. In many countries, DRA is considered a "disappearing act" or complication. Although the prevalence of patients living with RRT increases, not all will have access to kidney transplantation. Consequently, the number of patients requiring interventions for treatment of DRA is postulated to increase. This postulate has been borne out in Japan, where the number of patients with ESKD requiring surgery for carpal tunnel continues to increase. Clinicians treating patients with ESKD have treatment options to improve B2M clearance; however, there is a need to identify ways to translate improved B2M clearance into improved quality of life for patients undergoing long-term dialysis.
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Affiliation(s)
- Ignacio Portales-Castillo
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
| | - Hiroshi Tanaka
- Division of Nephrology, Department of Medicine, Mihara Red Cross Hospital, Mihara, Japan
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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4
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Grewal MK, Mehta A, Chakraborty R, Raina R. Nocturnal home hemodialysis in children: Advantages, implementation, and barriers. Semin Dial 2020; 33:109-119. [PMID: 32155297 DOI: 10.1111/sdi.12863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/08/2020] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
Abstract
Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.
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Affiliation(s)
- Manpreet K Grewal
- Department of Pediatric Nephrology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Arul Mehta
- Saint Ignatius High School, Cleveland, OH, USA
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General, Akron, OH, USA
| | - Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
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5
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Lavoie MR, Patel JA, Camacho M. Nocturnal dialysis improves sleep apnea more than daytime dialysis: a meta-analysis of crossover studies. Sleep Med 2019; 64:37-42. [PMID: 31655324 DOI: 10.1016/j.sleep.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To systematically review the literature for articles evaluating differences in polysomnography (PSG) data when patients are on primarily daytime hemodialysis (conventional hemodialysis or continuous ambulatory peritoneal dialysis) versus nocturnal hemodialysis (nocturnal hemodialysis or nocturnal peritoneal dialysis). Then to perform a meta-analysis on the available PSG data, specifically evaluating differences in apnea hypopnea index (AHI) and mean saturation of oxygen (SpO2) between these two groups. METHODS Two authors systematically searched MEDLINE/Pubmed, Scopus, EMBASE, CINAHL, and Cochrane. Searches were performed through December 6, 2018. RESULTS A total of four adult crossover studies (91 patients, age 50.4 ± 12.4, BMI 25.1 ± 5.3) reported PSG data. The daytime hemodialysis (DHD) and nocturnal hemodialysis (NHD) AHI decreased from 24.6 ± 18.2 to 12.6 ± 11.8 (events/hour) with a mean difference of -11.9 [95% CI -13.47, -10.37], Z score of 15.07 (P < 0.00001). The standardized mean difference was -1.35 [95% CI -2.70, 0.01]. Two studies reported mean SpO2 changes during PSG. The DHD and NHD SpO2 increased from 92.7 ± 2.4 to 94.7 ± 2.2 with a mean difference of 2.26 [95% CI -0.18, 4.71], Z score 1.82 (P = 0.07). CONCLUSION In the current literature, nocturnal hemodialysis improves AHI more than daytime hemodialysis. A trend towards improvement in mean SpO2 with nocturnal dialysis was noted, but did not reach statistical significance. Consideration can be given for transitioning patients who have end stage renal disease and sleep apnea from daytime to nocturnal hemodialysis as an adjunct to other treatment modalities.
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Affiliation(s)
- Matthew R Lavoie
- Madigan Army Medical Center, Department of Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, WA, 98431, USA.
| | - Jagatkumar A Patel
- Madigan Army Medical Center, Department of Otolaryngology, 9040A Jackson Ave, Joint Base Lewis-McChord, WA, 98431, USA
| | - Macario Camacho
- Tripler Army Medical Center, Division of Otolaryngology-Head and Neck Surgery, 1 Jarrett White Rd, Tripler AMC, HI, 96859, USA.
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Lima A, Tavares J, Pestana N, Carvalho MJ, Cabrita A, Rodrigues A. Sodium removal in peritoneal dialysis: is there room for a new parameter in dialysis adequacy? BULLETIN DE LA DIALYSE À DOMICILE 2019. [DOI: 10.25796/bdd.v2i3.21343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In peritoneal dialysis (PD) (as well as in hemodialysis) small solute clearance measured as Kt/v urea has long been used as a surrogate of dialysis adequacy. A better urea clearance was initially thought to increase survival in dialysis patients (as shown in the CANUSA trial)(1), but reanalysis of the data showed a superior contribution of residual renal function as a predictor of patient survival. Two randomized controlled trials (RCT)(2, 3) supported this observation, demonstrating no survival benefit in patients with higher achieved Kt/v. Then guidelines were revised and a minimum Kt/v of 1,7/week was recommended but little emphasis was given to additional parameters of dialysis adequacy. As such, volume overload and sodium removal have gained major attention, since their optimization has been associated with decreased mortality in PD patients(4, 5). Inadequate sodium removal is associated with fluid overload which leads to ventricular hypertrophy and increased cardiovascular mortality(6). Individualized prescription is key for optimal sodium removal as there are differences between PD techniques (CAPD versus APD) and new strategies for sodium removal have emerged (low sodium solutions and adapted PD). In conclusion, future guidelines should address parameters associated with increased survival outcomes (sodium removal playing an important role) and abandon the current one fit all prescription model.
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7
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Wong CKH, Chen JY, Fung SKS, Lo WK, Lui SL, Chan TM, Cheng YL, Kong I, Wan EYF, Lam CLK. Health-related quality of life and health utility of Chinese patients undergoing nocturnal home haemodialysis in comparison with other modes of dialysis. Nephrology (Carlton) 2019; 24:630-637. [PMID: 29926521 DOI: 10.1111/nep.13429] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND To compare the health-related quality of life (HRQOL) and health utility of Chinese patients with end-stage renal disease (ESRD) undergoing nocturnal home haemodialysis (Home HD) against those patients undergoing other modes of dialysis. METHODS Chinese ESRD patients undergoing Home HD were recruited in renal specialist outpatient clinics at three public hospitals in Hong Kong. SF-12 Health Survey (SF-12) was used to measure HRQOL and generate the SF-6D heath utility score. Mean scores of SF-12 domains, physical and mental component summary and SF-6D health utility of 41 patients undergoing Home HD were compared with available scores of patients receiving other forms of dialysis, namely, peritoneal dialysis (PD) (n = 103), hospital in-centre HD (n = 135) or community in-centre HD (n = 118). Adjusted linear regression models were used to examine the impact of mode of dialysis on the HRQOL and health utility scores, accounting for the sociodemographic and clinical characteristics. RESULTS ESRD patients undergoing PD and community in-centre HD had better health utility, physical and mental component summary scores than the hospital in-centre HD. Adjusted analysis showed that hospital in-centre HD reported worse physical component summary and health utility scores when compared with PD and community in-centre HD. CONCLUSION HRQOL and health utility scores of patients undergoing Home HD were similar to those undergoing PD and community in-centre HD. Better physical aspects of HRQOL and health utility was observed in PD and community-based HD than hospital in-centre HD, providing evidence for the increase in capacity of non-hospital-based HD, which provided flexibility as well as patient centredness and empowerment in Hong Kong.
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Affiliation(s)
- Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Julie Y Chen
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China.,Bau Institute of Medical and Health Sciences Education, The University of Hong Kong, Hong Kong SAR, China
| | - Samuel K S Fung
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
| | - Sing Leung Lui
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
| | - Tak Mao Chan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yuk Lun Cheng
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Irene Kong
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Eric Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
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8
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Huang SHS, Kaysen GA, Levin NW, Kliger AS, Beck GJ, Rocco MV, Filler G, Lindsay RM. The effect of increased frequency of hemodialysis on serum cystatin C and β2-microglobulin concentrations: A secondary analysis of the frequent hemodialysis network (FHN) trial. Hemodial Int 2019; 23:297-305. [DOI: 10.1111/hdi.12749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/25/2019] [Accepted: 02/09/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Shih-Han S. Huang
- Department of Medicine, Division of Nephrology; Western University; London Canada
- Department of Medical Biophysics; Western University; London Canada
- Departments of Paediatrics and Pathology and Laboratory Medicine; Western University; London Canada
| | - George A. Kaysen
- Department of Medicine, Division of Nephrology and Department of Biochemistry and Molecular Medicine; University of California Davis School of Medicine; Davis California USA
| | - Nathan W. Levin
- Mount Sinai Icahn School of Medicine; New York City New York USA
| | - Alan S. Kliger
- School of Medicine, and Yale New Haven Health System; New Haven Connecticut USA
| | | | - Michael V. Rocco
- Department of Medicine, Section on Nephrology; Wake Forest University School of Medicine; Winston-Salem North Carolina USA
| | - Guido Filler
- Department of Medicine, Division of Nephrology; Western University; London Canada
- Departments of Paediatrics and Pathology and Laboratory Medicine; Western University; London Canada
| | - Robert M. Lindsay
- Department of Medicine, Division of Nephrology; Western University; London Canada
- Department of Medical Biophysics; Western University; London Canada
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9
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Kaneko S, Yamagata K. Hemodialysis-related amyloidosis: Is it still relevant? Semin Dial 2018; 31:612-618. [DOI: 10.1111/sdi.12720] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Shuzo Kaneko
- Department of Nephrology; Faculty of Medicine; University of Tsukuba; Tsukuba Ibaraki Japan
| | - Kunihiro Yamagata
- Department of Nephrology; Faculty of Medicine; University of Tsukuba; Tsukuba Ibaraki Japan
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10
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Affiliation(s)
- A. Pierratos
- Humber River Regional Hospital, University of Toronto, Toronto, Ontario - Canada
| | - M. Ouwendyk
- Humber River Regional Hospital, University of Toronto, Toronto, Ontario - Canada
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12
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Vanholder R, Pletinck A, Schepers E, Glorieux G. Biochemical and Clinical Impact of Organic Uremic Retention Solutes: A Comprehensive Update. Toxins (Basel) 2018; 10:toxins10010033. [PMID: 29316724 PMCID: PMC5793120 DOI: 10.3390/toxins10010033] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/21/2017] [Accepted: 12/23/2017] [Indexed: 02/07/2023] Open
Abstract
In this narrative review, the biological/biochemical impact (toxicity) of a large array of known individual uremic retention solutes and groups of solutes is summarized. We classified these compounds along their physico-chemical characteristics as small water-soluble compounds or groups, protein bound compounds and middle molecules. All but one solute (glomerulopressin) affected at least one mechanism with the potential to contribute to the uremic syndrome. In general, several mechanisms were influenced for each individual solute or group of solutes, with some impacting up to 7 different biological systems of the 11 considered. The inflammatory, cardio-vascular and fibrogenic systems were those most frequently affected and they are one by one major actors in the high morbidity and mortality of CKD but also the mechanisms that have most frequently been studied. A scoring system was built with the intention to classify the reviewed compounds according to the experimental evidence of their toxicity (number of systems affected) and overall experimental and clinical evidence. Among the highest globally scoring solutes were 3 small water-soluble compounds [asymmetric dimethylarginine (ADMA); trimethylamine-N-oxide (TMAO); uric acid], 6 protein bound compounds or groups of protein bound compounds [advanced glycation end products (AGEs); p-cresyl sulfate; indoxyl sulfate; indole acetic acid; the kynurenines; phenyl acetic acid;] and 3 middle molecules [β2-microglobulin; ghrelin; parathyroid hormone). In general, more experimental data were provided for the protein bound molecules but for almost half of them clinical evidence was missing in spite of robust experimental data. The picture emanating is one of a complex disorder, where multiple factors contribute to a multisystem complication profile, so that it seems of not much use to pursue a decrease of concentration of a single compound.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Anneleen Pletinck
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Eva Schepers
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
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13
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Spontaneous variability of pre-dialysis concentrations of uremic toxins over time in stable hemodialysis patients. PLoS One 2017; 12:e0186010. [PMID: 29016645 PMCID: PMC5634633 DOI: 10.1371/journal.pone.0186010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/22/2017] [Indexed: 02/07/2023] Open
Abstract
Background and aim Numerous outcome studies and interventional trials in hemodialysis (HD) patients are based on uremic toxin concentrations determined at one single or a limited number of time points. The reliability of these studies however entirely depends on how representative these cross-sectional concentrations are. We therefore investigated the variability of predialysis concentrations of uremic toxins over time. Methods Prospectively collected predialysis serum samples of the midweek session of week 0, 1, 2, 3, 4, 8, 12, and 16 were analyzed for a panel of uremic toxins in stable chronic HD patients (N = 18) while maintaining dialyzer type and dialysis mode during the study period. Results Concentrations of the analyzed uremic toxins varied substantially between individuals, but also within stable HD patients (intra-patient variability). For urea, creatinine, beta-2-microglobulin, and some protein-bound uremic toxins, Intra-class Correlation Coefficient (ICC) was higher than 0.7. However, for phosphorus, uric acid, symmetric and asymmetric dimethylarginine, and the protein-bound toxins hippuric acid and indoxyl sulfate, ICC values were below 0.7, implying a concentration variability within the individual patient even exceeding 65% of the observed inter-patient variability. Conclusion Intra-patient variability may affect the interpretation of the association between a single concentration of certain uremic toxins and outcomes. When performing future outcome and interventional studies with uremic toxins other than described here, one should quantify their intra-patient variability and take into account that for solutes with a large intra-patient variability associations could be missed.
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Tangvoraphonkchai K, Davenport A. Increasing Haemodialytic Clearances as Residual Renal Function Declines: An Incremental Approach. Blood Purif 2017; 44:217-226. [DOI: 10.1159/000475458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/02/2017] [Indexed: 11/19/2022]
Abstract
Many patients with chronic kidney disease start undergoing thrice-weekly haemodialysis (HD), aiming for an HD sessional dialyzer urea clearance target, irrespective of whether they have residual renal function (RRF). While increasing sessional dialyzer urea clearance above a target of 1.2 has not been shown to improve patient survival, it has been shown that the preservation of RRF improves patient self-reported outcomes and survival. Observational studies have suggested that initiating twice-weekly HD schedules leads to greater preservation of RRF. This has led to the concept of following an incremental approach to initiating HD, steadily increasing the amount of weekly dialyzer clearance as RRF decreases. Incremental dialysis practice requires the regular assessment of RRF to prevent inadequate delivery of dialysis treatment. Once RRF is lost, then the dialysis schedule and modality need to be adjusted to try to increase the middle-sized solute clearance and protein-bound toxins.
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15
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Sirich TL. Obstacles to reducing plasma levels of uremic solutes by hemodialysis. Semin Dial 2017; 30:403-408. [DOI: 10.1111/sdi.12609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Tammy L. Sirich
- The Department of Medicine; VA Palo Alto Health Care System and Stanford University; Palo Alto CA USA
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16
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Labriola L, Jadoul M. Dialysis-related Amyloidosis: Is It Gone or Should It Be? Semin Dial 2017; 30:193-196. [DOI: 10.1111/sdi.12590] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Laura Labriola
- Department of Nephrology; Cliniques universitaires Saint-Luc; Université catholique de Louvain; Brussels Belgium
| | - Michel Jadoul
- Department of Nephrology; Cliniques universitaires Saint-Luc; Université catholique de Louvain; Brussels Belgium
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17
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Underwood CF, Hildreth CM, Wyse BF, Boyd R, Goodchild AK, Phillips JK. Uraemia: an unrecognized driver of central neurohumoral dysfunction in chronic kidney disease? Acta Physiol (Oxf) 2017; 219:305-323. [PMID: 27247097 DOI: 10.1111/apha.12727] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 01/21/2016] [Accepted: 05/31/2016] [Indexed: 12/12/2022]
Abstract
Chronic kidney disease (CKD) carries a large cardiovascular burden in part due to hypertension and neurohumoral dysfunction - manifesting as sympathetic overactivity, baroreflex dysfunction and chronically elevated circulating vasopressin. Alterations within the central nervous system (CNS) are necessary for the expression of neurohumoral dysfunction in CKD; however, the underlying mechanisms are poorly defined. Uraemic toxins are a diverse group of compounds that accumulate as a direct result of renal disease and drive dysfunction in multiple organs, including the brain. Intensive haemodialysis improves both sympathetic overactivity and cardiac baroreflex sensitivity in renal failure patients, indicating that uraemic toxins participate in the maintenance of autonomic dysfunction in CKD. In rodents exposed to uraemia, immediate early gene expression analysis suggests upregulated activity of not only pre-sympathetic but also vasopressin-secretory nuclei. We outline several potential mechanisms by which uraemia might drive neurohumoral dysfunction in CKD. These include superoxide-dependent effects on neural activity, depletion of nitric oxide and induction of low-grade systemic inflammation. Recent evidence has highlighted superoxide production as an intermediate for the depolarizing effect of some uraemic toxins on neuronal cells. We provide preliminary data indicating augmented superoxide production within the hypothalamic paraventricular nucleus in the Lewis polycystic kidney rat, which might be important for mediating the neurohumoral dysfunction exhibited in this CKD model. We speculate that the uraemic state might serve to sensitize the central actions of other sympathoexcitatory factors, including renal afferent nerve inputs to the CNS and angiotensin II, by way of recruiting convergent superoxide-dependent and pro-inflammatory pathways.
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Affiliation(s)
- C. F. Underwood
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - C. M. Hildreth
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - B. F. Wyse
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - R. Boyd
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - A. K. Goodchild
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - J. K. Phillips
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
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18
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Scarpioni R, Ricardi M, Albertazzi V, De Amicis S, Rastelli F, Zerbini L. Dialysis-related amyloidosis: challenges and solutions. Int J Nephrol Renovasc Dis 2016; 9:319-328. [PMID: 27994478 PMCID: PMC5153266 DOI: 10.2147/ijnrd.s84784] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Amyloidosis refers to the extracellular tissue deposition of fibrils composed of low-molecular-weight subunits of a variety of proteins. These deposits may result in a wide range of clinical manifestations depending upon their type, location, and the amount of deposition. Dialysis-related amyloidosis is a serious complication of long-term dialysis therapy and is characterized by the deposition of amyloid fibrils, principally composed of β2 microglobulins (β2M), in the osteoarticular structures and viscera. Most of the β2M is eliminated through glomerular filtration and subsequent reabsorption and catabolism by the proximal tubules. As a consequence, the serum levels of β2M are inversely related to the glomerular filtration rate; therefore, in end-stage renal disease patients, β2M levels increase up to 60-fold. Serum levels of β2M are also elevated in several pathological conditions such as chronic inflammation, liver disease, and above all, in renal dysfunction. Retention of amyloidogenic protein has been attributed to several factors including type of dialysis membrane, prolonged uremic state and/or decreased diuresis, advanced glycation end products, elevated levels of cytokines and dialysate. Dialysis treatment per se has been considered to be an inflammatory stimulus, inducing cytokine production (such as interleukin-1, tumor necrosis factor-α, interleukin-6) and complement activation. The released cytokines are thought to stimulate the synthesis and release of β2M by the macrophages and/or augment the expression of human leukocyte antigens (class I), increasing β2M expression. Residual renal function is probably the best determinant of β2M levels. Therefore, it has to be maintained as long as possible. In this article, we will focus our attention on the etiology of dialysis-related amyloidosis, its prevention, therapy, and future solutions.
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Affiliation(s)
- R Scarpioni
- Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital "Guglielmo da Saliceto", Piacenza, Italy
| | - M Ricardi
- Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital "Guglielmo da Saliceto", Piacenza, Italy
| | - V Albertazzi
- Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital "Guglielmo da Saliceto", Piacenza, Italy
| | - S De Amicis
- Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital "Guglielmo da Saliceto", Piacenza, Italy
| | - F Rastelli
- Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital "Guglielmo da Saliceto", Piacenza, Italy
| | - L Zerbini
- Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital "Guglielmo da Saliceto", Piacenza, Italy
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Kraus MA, Fluck RJ, Weinhandl ED, Kansal S, Copland M, Komenda P, Finkelstein FO. Intensive Hemodialysis and Health-Related Quality of Life. Am J Kidney Dis 2016; 68:S33-S42. [DOI: 10.1053/j.ajkd.2016.05.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 02/08/2023]
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Leypoldt JK, Meijers BKI. Effect of Treatment Duration and Frequency on Uremic Solute Kinetics, Clearances and Concentrations. Semin Dial 2016; 29:463-470. [PMID: 27578429 DOI: 10.1111/sdi.12531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The kinetics of uremic solute clearances are discussed based on two categories of uremic solutes, namely those that are and those that are not derived directly from nutrient intake, particularly dietary protein intake. This review highlights dialysis treatments that are more frequent and longer (high-dose hemodialysis) than conventional thrice weekly therapy. It is proposed that the dialysis dose measures based on urea as a marker uremic solute, such as Kt/V and stdKt/V, be referred to as measures of dialysis inadequacy, not dialysis adequacy. For uremic solutes derived directly from nutrient intake, it is suggested that inorganic phosphorus and protein-bound uremic solutes be considered as markers in the development of alternative measures of dialysis dose for high-dose hemodialysis prescriptions. As the current gap in understanding the detailed kinetics of protein-bound uremic solutes, it is proposed that normalization of serum phosphorus concentration with a minimum (or preferably without a) need for oral-phosphorus binders be targeted as a measure of dialysis adequacy in high-dose hemodialysis. For large uremic solutes not derived directly from nutrient intake (middle molecules), use of extracorporeal clearances for β2 -microglobulin that are higher than currently available during thrice weekly therapy is unlikely to reduce predialysis serum β2 -microglobulin concentrations. High-dose hemodialysis prescriptions will lead to reductions in predialysis serum β2 -microglobulin concentrations, but such reductions are also limited by significant residual kidney clearance. Kinetic data regarding middle molecules larger than β2 -microglobulin are scarce; additional studies on such uremic solutes are of high interest to better understand improved methods for prescribing high-dose hemodialysis prescriptions to improve patient outcomes.
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Affiliation(s)
- John K Leypoldt
- Renal Therapeutic Area and Medical Affairs, Baxter Healthcare Corporation, Deerfield, Illinois.
| | - Björn K I Meijers
- Division of Nephrology, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
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Churchward DR, Graham-Brown MPM, Preston R, Pickering W, McCann GP, Burton JO. Investigating the effects of 6 months extended duration, in-centre nocturnal versus conventional haemodialysis treatment: a non-randomised, controlled feasibility study. BMJ Open 2016; 6:e012583. [PMID: 27609856 PMCID: PMC5020664 DOI: 10.1136/bmjopen-2016-012583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/28/2016] [Accepted: 08/12/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION In-centre nocturnal haemodialysis (INHD) is an underutilised dialysis regimen that can potentially provide patients with better clinical outcomes due to extended treatment times. We have established an INHD programme within our clinical network, fulfilling a previously unmet patient need. This feasibility study aims to gather sufficient data on numerous outcome measures to inform the design of a multicentre randomised controlled trial that will establish the potential benefits of INHD and increase the availability of this service nationally and internationally. METHODS AND ANALYSIS This will be a non-randomised controlled study. Prevalent patients on haemodialysis (HD) will electively change from a conventional in-centre HD regimen of 4 hours thrice weekly to a regimen of extended treatment times (5-8 hours) delivered in-centre overnight thrice weekly. After recruitment of the INHD cohort, a group of patients matched for age, gender and dialysis vintage will be selected from patients remaining on a conventional daytime dialysis programme. Outcome measures will include left ventricular mass as measured by MRI, physical performance measured by the short physical performance battery and physical activity measured by accelerometry. Additionally we will measure quality of life using validated questionnaires, nutritional status by bioimpedance spectroscopy and food diaries, and blood sampling for markers of cardiovascular disease, systemic inflammation. Suitable statistical tests shall be used to analyse the data. We will use omnibus tests to observe changes over the duration of the intervention and between groups. We will also look for associations between outcome measures that may warrant further investigation. These data will be used to inform the power calculation for future studies. ETHICS AND DISSEMINATION A favourable opinion was granted by Northampton Research Ethics Committee (15/EM/0268). It is anticipated that results of this study will be presented at national and international meetings, with reports being published in journals during 2017. TRIAL REGISTRATION NUMBER ISRCTN16672784.
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Affiliation(s)
- Darren R Churchward
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Matthew P M Graham-Brown
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Robert Preston
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Warren Pickering
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiology, NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - James O Burton
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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A systematic review of central sleep apnea in adult patients with chronic kidney disease. Sleep Breath 2016; 20:957-64. [DOI: 10.1007/s11325-016-1317-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/31/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
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Rassaf T, Rammos C, Hendgen-Cotta UB, Heiss C, Kleophas W, Dellanna F, Floege J, Hetzel GR, Kelm M. Vasculoprotective Effects of Dietary Cocoa Flavanols in Patients on Hemodialysis: A Double-Blind, Randomized, Placebo-Controlled Trial. Clin J Am Soc Nephrol 2015; 11:108-18. [PMID: 26681132 DOI: 10.2215/cjn.05560515] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/15/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Hemodialysis (HD) per se entails vascular dysfunction in patients with ESRD. Endothelial dysfunction is a key step in atherosclerosis and is characterized by impaired flow-mediated dilation (FMD). Interventional studies have shown that cocoa flavanol (CF)-rich supplements improve vascular function. Aim of this study was to investigate the effect of flavanol-rich bioactive food ingredients on acute and chronic HD-induced vascular dysfunction in ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a randomized, double-blind, placebo-controlled trial from 2012 to 2013. Fifty-seven participants were enrolled, ingested CF-rich beverages (900 mg CF per study day), and were compared with those ingesting CF-free placebo. This included (1) a baseline cross-over acute study to determine safety and efficacy of CF and (2) a subsequent chronic parallel group study with a 30-day follow-up period to study effects of CF on HD-mediated vascular dysfunction entailing (3) an acute substudy during HD in flavanol-naive patients and (4) an acute on chronic study during HD. Primary and secondary outcome measures included changes in FMD and hemodynamics. RESULTS CF ingestion was well tolerated. Acute ingestion improved FMD by 53% (3.2±0.6% to 4.8±0.9% versus placebo, 3.2±0.7% to 3.3±0.8%; P<0.001), with no effects on BP or heart rate. A 30-day ingestion of CF led to an increase in baseline FMD by 18% (3.4±0.9% to 3.9±0.8% versus placebo, 3.5±0.7% to 3.5±0.7%; P<0.001), with reduced diastolic BP (73±12 to 69±11 mmHg versus placebo, 70±11 to 73±13 mmHg; P=0.03) and increased heart rate (70±12 to 74±13 bpm versus placebo, 75±15 to 74±13 bpm; P=0.01). No effects were observed for placebo. Acute ingestion of CF during HD alleviated HD-induced vascular dysfunction (3.4±0.9% to 2.7±0.6% versus placebo, 3.5±0.7% to 2.0±0.6%; P<0.001). This effect was sustained throughout the study (acute on chronic, 3.9±0.9% to 3.0±0.7% versus placebo, 3.5±0.7% to 2.2±0.6; P=0.01). CONCLUSIONS Dietary CF ingestion mitigates acute HD-induced and chronic endothelial dysfunction in patients with ESRD and thus, improves vascular function in this high-risk population. Larger clinical trials are warranted to test whether this translates into an improved cardiovascular prognosis in patients with ESRD.
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Affiliation(s)
- Tienush Rassaf
- Department of Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany;
| | - Christos Rammos
- Department of Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Ulrike B Hendgen-Cotta
- Department of Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Heiss
- Department of Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | | | - Jürgen Floege
- Department of Nephrology, Rheinish-Westphalian Technical High School, University of Aachen, Aachen, Germany; and
| | | | - Malte Kelm
- Department of Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany; Medical Faculty, Cardiovascular Research Institute Düsseldorf (CARID), University Hospital Düsseldorf, Düsseldorf, Germany
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Palmer SC, Palmer AR, Craig JC, Johnson DW, Stroumza P, Frantzen L, Leal M, Hoischen S, Hegbrant J, Strippoli GFM. Home versus in-centre haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2014; 2014:CD009535. [PMID: 25412074 PMCID: PMC7390476 DOI: 10.1002/14651858.cd009535.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Home haemodialysis is associated with improved survival and quality of life in uncontrolled studies. However, relative benefits and harms of home versus in-centre haemodialysis in randomised controlled trials (RCTs) are uncertain. OBJECTIVES To evaluate the benefits and harms of home haemodialysis versus in-centre haemodialysis in adults with end-stage kidney disease (ESKD). SEARCH METHODS The Cochrane Renal Group's Specialised Register was searched up to 31 October 2014. SELECTION CRITERIA RCTs of home versus in-centre haemodialysis in adults with ESKD were included. DATA COLLECTION AND ANALYSIS Data were extracted by two investigators independently. Study risk of bias and other patient-centred outcomes were extracted. Insufficient data were available to conduct meta-analyses. MAIN RESULTS We identified a single cross-over RCT (enrolling 9 participants) that compared home haemodialysis (long hours: 6 to 8 hours, 3 times/week) with in-centre haemodialysis (short hours: 3.5 to 4.5 hours, 3 times/weeks) for 8 weeks in prevalent home haemodialysis patients. Outcome data were limited and not available for the end of the first phase of treatment in this cross-over study which was at risk of bias due to differences in dialysate composition between the two treatment comparisons.Overall, home haemodialysis reduced 24 hour ambulatory blood pressure and improved uraemic symptoms, but increased treatment-related burden of disease and interference in social activities. Insufficient data were available for mortality, hospitalisation or dialysis vascular access complications or treatment durability. AUTHORS' CONCLUSIONS Insufficient randomised data were available to determine the effects of home haemodialysis on survival, hospitalisation, and quality of life compared with in-centre haemodialysis. Given the consistently observed benefits of home haemodialysis on quality of life and survival in uncontrolled studies, and the low prevalence of home haemodialysis globally, randomised studies evaluating home haemodialysis would help inform clinical practice and policy.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Andrew R Palmer
- Consorzio Mario Negri SudDepartment of Clinical Pharmacology and EpidemiologyVia Nationale 8/aMaria ImbaroItaly66030
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Paul Stroumza
- Diaverum MarseilleMedical OfficeRue Gaston BergerMarseilleFrance13010
| | - Luc Frantzen
- Diaverum MarseilleMedical OfficeRue Gaston BergerMarseilleFrance13010
| | - Miguel Leal
- Diaverum PortugalMedical OfficeSintra Business Park, Zona Industrial da AbrunheiraEdificio 4 ‐ Escritorio 2CSintraPortugal2710‐089
| | | | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- DiaverumMedical‐Scientific OfficeLundSweden
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Cornelis T, van der Sande FM, Eloot S, Cardinaels E, Bekers O, Damoiseaux J, Leunissen KM, Kooman JP. Acute Hemodynamic Response and Uremic Toxin Removal in Conventional and Extended Hemodialysis and Hemodiafiltration: A Randomized Crossover Study. Am J Kidney Dis 2014; 64:247-56. [DOI: 10.1053/j.ajkd.2014.02.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 02/10/2014] [Indexed: 01/06/2023]
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Lamy T, Henri P, Lobbedez T, Comby E, Ryckelynck JP, Ficheux M. Comparison between on-line high-efficiency hemodiafiltration and conventional high-flux hemodialysis for polyclonal free light chain removal. Blood Purif 2014; 37:93-8. [PMID: 24603634 DOI: 10.1159/000357968] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 12/12/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Polyclonal free light chains (FLC) are considered as middle molecular weight uremic toxins in chronic kidney disease. In this study, we investigate polyclonal FLC removal by comparing conventional high-flux hemodialysis (HD) and online high-efficiency hemodiafiltration (ol-HDF) in end-stage renal disease patients. METHODS We analyzed 31 chronic dialysis patients who were treated by HD then by postdilution ol-HDF during a prospective study. All patients were anuric and without monoclonal gammopathy. Serum pre- and postdialysis FLC were collected during 4 sessions: 1 HD session and 3 ol-HDF sessions. We calculated the reduction ratio using kinetic modeling. RESULTS The κ reduction ratio was higher with ol-HDF than with HD (66 ± 14 vs. 52 ± 13%, p < 0.001). However, the λ reduction ratio was not significantly higher with ol-HDF (37 ± 20 vs. 37 ± 15%, p = 0.67). Furthermore, predialysis κ- and λ-FLC increased with ol-HDF compared with HD (κ 155 ± 82 vs. 87 ± 47 mg/l, p < 0.05; λ 101 ± 46 vs. 72 ± 41 mg/l, p < 0.05). Postdialysis FLC levels were raised only for λ-FLC with ol-HDF (74 ± 39 vs. 53 ± 31 mg/l, p < 0.05) and were not significantly different for κ. CONCLUSIONS This study shows that κ-FLC removal is better in ol-HDF compared with HD, whereas there is no difference in λ-FLC removal. Surprisingly, predialysis κ and λ levels are both increased in ol-HDF, which is disturbing since polyclonal excess of λ-FLC is associated with mortality in chronic kidney disease.
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Affiliation(s)
- Thomas Lamy
- Department of Nephrology, CHU Clemenceau, Caen, France
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Eloot S, Ledebo I, Ward RA. Extracorporeal Removal of Uremic Toxins: Can We Still Do Better? Semin Nephrol 2014; 34:209-27. [DOI: 10.1016/j.semnephrol.2014.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Leypoldt JK, Holmes CJ, Rutherford P. Clearance of middle molecules during haemodialysis and haemodiafiltration: new insights. Nephrol Dial Transplant 2013; 27:4245-7. [PMID: 23235952 DOI: 10.1093/ndt/gfs475] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- John K Leypoldt
- Medical Products (Renal), Baxter Healthcare Corporation, One Baxter Parkway, DF5-1E, Deerfield, IL 60015,USA.
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Nesrallah GE, Mustafa RA, MacRae J, Pauly RP, Perkins DN, Gangji A, Rioux JP, Steele A, Suri RS, Chan CT, Copland M, Komenda P, McFarlane PA, Pierratos A, Lindsay R, Zimmerman DL. Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis. Am J Kidney Dis 2013; 62:187-98. [DOI: 10.1053/j.ajkd.2013.02.351] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/14/2013] [Indexed: 11/11/2022]
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Abstract
Patients receiving conventional hemodialysis have high hospitalisation rates, poor quality of life and survival compared to the general population. Many centres around the world are providing longer hours of hemodialysis - short daily hemodialysis and nocturnal hemodialysis - with a view to improving patient survival and quality of life. Studies have shown that nocturnal haemodiaysis is more effective than conventional hemodialysis in clearing most small, middle and larger molecule toxins and suggest nocturnal dialysis enhances patient survival and quality of life. Concerns include patient acceptance, vascular access related complications and increased cost. The purpose of this review is to examine the advantages and drawbacks of nocturnal dialysis, with a focus on applicability to India where the renal physician has to face cultural and economic barriers, erratic power supply and poor water quality.
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Affiliation(s)
- D Ranganathan
- Department of Renal Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Heaf JG, Axelsen M, Pedersen RS. Multipass haemodialysis: a novel dialysis modality. Nephrol Dial Transplant 2012; 28:1255-64. [PMID: 23136214 PMCID: PMC3661003 DOI: 10.1093/ndt/gfs484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Heaf et al. describe the novel multipass system as a most useful application in the setting of daily extended dialysis at home and suggests a number of modifications to our classical dialysis paradigm aimed at reducing water consumption. Their paper shows how continued creative thinking can modify the classical set-up of dialysis to obtain a system which at the same time could be more economical, ecological and simple. Introduction Most home haemodialysis (HD) modalities are limited to home use since they are based on a single-pass (SP) technique, which requires preparation of large amounts of dialysate. We present a new dialysis method, which requires minimal dialysate volumes, continuously recycled during treatment [multipass HD (MPHD)]. Theoretical calculations suggest that MPHD performed six times weekly for 8 h/night, using a dialysate bath containing 50% of the calculated body water, will achieve urea clearances equivalent to conventional HD 4 h thrice weekly, and a substantial clearance of higher middle molecules. Methods Ten stable HD patients were dialyzed for 4 h using standard SPHD (dialysate flow 500 mL/min). Used dialysate was collected. One week later, an 8-h MPHD was performed. The dialysate volume was 50% of the calculated water volume, the dialysate inflow 500 mL/min−0.5 × ultrafiltration/min and the outflow 500 mL/min + 0.5 × ultrafiltration/min. Elimination rates of urea, creatinine, uric acid, phosphate and β2-microglobulin (B2M) and dialysate saturation were determined hourly. Results Three hours of MPHD removed 49, 54, 50, 51 and 57%, respectively, of the amounts of urea, creatinine, uric acid, phosphate and B2M that were removed by 4 h conventional HD. The corresponding figures after 8 h MPHD were 63, 78, 74, 78 and 111%. Conclusions Clearance of small molecules using MPHD 6 × 8 h/week will exceed traditional HD 3 × 4 h/week. Similarly, clearance of large molecules will significantly exceed traditional HD and HD 5 × 2.5 h/week. This modality will increase patients' freedom of movement compared with traditional home HD. The new method can also be used in the intensive care unit and for automated peritoneal dialysis.
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Affiliation(s)
- James Goya Heaf
- Department of Nephrology B, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Eloot S, Van Biesen W, Vanholder R. A Sad but Forgotten Truth: The Story of Slow-Moving Solutes in Fast Hemodialysis. Semin Dial 2012; 25:505-9. [DOI: 10.1111/j.1525-139x.2012.01107.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
The recently concluded Frequent Hemodialysis Network (FHN) trials have demonstrated some striking and unexpected results. Both the daily arm and the nocturnal arm of the trial clearly demonstrated that frequent (daily or nightly) dialysis reduced blood pressure, reduced the number of antihypertensive medications, and reduced serum phosphorous concentration. One of the major questions addressed by these studies was the extent to which left ventricular mass was reduced by frequent dialysis. While the daily FHN trial showed a clear effect of frequent dialysis to reduce left ventricular mass, the nocturnal FHN trial produced inconclusive results. These apparently contradictory results are probably influenced by inadequate power and the somewhat skewed patient selection in the nocturnal arm. Patients in the nocturnal FHN trial had a shorter time on dialysis prior to enrollment, and greater residual renal function than did patients in the daily FHN trial. From a general perspective, it appears that there is minimal difference in the effect on left ventricular mass between frequent daily dialysis and nocturnal dialysis. The FHN trial was not designed to determine the effects of frequent dialysis on mortality. The analyses of this question using retrospective data strongly suggest that frequent dialysis prolongs life. The nephrology community now has the task to develop new ways to deliver improved therapy to patients on dialysis. This task will be challenging as resources for health care are constrained. New approaches to the care of such patients will be needed to realize the important conceptual advances embedded in the results of the FHN trials.
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Affiliation(s)
- John B Stokes
- Division of Nephrology, Department of Internal Medicine, University of Iowa Carver College of Medicine and Department of Veteran's Affairs Medical Center, Iowa City, Iowa, USA.
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Maduell F, Arias M, Duran CE, Vera M, Fontsere N, Azqueta M, Rico N, Perez N, Sentis A, Elena M, Rodriguez N, Arcal C, Bergada E, Cases A, Bedini JL, Campistol JM. Nocturnal, every-other-day, online haemodiafiltration: an effective therapeutic alternative. Nephrol Dial Transplant 2011; 27:1619-31. [DOI: 10.1093/ndt/gfr491] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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TANG HONLOK, WONG JOSEPHHS, POON CLARAKY, TANG CANDICMK, CHU KWOKHONG, LEE WILLIAM, FUNG SAMUELKS, CHAU KAFOON, LI CHUNSANG, TONG KWOKLUNG. One year experience of nocturnal home haemodialysis with an alternate night schedule in Hong Kong. Nephrology (Carlton) 2010; 16:57-62. [DOI: 10.1111/j.1440-1797.2010.01371.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ok E, Duman S, Asci G, Tumuklu M, Onen Sertoz O, Kayikcioglu M, Toz H, Adam SM, Yilmaz M, Tonbul HZ, Ozkahya M. Comparison of 4- and 8-h dialysis sessions in thrice-weekly in-centre haemodialysis: A prospective, case-controlled study. Nephrol Dial Transplant 2010; 26:1287-96. [DOI: 10.1093/ndt/gfq724] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lameire N, Van Biesen W, Vanholder R. Did 20 years of technological innovations in hemodialysis contribute to better patient outcomes? Clin J Am Soc Nephrol 2010; 4 Suppl 1:S30-40. [PMID: 19996003 DOI: 10.2215/cjn.04000609] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
During the past two decades, impressive technological innovations have been introduced in the field of hemodialysis. This review analyzes whether these have been translated into better patient survival. The potential impacts of an increase in dialysis dosage, the preference of high-flux versus low-flux membranes, the choice between convection and diffusion as dialysis strategy, the chemical composition and biologic purity of dialysate, the effect of sodium, potassium, volume profiling, and the intradialytic volume monitoring aiming at improving hemodynamic stability are explored. Studies in which the dialysis dosage was increased were not associated with increased patient survival, whereas the superiority of high-flux over low-flux membranes is not convincingly demonstrated. Although strict evidence is lacking, observational data suggest an advantage of convective over pure diffusive strategies. Longer duration of the dialysis sessions and/or higher frequency of dialysis is probably beneficial, but the results of powerful randomized, controlled trials should be awaited. Sodium profiling has more disadvantages than advantages, whereas potassium profiling mainly in arrhythmia-prone patients with ventricular hypertrophy should be considered. Intradialytic blood volume monitoring has reduced intradialytic hypotension episodes, but hard evidence for improving patient survival is lacking. Overall, the major technological advances in dialysis have not yet been translated into longer patient survival. Optimal predialysis care in preventing the cardiovascular damage that accumulates before the start of dialysis and timely creation of an arteriovenous fistula as vascular access is a more effective and more economic strategy in the long-term outcome of the dialysis patient.
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Affiliation(s)
- Norbert Lameire
- Renal Division, Department of Medicine, University Hospital, 185, De Pintelaan, 9000 Gent-Belgium.
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TOUSSAINT NIGELD. Review: Differences in prescription between conventional and alternative haemodialysis. Nephrology (Carlton) 2010; 15:399-405. [DOI: 10.1111/j.1440-1797.2010.01287.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Penne EL, van der Weerd NC, Blankestijn PJ, van den Dorpel MA, Grooteman MPC, Nubé MJ, Ter Wee PM, Lévesque R, Bots ML. Role of residual kidney function and convective volume on change in beta2-microglobulin levels in hemodiafiltration patients. Clin J Am Soc Nephrol 2009; 5:80-6. [PMID: 19965537 DOI: 10.2215/cjn.03340509] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Removal of beta2-microglobulin (beta2M) can be increased by adding convective transport to hemodialysis (HD). The aim of this study was to investigate the change in beta2M levels after 6-mo treatment with hemodiafiltration (HDF) and to evaluate the role of residual kidney function (RKF) and the amount of convective volume with this change. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Predialysis serum beta2M levels were evaluated in 230 patients with and 176 patients without RKF from the CONvective TRAnsport STudy (CONTRAST) at baseline and 6 mo after randomization for online HDF or low-flux HD. In HDF patients, potential determinants of change in beta2M were analyzed using multivariable linear regression models. RESULTS Mean serum beta2M levels decreased from 29.5 +/- 0.8 (+/-SEM) at baseline to 24.3 +/- 0.6 mg/L after 6 mo in HDF patients and increased from 31.9 +/- 0.9 to 34.4 +/- 1.0 mg/L in HD patients, with the difference of change between treatment groups being statistically significant (regression coefficient -7.7 mg/L, 95% confidence interval -9.5 to -5.6, P < 0.001). This difference was more pronounced in patients without RKF as compared with patients with RKF. In HDF patients, beta2M levels remained unchanged in patients with GFR >4.2 ml/min/1.73 m2. The beta2M decrease was not related to convective volume. CONCLUSIONS This study demonstrated effective lowering of beta2M levels by HDF, especially in patients without RKF. The role of the amount of convective volume on beta2M decrease appears limited, possibly because of resistance to beta2M transfer between body compartments.
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Affiliation(s)
- E Lars Penne
- Department of Nephrology, VU Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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TROIDLE L, FINKELSTEIN F, HOTCHKISS M, LEYPOLDT JK. Enhanced solute removal with intermittent, in-center, 8-hour nocturnal hemodialysis. Hemodial Int 2009; 13:487-91. [DOI: 10.1111/j.1542-4758.2009.00383.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bayliss G, Danziger J. Nocturnal versus conventional haemodialysis: some current issues. Nephrol Dial Transplant 2009; 24:3612-7. [PMID: 19767631 DOI: 10.1093/ndt/gfp491] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chan CT, Lovren F, Pan Y, Verma S. Nocturnal haemodialysis is associated with improved vascular smooth muscle cell biology. Nephrol Dial Transplant 2009; 24:3867-71. [DOI: 10.1093/ndt/gfp495] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Kohn OF, Coe FL, Ing TS. Solute kinetics with short-daily home hemodialysis using slow dialysate flow rate. Hemodial Int 2009; 14:39-46. [PMID: 19758296 DOI: 10.1111/j.1542-4758.2009.00399.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
"NxStage System One()" is increasingly used for daily home hemodialysis. The ultrapure dialysate volumes are typically between 15 L and 30 L per dialysis, substantially smaller than the volumes used in conventional dialysis. In this study, the impact of the use of low dialysate volumes on the removal rates of solutes of different molecular weights and volumes of distribution was evaluated. Serum measurements before and after dialysis and total dialysate collection were performed over 30 times in 5 functionally anephric patients undergoing short-daily home hemodialysis (6 d/wk) over the course of 8 to 16 months. Measured solutes included beta(2) microglobulin (beta(2)M), phosphorus, urea nitrogen, and potassium. The average spent dialysate volume (dialysate plus ultrafiltrate) was 25.4+/-4.7 L and the dialysis duration was 175+/-15 min. beta(2) microglobulin clearance of the polyethersulfone dialyzer averaged 53+/-14 mL/min. Total beta(2)M recovered in the dialysate was 106+/-42 mg per treatment (n=38). Predialysis serum beta(2)M levels remained stable over the observation period. Phosphorus removal averaged 694+/-343 mg per treatment with a mean predialysis serum phosphorus of 5.2+/-1.8 mg/dL (n=34). Standard Kt/V averaged 2.5+/-0.3 per week and correlated with the dialysate-based weekly Kt/V. Weekly beta(2)M, phosphorus, and urea nitrogen removal in patients dialyzing 6 d/wk with these relatively low dialysate volumes compared favorably with values published for thrice weekly conventional and with short-daily hemodialysis performed with machines using much higher dialysate flow rates. Results of the present study were achieved, however, with an average of 17.5 hours of dialysis per week.
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Affiliation(s)
- Orly F Kohn
- University of Chicago, Chicago, Illinois, USA.
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Gura V, Davenport A, Beizai M, Ezon C, Ronco C. β2-Microglobulin and Phosphate Clearances Using a Wearable Artificial Kidney: A Pilot Study. Am J Kidney Dis 2009; 54:104-11. [DOI: 10.1053/j.ajkd.2009.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 02/04/2009] [Indexed: 11/11/2022]
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Baurmeister U, Vienken J, Ward RA. Should Dialysis Modalities be Designed to Remove Specific Uremic Toxins? Semin Dial 2009; 22:454-7. [DOI: 10.1111/j.1525-139x.2009.00599.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Eloot S, van Biesen W, Dhondt A, de Smet R, Marescau B, De Deyn PP, Verdonck P, Vanholder R. Impact of increasing haemodialysis frequency versus haemodialysis duration on removal of urea and guanidino compounds: a kinetic analysis. Nephrol Dial Transplant 2009; 24:2225-32. [DOI: 10.1093/ndt/gfp059] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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