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Chan CT, Chertow GM, Daugirdas JT, Greene TH, Kotanko P, Larive B, Pierratos A, Stokes JB. Effects of daily hemodialysis on heart rate variability: results from the Frequent Hemodialysis Network (FHN) Daily Trial. Nephrol Dial Transplant 2014; 29:168-78. [PMID: 24078335 PMCID: PMC3888308 DOI: 10.1093/ndt/gft212] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 03/14/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND End-stage renal disease is associated with reduced heart rate variability (HRV), components of which generally are associated with advanced age, diabetes mellitus and left ventricular hypertrophy. We hypothesized that daily in-center hemodialysis (HD) would increase HRV. METHODS The Frequent Hemodialysis Network (FHN) Daily Trial randomized 245 patients to receive 12 months of six versus three times per week in-center HD. Two hundred and seven patients had baseline Holter recordings. HRV measures were calculated from 24-h Holter electrocardiograms at both baseline and 12 months in 131 patients and included low-frequency power (LF, a measure of sympathetic modulation), high-frequency power (HF, a measure of parasympathetic modulation) and standard deviation (SD) of the R-R interval (SDNN, a measure of beat-to-beat variation). RESULTS Baseline to Month 12 change in LF was augmented by 50% [95% confidence interval (95% CI) 6.1-112%, P =0.022] and LF + HF was augmented by 40% (95% CI 3.3-88.4%, P = 0.03) in patients assigned to daily hemodialysis (DHD) compared with conventional HD. Changes in HF and SDNN were similar between the randomized groups. The effects of DHD on LF were attenuated by advanced age and diabetes mellitus (predefined subgroups). Changes in HF (r = -0.20, P = 0.02) and SDNN (r = -0.18, P = 0.04) were inversely associated with changes in left ventricular mass (LVM). CONCLUSIONS DHD increased the LF component of HRV. Reduction of LVM by DHD was associated with increased vagal modulation of heart rate (HF) and with increased beat-to-beat heart rate variation (SDNN), suggesting an important functional correlate to the structural effects of DHD on the heart in uremia.
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Chan CT, Greene T, Chertow GM, Kliger AS, Stokes JB, Beck GJ, Daugirdas JT, Kotanko P, Larive B, Levin NW, Mehta RL, Rocco M, Sanz J, Yang PC, Rajagopalan S. Effects of frequent hemodialysis on ventricular volumes and left ventricular remodeling. Clin J Am Soc Nephrol 2013; 8:2106-16. [PMID: 23970131 PMCID: PMC3848394 DOI: 10.2215/cjn.03280313] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 07/02/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Higher left ventricular volume is associated with death in patients with ESRD. This work investigated the effects of frequent hemodialysis on ventricular volumes and left ventricular remodeling. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Frequent Hemodialysis Network daily trial randomized 245 patients to 12 months of six times per week versus three times per week in-center hemodialysis; the Frequent Hemodialysis Network nocturnal trial randomized 87 patients to 12 months of six times per week nocturnal hemodialysis versus three times per week predominantly home-based hemodialysis. Left and right ventricular end systolic and diastolic volumes, left ventricular mass, and ejection fraction at baseline and end of the study were ascertained by cardiac magnetic resonance imaging. The ratio of left ventricular mass/left ventricular end diastolic volume was used as a surrogate marker of left ventricular remodeling. In each trial, the effect of frequent dialysis on left or right ventricular end diastolic volume was tested between predefined subgroups. RESULTS In the daily trial, frequent hemodialysis resulted in significant reductions in left ventricular end diastolic volume (-11.0% [95% confidence interval, -16.1% to -5.5%]), left ventricular end systolic volume (-14.8% [-22.7% to -6.2%]), right ventricular end diastolic volume (-11.6% [-19.0% to -3.6%]), and a trend for right ventricular end systolic volume (-11.3% [-21.4% to 0.1%]) compared with conventional therapy. The magnitude of reduction in left and right ventricular end diastolic volumes with frequent hemodialysis was accentuated among patients with residual urine output<100 ml/d (P value [interaction]=0.02). In the nocturnal trial, there were no significant changes in left or right ventricular volumes. The frequent dialysis interventions had no substantial effect on the ratio of left ventricular mass/left ventricular end diastolic volume in either trial. CONCLUSIONS Frequent in-center hemodialysis reduces left and right ventricular end systolic and diastolic ventricular volumes as well as left ventricular mass, but it does not affect left ventricular remodeling.
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MESH Headings
- Adult
- Aged
- Female
- Hemodialysis, Home
- Humans
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/pathology
- Hypertrophy, Left Ventricular/physiopathology
- Hypertrophy, Left Ventricular/prevention & control
- Hypertrophy, Right Ventricular/etiology
- Hypertrophy, Right Ventricular/pathology
- Hypertrophy, Right Ventricular/physiopathology
- Hypertrophy, Right Ventricular/prevention & control
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/therapy
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Prospective Studies
- Renal Dialysis/methods
- Stroke Volume
- Time Factors
- Treatment Outcome
- United States
- Ventricular Function, Left
- Ventricular Function, Right
- Ventricular Remodeling
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Daugirdas JT. Bioimpedance technology and optimal fluid management. Am J Kidney Dis 2013; 61:861-4. [PMID: 23684491 DOI: 10.1053/j.ajkd.2013.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 03/13/2013] [Indexed: 11/11/2022]
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Ornt DB, Larive B, Rastogi A, Rashid M, Daugirdas JT, Hernandez A, Kurella Tamura M, Suri RS, Levin NW, Kliger AS. Impact of frequent hemodialysis on anemia management: results from the Frequent Hemodialysis Network (FHN) Trials. Nephrol Dial Transplant 2013; 28:1888-98. [PMID: 23358899 DOI: 10.1093/ndt/gfs593] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The extent to which anemia management is facilitated by more frequent hemodialysis (HD) is controversial. We hypothesized as a preselected outcome that patients receiving HD six times (6×) compared with three times (3×) per week would require lower doses of erythropoietin-stimulating agents (ESA) and/or achieve higher blood hemoglobin (Hb) concentrations. METHODS Subjects enrolled in the Frequent Hemodialysis Network (FHN) daily and nocturnal trials were studied. As the primary outcome for anemia, the dose of ESAs was recorded at 4-month intervals and the monthly dose of intravenous iron (IV Fe) was reported. Serum iron, transferrin saturation and ferritin were measured at baseline and then at 4-month intervals, whereas Hb concentration was measured monthly. RESULTS There was no significant treatment effect in the 6× versus 3× treatment groups on logESA dose or the ratio of log of ESA dose to Hb concentration in either trial. In the daily trial, Hb concentrations increased significantly in the 6× versus 3× group, at Month 12 compared with baseline (0.3 g/dL; 95% CI: 0.05-0.58, P<0.021), but both groups had Hb concentrations in the usual target range. In the daily trial, the weekly logESA dose and the logESA dose to Hb concentration ratio tended to decline more in the 6× versus 3× group. This trend was not observed in the nocturnal trial. IV Fe doses were significantly lower in the 6× compared with the 3× group by Month 12 in the nocturnal trial, but not different in the daily trial. CONCLUSIONS In the FHN Daily and Nocturnal Trials, more frequent HD did not have a significant or clinically important effect on anemia management.
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Daugirdas JT. Potential Importance of Low-Sodium Bread and Breakfast Cereal to a Reduced Sodium Diet. J Ren Nutr 2013; 23:1-3. [PMID: 22633991 DOI: 10.1053/j.jrn.2012.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 03/12/2012] [Accepted: 03/15/2012] [Indexed: 11/11/2022] Open
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Ramirez SPB, Kapke A, Port FK, Wolfe RA, Saran R, Pearson J, Hirth RA, Messana JM, Daugirdas JT. Dialysis dose scaled to body surface area and size-adjusted, sex-specific patient mortality. Clin J Am Soc Nephrol 2012; 7:1977-87. [PMID: 22977208 PMCID: PMC3513738 DOI: 10.2215/cjn.00390112] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 08/15/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES When hemodialysis dose is scaled to body water (V), women typically receive a greater dose than men, but their survival is not better given a similar dose. This study sought to determine whether rescaling dose to body surface area (SA) might reveal different associations among dose, sex, and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Single-pool Kt/V (spKt/V), equilibrated Kt/V, and standard Kt/V (stdKt/V) were computed using urea kinetic modeling on a prevalent cohort of 7229 patients undergoing thrice-weekly hemodialysis. Data were obtained from the Centers for Medicare & Medicaid Services 2008 ESRD Clinical Performance Measures Project. SA-normalized stdKt/V (SAN-stdKt/V) was calculated as stdKt/V × ratio of anthropometric volume to SA/17.5. Patients were grouped into sex-specific dose quintiles (reference: quintile 1 for men). Adjusted hazard ratios (HRs) for 1-year mortality were calculated using Cox regression. RESULTS spKt/V was higher in women (1.7 ± 0.3) than in men (1.5 ± 0.2; P<0.001), but SAN-stdKt/V was lower (women: 2.3 ± 0.2; men: 2.5 ± 0.3; P<0.001). For both sexes, mortality decreased as spKt/V increased, until spKt/V was 1.6-1.7 (quintile 4 for men: HR, 0.62; quintile 3 for women: HR, 0.64); no benefit was observed with higher spKt/V. HR for mortality decreased further at higher SAN-stdKt/V in both sexes (quintile 5 for men: HR, 0.69; quintile 5 for women: HR, 0.60). CONCLUSIONS SA-based dialysis dose results in dose-mortality relationships substantially different from those with volume-based dosing. SAN-stdKt/V analyses suggest women may be relatively underdosed when treated by V-based dosing. SAN-stdKt/V as a measure for dialysis dose may warrant further study.
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Daugirdas JT, Leypoldt JK, Akonur A, Greene T, Depner TA. Improved equation for estimating single-pool Kt/V at higher dialysis frequencies. Nephrol Dial Transplant 2012; 28:2156-60. [PMID: 22561585 DOI: 10.1093/ndt/gfs115] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
RATIONALE To measure adequacy in patients dialyzed other than three times per week, guidelines recommend the use of 'standard' Kt/V, which commonly is estimated from treatment Kt/V, time and frequency; however, the accuracy of equations that predict treatment Kt/V in patients being dialyzed other than three times per week has not been evaluated. METHODS In patients enrolled in the Frequent Hemodialysis Network (FHN) Daily and Nocturnal Trials who were being dialyzed three, four or six times per week, we tested the accuracy of the following Kt/V prediction equation: Kt/V = -ln(R - GFAC × T_hours) + (4-3.5 × R) × 0.55 × weight loss/V, where R = post-dialysis/pre-dialysis blood urea nitrogen and GFAC, originally set to 0.008 for a 3/week schedule (Daugirdas, J Am Soc Nephrol 1993), is a factor that adjusts for urea generation. RESULTS With the above equation, there was <0.1% mean error in predicted treatment Kt/V for 3/week patients, but mean errors were -5, -9 and -13% for the 6/week daily, 4/week nocturnal and 6/week nocturnal patients. Modeling simulations were performed to optimize the GFAC term for dialysis schedule and length of the preceding interdialysis interval (PIDI). After substituting schedule- and interval-optimized GFAC terms, the treatment Kt/V prediction errors were reduced to -0.81, +0.1 and -1.3% for the three frequent dialysis schedules tested. CONCLUSION For frequent dialysis schedules, the urea generation factor (GFAC) of one commonly used Kt/V prediction equation should be adjusted based on length in days of the PIDI and number of treatments per week.
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Daugirdas JT, Chertow GM, Larive B, Pierratos A, Greene T, Ayus JC, Kendrick CA, James SH, Miller BW, Schulman G, Salusky IB, Kliger AS. Effects of frequent hemodialysis on measures of CKD mineral and bone disorder. J Am Soc Nephrol 2012; 23:727-38. [PMID: 22362907 PMCID: PMC3312501 DOI: 10.1681/asn.2011070688] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 12/03/2011] [Indexed: 11/03/2022] Open
Abstract
More frequent hemodialysis sessions and longer session lengths may offer improved phosphorus control. We analyzed data from the Frequent Hemodialysis Network Daily and Nocturnal Trials to examine the effects of treatment assignment on predialysis serum phosphorus and on prescribed dose of phosphorus binder, expressed relative to calcium carbonate on a weight basis. In the Daily Trial, with prescribed session lengths of 1.5-2.75 hours six times per week, assignment to frequent hemodialysis associated with both a 0.46 mg/dl decrease (95% confidence interval [95% CI], 0.13-0.78 mg/dl) in mean serum phosphorus and a 1.35 g/d reduction (95% CI, 0.20-2.50 g/d) in equivalent phosphorus binder dose at month 12 compared with assignment to conventional hemodialysis. In the Nocturnal Trial, with prescribed session lengths of 6-8 hours six times per week, assignment to frequent hemodialysis associated with a 1.24 mg/dl decrease (95% CI, 0.68-1.79 mg/dl) in mean serum phosphorus compared with assignment to conventional hemodialysis. Among patients assigned to the group receiving six sessions per week, 73% did not require phosphorus binders at month 12 compared with only 8% of patients assigned to sessions three times per week (P<0.001). At month 12, 42% of patients on nocturnal hemodialysis required the addition of phosphorus into the dialysate to prevent hypophosphatemia. Frequent hemodialysis did not have major effects on calcium or parathyroid hormone concentrations in either trial. In conclusion, frequent hemodialysis facilitates control of hyperphosphatemia and extended session lengths could allow more liberal diets and freedom from phosphorus binders.
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Chan CT, Greene T, Chertow GM, Kliger AS, Stokes JB, Beck GJ, Daugirdas JT, Kotanko P, Larive B, Levin NW, Mehta RL, Rocco M, Sanz J, Schiller BM, Yang PC, Rajagopalan S. Determinants of left ventricular mass in patients on hemodialysis: Frequent Hemodialysis Network (FHN) Trials. Circ Cardiovasc Imaging 2012; 5:251-61. [PMID: 22360996 PMCID: PMC3328963 DOI: 10.1161/circimaging.111.969923] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND An increase in left ventricular mass (LVM) is associated with mortality and cardiovascular morbidity in patients with end-stage renal disease. METHODS AND RESULTS The Frequent Hemodialysis Network (FHN) Daily Trial randomized 245 patients to 12 months of 6 times per week daily in-center hemodialysis or conventional hemodialysis; the FHN Nocturnal Trial randomized 87 patients to 12 months of 6 times per week nocturnal hemodialysis or conventional hemodialysis. The main cardiac secondary outcome was change in LVM. In each trial, we examined whether several predefined baseline demographic or clinical factors as well as change in volume removal, blood pressure, or solute clearance influenced the effect of frequent hemodialysis on LVM. In the Daily Trial, frequent hemodialysis resulted in a significant reduction in LVM (13.1 g; 95% CI, 5.0-21.3 g; P=0.002), LVM index (6.9 g/m(2); 95% CI, 2.4-11.3 g/m(2); P=0.003), and percent change in geometric mean of LVM (7.0%; 95% CI, 1.0%-12.6; P=0.02). Similar trends were noted in the Nocturnal Trial but did not reach statistical significance. In the Daily Trial, a more pronounced effect of frequent hemodialysis on LVM was evident among patients with left ventricular hypertrophy at baseline. Changes in LVM were associated with changes in blood pressure (conventional hemodialysis: R=0.28, P=0.01, daily hemodialysis: R=0.54, P<0.001) and were not significantly associated with changes in other parameters. CONCLUSIONS Frequent in-center hemodialysis reduces LVM. The benefit of frequent hemodialysis on LVM may be mediated by salutary effects on blood pressure. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00264758.
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Daugirdas JT. Is there a minimal amount of time a patient should be dialyzed regardless of measured KT/V? Semin Dial 2011; 24:423-5. [PMID: 21801229 DOI: 10.1111/j.1525-139x.2011.00941.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Phosphate binders include calcium acetate or carbonate, sevelamer hydrochloride or carbonate, magnesium and lanthanum carbonate, and aluminum carbonate or hydroxide. Their relative phosphate-binding capacity has been assessed in human, in vivo studies that have measured phosphate recovery from stool and/or changes in urinary phosphate excretion or that have compared pairs of different binders where dose of binder in each group was titrated to a target level of serum phosphate. The relative phosphate-binding coefficient (RPBC) based on weight of each binder can be estimated relative to calcium carbonate, the latter being set to 1.0. A systematic review of these studies gave the following estimated RPBC: for elemental lanthanum, 2.0, for sevelamer hydrochloride or carbonate 0.75, for calcium acetate 1.0, for anhydrous magnesium carbonate 1.7, and for "heavy" or hydrated, magnesium carbonate 1.3. Estimated RPBC for aluminum-containing binders were 1.5 for aluminum hydroxide and 1.9 for aluminum carbonate. The phosphate-binding equivalent dose was then defined as the dose of each binder in g × its RPBC, which would be the binding ability of an equivalent weight of calcium carbonate. The phosphate-binding equivalent dose may be useful in comparing changes in phosphate binder prescription over time when multiple binders are being prescribed, when estimating an initial binder prescription, and also in phosphate kinetic modeling.
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Daugirdas JT, Greene T, Depner TA, Levin NW, Chertow GM. Modeled urea distribution volume and mortality in the HEMO Study. Clin J Am Soc Nephrol 2011; 6:1129-38. [PMID: 21511841 DOI: 10.2215/cjn.06340710] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the Hemodialysis (HEMO) Study, observed small decreases in achieved equilibrated Kt/V(urea) were noncausally associated with markedly increased mortality. Here we examine the association of mortality with modeled volume (V(m)), the denominator of equilibrated Kt/V(urea). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Parameters derived from modeled urea kinetics (including V(m)) and blood pressure (BP) were obtained monthly in 1846 patients. Case mix-adjusted time-dependent Cox regressions were used to relate the relative mortality hazard at each time point to V(m) and to the change in V(m) over the preceding 6 months. Mixed effects models were used to relate V(m) to changes in intradialytic systolic BP and to other factors at each follow-up visit. RESULTS Mortality was associated with V(m) and change in V(m) over the preceding 6 months. The association between change in V(m) and mortality was independent of vascular access complications. In contrast, mortality was inversely associated with V calculated from anthropometric measurements (V(ant)). In case mix-adjusted analysis using V(m) as a time-dependent covariate, the association of mortality with V(m) strengthened after statistical adjustment for V(ant). After adjustment for V(ant), higher V(m) was associated with slightly smaller reductions in intradialytic systolic BP and with risk factors for mortality including recent hospitalization and reductions in serum albumin concentration and body weight. CONCLUSIONS An increase in V(m) is a marker for illness and mortality risk in hemodialysis patients.
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Kaysen GA, Larive B, Painter P, Craig A, Lindsay RM, Rocco MV, Daugirdas JT, Schulman G, Chertow GM. Baseline physical performance, health, and functioning of participants in the Frequent Hemodialysis Network (FHN) trial. Am J Kidney Dis 2011; 57:101-12. [PMID: 21184919 DOI: 10.1053/j.ajkd.2010.08.021] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 08/16/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Self-reported physical health and functioning and direct measures of physical performance are decreased in hemodialysis patients and are associated with mortality and hospitalization. STUDY DESIGN We determined baseline cross-sectional associations of physical performance, health, and functioning with demographics, clinical characteristics, nutritional indexes, laboratory benchmarks, and measures of body composition in participants in the Frequent Hemodialysis Network (FHN) trial. SETTING & PARTICIPANTS 375 persons enrolled in the FHN with data for physical performance, health, and functioning. PREDICTORS Explanatory variables were categorized into fixed factors of age, race, comorbid conditions (diabetes mellitus, heart failure, and peripheral arterial disease) and potentially modifiable factors of dialysis dose, phosphorus level, hemoglobin level, equilibrated normalized protein catabolic rate (enPCR), body composition, body mass index, phase angle, and ratio of intracellular water volume to body weight (calculated from bioelectrical impedance). OUTCOMES Scores on tests of physical performance, health, and functioning. MEASUREMENTS Physical performance measured using the Short Physical Performance Battery, self-reported physical health and functioning using the 36-Item Short Form Health Survey (SF-36). Body composition (body mass index and bioimpedance analysis) and laboratory data were obtained from affiliated dialysis providers. RESULTS Relative to population norms, scores for all 3 physicality metrics were low. Poorer scores on all 3 metrics were associated with diabetes mellitus and peripheral arterial disease. Poorer scores on the SF-36 Physical Functioning subscale and Short Physical Performance Battery also were associated with age, lower ratio of intracellular water volume to body weight, and lower enPCR. Black race was associated with poorer scores on the Short Physical Performance Battery. LIMITATIONS This was a cross-sectional study of individuals agreeing to participate in the FHN study and may not be generalizable to the general dialysis population. CONCLUSIONS Hemodialysis patients show markedly impaired physical performance, health, and functioning relative to population norms. Although some factors associated with these impairments are not modifiable, others may change with improvement in nutritional status or body composition.
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Daugirdas JT, Tattersall JE. Automated monitoring of hemodialysis adequacy by dialysis machines: potential benefits to patients and cost savings. Kidney Int 2010; 78:833-5. [DOI: 10.1038/ki.2010.218] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Daugirdas JT, Greene T, Chertow GM, Depner TA. Can rescaling dose of dialysis to body surface area in the HEMO study explain the different responses to dose in women versus men? Clin J Am Soc Nephrol 2010; 5:1628-36. [PMID: 20595687 PMCID: PMC2974404 DOI: 10.2215/cjn.02350310] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 05/13/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the Hemodialysis (HEMO) Study, the lower death rate in women but not in men assigned to the higher dose (Kt/V) could have resulted from use of "V" as the normalizing factor, since women have a lower anthropometric V per unit of surface area (V/SA) than men. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The effect of Kt/V on mortality was re-examined after normalizing for surface area and expressing dose as surface area normalized standard Kt/V (SAn-stdKt/V). RESULTS Both men and women in the high-dose group received approximately 16% more dialysis (when expressed as SAn-stdKt/V) than the controls. SAn-stdKt/V clustered into three levels: 2.14/wk for conventional dose women, 2.44/wk for conventional dose men or 2.46/wk for high-dose women, and 2.80/wk for high-dose men. V/SA was associated with the effect of dose assignment on the risk of death; above 20 L/m(2), the mortality hazard ratio = 1.23 (0.99 to 1.53); below 20 L/m(2), hazard ratio = 0.78 (0.65 to 0.95), P = 0.002. Within gender, V/SA did not modify the effect of dose on mortality. CONCLUSIONS When normalized to body surface area rather than V, the dose of dialysis in women in the HEMO Study was substantially lower than in men. The lowest surface-area-normalized dose was received by women randomized to the conventional dose arm, possibly explaining the sex-specific response to dialysis dose. Results are consistent with the hypothesis that when dialysis dose is expressed as Kt/V, women, due to their lower V/SA ratio, require a higher amount than men.
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Daugirdas JT, Hanna MG, Becker-Cohen R, Langman CB. Dose of dialysis based on body surface area is markedly less in younger children than in older adolescents. Clin J Am Soc Nephrol 2010; 5:821-7. [PMID: 20299373 PMCID: PMC2863971 DOI: 10.2215/cjn.08171109] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 02/10/2010] [Indexed: 11/23/2022]
Abstract
UNLABELLED BACKGROUND AND OBSERVATIONS: The current denominator for dosing dialysis is the urea distribution volume (V). Normalizing Kt/V to body surface area (S) has been proposed, but the implications of doing this in children have not been examined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Dialysis dose given to children and adolescents was calculated in terms of conventional V-based scaling and surface-area-normalized standard Kt/V (SAN-stdKt/V) calculated as stdKt/V x (Vant/S)/17.5, where Vant was an anthropometric estimate of V calculated using the Morgenstern equation. Formal 2-pool modeling was used to compute all dialysis adequacy outputs. RESULTS In 34 children (11 girls, 23 boys) dialyzed 3 times a week, age range 1.4 to 18 years, the mean delivered equilibrated Kt/V (eKt/V) was 1.40, and the mean stdKt/V was 2.49, both of which tended to be higher in younger children. The ratio of Vant to S was 15.6 +/- 2.69 and was strongly associated with age between ages 2 and 16. SAN-stdKt/V averaged 2.21 and was strongly correlated with age between ages 2 and 16. If one considers a desired target for SAN-stdKt/V to be 2.45, all children less than 10 years of age were below target, despite having relatively high values of eKt/V and stdKt/V. CONCLUSIONS If a surface-area-based denominator were to be adopted for dialysis dosing, most children under 10 years of age would receive markedly less dialysis than adolescent patients and would require 6- to 8-hour hemodialysis sessions or, for the youngest children, treatments given more frequently than 3 times/wk.
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Daugirdas JT, Depner TA, Greene T, Levin NW, Chertow GM, Rocco MV. Standard Kt/Vurea: a method of calculation that includes effects of fluid removal and residual kidney clearance. Kidney Int 2010; 77:637-44. [DOI: 10.1038/ki.2009.525] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Daugirdas JT, Depner TA, Greene T, Levin NW, Chertow GM, Rocco MV, Stokes JB. Effects of Reduced Intradialytic Urea Generation Rate and Residual Renal Clearance on Modeled Urea Distribution Volume andKt/Vin Conventional, Daily, and Nocturnal Dialysis. Semin Dial 2010; 23:19-24. [DOI: 10.1111/j.1525-139x.2009.00688.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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Daugirdas JT, Depner TA, Greene T, Silisteanu P. Solute-Solver: A Web-Based Tool for Modeling Urea Kinetics for a Broad Range of Hemodialysis Schedules in Multiple Patients. Am J Kidney Dis 2009; 54:798-809. [DOI: 10.1053/j.ajkd.2009.06.033] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 06/11/2009] [Indexed: 11/11/2022]
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Daugirdas JT, Meyer K, Greene T, Butler RS, Poggio ED. Scaling of measured glomerular filtration rate in kidney donor candidates by anthropometric estimates of body surface area, body water, metabolic rate, or liver size. Clin J Am Soc Nephrol 2009; 4:1575-83. [PMID: 19808242 PMCID: PMC2758254 DOI: 10.2215/cjn.05581008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 07/23/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES GFR is scaled to body surface area (S), whereas hemodialysis dosage is scaled to total body water (V). Scaling to metabolic rate (M) or liver size (L) has also been proposed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In 1551 potential kidney donors (662 men and 889 women) for whom GFR had been estimated from (125)I-iothalamate clearance (iGFR) between the years 1973 and 2005, iGFR scaling was examined. Scaling was to estimates of S, V, M, or L. The study looked at the variation of iGFR by gender, age, S, V, M, and L within the study population. RESULTS In multiple regression analysis, neither gender nor race was significantly associated with iGFR after controlling for height, weight, and age. Raw iGFR averaged 122 +/- 23 ml/min in men and 106 +/- 21 ml/min in women (P < 0.001). In an adjusted analysis, iGFR scaled to S or L was similar for men and women (NS), whereas iGFR scaled to either V or M was substantially different between the genders (P < 0.001). When the patients by gender were divided into five quintiles of V or S, the iGFR-V ratio varied more with body size than iGFR scaled to the other measures. CONCLUSIONS iGFR scaled to S or L was similar in men and women. Scaling to either M or V resulted in a sizeable gender difference, whereas scaling to V led to markedly different values of iGFR across body size.
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Greene T, Daugirdas JT, Depner TA, Gotch F, Kuhlman M. Solute Clearances and Fluid Removal in the Frequent Hemodialysis Network Trials. Am J Kidney Dis 2009; 53:835-44. [DOI: 10.1053/j.ajkd.2008.12.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 12/26/2008] [Indexed: 11/11/2022]
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Schneditz D, Platzer D, Daugirdas JT. A diffusion-adjusted regional blood flow model to predict solute kinetics during haemodialysis. Nephrol Dial Transplant 2009; 24:2218-24. [DOI: 10.1093/ndt/gfp023] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Priester-Coary A, Daugirdas JT. Mechanical Aspects of Dialysis: A Recommended Technique for Obtaining the Post-Dialysis BUN. Semin Dial 2008; 10:23-5. [DOI: 10.1111/j.1525-139x.1997.tb00454.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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Daugirdas JT, Levin NW, Kotanko P, Depner TA, Kuhlmann MK, Chertow GM, Rocco MV. Comparison of proposed alternative methods for rescaling dialysis dose: resting energy expenditure, high metabolic rate organ mass, liver size, and body surface area. Semin Dial 2008; 21:377-84. [PMID: 18945324 PMCID: PMC2692384 DOI: 10.1111/j.1525-139x.2008.00483.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A number of denominators for scaling the dose of dialysis have been proposed as alternatives to the urea distribution volume (V). These include resting energy expenditure (REE), mass of high metabolic rate organs (HMRO), visceral mass, and body surface area. Metabolic rate is an unlikely denominator as it varies enormously among humans with different levels of activity and correlates poorly with the glomerular filtration rate. Similarly, scaling based on HMRO may not be optimal, as many organs with high metabolic rates such as spleen, brain, and heart are unlikely to generate unusually large amounts of uremic toxins. Visceral mass, in particular the liver and gut, has potential merit as a denominator for scaling; liver size is related to protein intake and the liver, along with the gut, is known to be responsible for the generation of suspected uremic toxins. Surface area is time-honored as a scaling method for glomerular filtration rate and scales similarly to liver size. How currently recommended dialysis doses might be affected by these alternative rescaling methods was modeled by applying anthropometric equations to a large group of dialysis patients who participated in the HEMO study. The data suggested that rescaling to REE would not be much different from scaling to V. Scaling to HMRO mass would mandate substantially higher dialysis doses for smaller patients of either gender. Rescaling to liver mass would require substantially more dialysis for women compared with men at all levels of body size. Rescaling to body surface area would require more dialysis for smaller patients of either gender and also more dialysis for women of any size. Of these proposed alternative rescaling measures, body surface area may be the best, because it reflects gender-based scaling of liver size and thereby the rate of generation of uremic toxins.
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