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Mangion K, McDowell K, Mark PB, Rutherford E. Characterizing Cardiac Involvement in Chronic Kidney Disease Using CMR-a Systematic Review. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018; 11:2. [PMID: 29497467 PMCID: PMC5818546 DOI: 10.1007/s12410-018-9441-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The aim of the review was to identify and describe recent advances (over the last 3 years) in cardiac magnetic resonance (CMR) imaging in patients with chronic kidney disease (CKD). We conducted a literature review in line with current guidelines. RECENT FINDINGS The authors identified 22 studies. Patients with CKD had left ventricular global and regional dysfunction and adverse remodeling. Stress testing with CMR revealed a reduced stress-response in CKD patients. Native T1 relaxation times (as a surrogate markers of fibrosis) are elevated in CKD patients, proportional to disease duration. Patients with CKD have reduced strain magnitudes and reduced aortic distensibility. SUMMARY CMR has diagnostic utility to identify and characterize cardiac involvement in this patient group. A number of papers have described novel findings over the last 3 years, suggesting that CMR has potential to become more widely used in studies in this patient group.
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Affiliation(s)
- Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
| | - Kirsty McDowell
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
| | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
- Glasgow Renal & Transplant Unit, NHS Greater Glasgow & Clyde, Queen Elizabeth University Hospital, Glasgow, UK
| | - Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
- Glasgow Renal & Transplant Unit, NHS Greater Glasgow & Clyde, Queen Elizabeth University Hospital, Glasgow, UK
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Abstract
PURPOSE OF REVIEW This review focuses on recent advances in our understanding of intradialytic hypotension (IDH) and measures that may reduce its frequency. RECENT FINDINGS The frequency and severity of IDH predict the risk for adverse clinical outcomes. The highest mortality risks associated with IDH were observed when the intradialytic systolic blood pressure (SBP) nadirs were <90 and <100 mmHg and the predialysis SBP were ≤159 mmHg or ≥160 mmHg, respectively. Interdialytic weight gain (IDWG) ≥3 kg occurs more frequently among patients with IDH. Prolonged and possibly more frequent dialysis, use of biofeedback devices, dialysate cooling and limiting sodium loading are useful measures to reduce the frequency of IDH. SUMMARY Frequent IDH is associated with high IDWGs and a poor prognosis. Studies on prolonged dialysis, biofeedback devices and cooled dialysate have yielded promising results. Intradialytic relative blood volume monitoring devices have been investigated in preventing IDH but results are mixed. Administration of a sodium/hydrogen exchange isoform 3 inhibitor increases stool sodium but has not been shown to decrease IDWG. IDH continues to be a significant dialysis complication deserving of further investigation.
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53
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de Sá Tinôco JD, de Paiva MDGMN, de Queiroz Frazão CMF, Lucio KDB, Fernandes MIDCD, de Oliveira Lopes MV, de Carvalho Lira ALB. Clinical validation of the nursing diagnosis of ineffective protection in haemodialysis patients. J Clin Nurs 2017; 27:e195-e202. [PMID: 28618060 DOI: 10.1111/jocn.13915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2017] [Indexed: 01/12/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the clinical validity of indicators of the nursing diagnosis of "ineffective protection" in haemodialysis patients. BACKGROUND Haemodialysis patients have reduced protection. Studies on the nursing diagnosis of "ineffective protection" are scarce in the literature. The use of indicators to diagnose "ineffective protection" could improve the care of haemodialysis patients. The clinical usefulness of the indicators requires clinical validation. DESIGN This was a diagnostic accuracy study. METHOD This study assessed a sample of 200 patients undergoing haemodialysis in a reference clinic for nephrology during the first half of 2015. Operational definitions were created for each clinical indicator based on concept analysis and content validation by experts for these indicators. Diagnostic accuracy measurement was performed with latent class analysis with randomised effects. RESULTS The clinical indicator of "fatigue" had high sensitivity (p = .999) and specificity (p = 1.000) for the identification of "ineffective protection." Additionally, "maladaptive response to stress" (p = .711) and "coagulation change" (p = .653) were sensitive indicators. The main indicators that showed high specificity were "fever" (p = .987), "increased number of hospitalisations" (p = .911), "weakness" (p = .937), "infected vascular access" (p = .962) and "vascular access dysfunction" (p = .722). CONCLUSION A set of nine clinical indicators of "ineffective protection" were accurate and statistically significant for haemodialysis patients. Three clinical indicators showed sensitivity, and six indicators showed specificity. RELEVANCE TO CLINICAL PRACTICE Accurate measures for nursing diagnoses can help nurses confirm or rule out the probability of the occurrence of "ineffective protection" in patients undergoing haemodialysis.
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Affiliation(s)
| | | | | | | | | | | | - Ana Luisa Brandão de Carvalho Lira
- Department of Nursing and in the Post-graduate Program in Nursing, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
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Patel S, Raimann JG, Kotanko P. The impact of dialysis modality and membrane characteristics on intradialytic hypotension. Semin Dial 2017; 30:518-531. [PMID: 28707330 DOI: 10.1111/sdi.12636] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The risk of intradialytic hypotension (IDH) is determined by various factors, among them dialysis modality and dialyzer membrane. We conducted a literature search in PubMed on November 1, 2016 and selected relevant randomized controlled and cross-over trials, and prospective and retrospective cohort studies published in English that investigated the association between IDH and dialysis modality and membrane, respectively. This literature search revealed 669 publications on dialysis modality, 64 on dialysis membrane, and 24 on acetate/bicarbonate dialysate. After omission of duplicate papers and publications outside the scope of this review, we selected 34 papers for inclusion, 19 on dialysis modality, 8 on dialyzer membrane, and 7 on acetate/bicarbonate dialysate. Several strands of evidence indicate that hemodiafiltration (HDF) is associated with lower IDH rates compared to hemodialysis (HD). Data do not show an unequivocal benefit of synthetic vs nonsynthetic dialyzer membranes with respect to IDH occurrence. Acetate-based vs bicarbonate-based dialysate appears to be associated with an increased IDH rate.
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Affiliation(s)
- Samir Patel
- Renal Research Institute, New York City, NY, USA
| | | | - Peter Kotanko
- Renal Research Institute, New York City, NY, USA.,Icahn School of Medicine at Mount Sinai Hospital, New York City, NY, USA
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55
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Larkin JW, Reviriego-Mendoza MM, Usvyat LA, Kotanko P, Maddux FW. To cool, or too cool: Is reducing dialysate temperature the optimal approach to preventing intradialytic hypotension? Semin Dial 2017; 30:501-508. [DOI: 10.1111/sdi.12628] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Len A. Usvyat
- Fresenius Medical Care North America; Waltham MA USA
| | - Peter Kotanko
- Renal Research Institute; New York NY USA
- Icahn School of Medicine at Mount Sinai; New York NY USA
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56
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Van Buren PN, Inrig JK. Special situations: Intradialytic hypertension/chronic hypertension and intradialytic hypotension. Semin Dial 2017; 30:545-552. [PMID: 28666072 DOI: 10.1111/sdi.12631] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hypertension is a comorbidity that is present in the majority of end-stage renal disease patients on maintenance hemodialysis. This population is particularly unique because of the dynamic nature of blood pressure (BP) during dialysis. Modest BP decreases are expected in most hemodialysis patients, but intradialytic hypotension and intradialytic hypertension are two special situations that deviate from this as either an exaggerated or paradoxical response to the dialysis procedure. Both of these phenomena are particularly important because they are associated with increased mortality risk compared to patients with modest decreases in BP during dialysis. While the detailed pathophysiology is complex, intradialytic hypotension occurs more often in patients prescribed fast ultrafiltration rates, and reducing this rate is recommended in patients that regularly exhibit this pattern. Patients with intradialytic hypertension have a poorly explained increase in vascular resistance during dialysis, but the consistent associations with extracellular volume overload point toward more aggressive fluid management as the initial management choices for these patients. This up to date review provides the most recent evidence supporting these recommendations as well as the most up to date epidemiologic and mechanistic research studies that have added to this area of dialysis management.
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Affiliation(s)
| | - Jula K Inrig
- QuintilesIMS, Orange, CA, USA.,UC Irvine Medical Center, Orange, CA, USA
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57
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Rutherford E, Stewart G, Houston JG, Jardine AG, Mark PB, Struthers AD. An Open-Label Dose-Finding Study of Allopurinol to Target Defined Reduction in Urate Levels in Hemodialysis Patients. J Clin Pharmacol 2017; 57:1409-1414. [PMID: 28597919 PMCID: PMC5655768 DOI: 10.1002/jcph.939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/14/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Elaine Rutherford
- Institute of Cardiovascular & Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Graham Stewart
- Renal Unit, Ninewells Hospital & Medical School, Dundee, UK
| | - J Graeme Houston
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Alan G Jardine
- Institute of Cardiovascular & Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular & Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Allan D Struthers
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, Dundee, UK
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58
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Presseau J, Mutsaers B, Al-Jaishi AA, Squires J, McIntyre CW, Garg AX, Sood MM, Grimshaw JM. Barriers and facilitators to healthcare professional behaviour change in clinical trials using the Theoretical Domains Framework: a case study of a trial of individualized temperature-reduced haemodialysis. Trials 2017; 18:227. [PMID: 28532509 PMCID: PMC5440991 DOI: 10.1186/s13063-017-1965-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/30/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Implementing the treatment arm of a clinical trial often requires changes to healthcare practices. Barriers to such changes may undermine the delivery of the treatment making it more likely that the trial will demonstrate no treatment effect. The 'Major outcomes with personalized dialysate temperature' (MyTEMP) is a cluster-randomised trial to be conducted in 84 haemodialysis centres across Ontario, Canada to investigate whether there is a difference in major outcomes with an individualized dialysis temperature (IDT) of 0.5 °C below a patient's body temperature measured at the beginning of each haemodialysis session, compared to a standard dialysis temperature of 36.5 °C. To inform how to deploy the IDT across many haemodialysis centres, we assessed haemodialysis physicians' and nurses' perceived barriers and enablers to IDT use. METHODS We developed two topic guides using the Theoretical Domains Framework (TDF) to assess perceived barriers and enablers to IDT ordering and IDT setting (physician and nurse behaviours, respectively). We recruited a purposive sample of haemodialysis physicians and nurses from across Ontario and conducted in-person or telephone interviews. We used directed content analysis to double-code transcribed utterances into TDF domains, and inductive thematic analysis to develop themes. RESULTS We interviewed nine physicians and nine nurses from 11 Ontario haemodialysis centres. We identified seven themes of potential barriers and facilitators to implementing IDTs: (1) awareness of clinical guidelines and how IDT fits with local policies (knowledge; goals), (2) benefits and motivation to use IDT (beliefs about consequences; optimism; reinforcement; intention; goals), (3) alignment of IDTs with usual practice and roles (social/professional role and identity; nature of the behaviour; beliefs about capabilities), (4) thermometer availability/accuracy and dialysis machine characteristics (environmental context and resources), (5) impact on workload (beliefs about consequences; beliefs about capabilities), (6) patient comfort (behavioural regulation; beliefs about consequences; emotion), and (7) forgetting to prescribe or set IDT (memory, attention, decision making processes; emotion). CONCLUSIONS There are anticipatable barriers to changing healthcare professionals' behaviours to effectively deliver an intervention within a randomised clinical trial. A behaviour change framework can help to systematically identify such barriers to inform better delivery and evaluation of the treatment, therefore potentially increasing the fidelity of the intervention to increase the internal validity of the trial. These findings will be used to optimise the delivery of IDT in the MyTEMP trial and demonstrate how this approach can be used to plan intervention delivery in other clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT02628366 . Registered November 16 2015.
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Affiliation(s)
- Justin Presseau
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Brittany Mutsaers
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Ahmed A. Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Janet Squires
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Christopher W. McIntyre
- Division of Nephrology, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON Canada
| | - Amit X. Garg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Division of Nephrology, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
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59
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Adenwalla SF, Graham-Brown MPM, Leone FMT, Burton JO, McCann GP. The importance of accurate measurement of aortic stiffness in patients with chronic kidney disease and end-stage renal disease. Clin Kidney J 2017; 10:503-515. [PMID: 28852490 PMCID: PMC5570016 DOI: 10.1093/ckj/sfx028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/21/2017] [Indexed: 12/27/2022] Open
Abstract
Cardiovascular (CV) disease is the leading cause of death in chronic kidney disease (CKD) and end-stage renal disease (ESRD). A key driver in this pathology is increased aortic stiffness, which is a strong, independent predictor of CV mortality in this population. Aortic stiffening is a potentially modifiable biomarker of CV dysfunction and in risk stratification for patients with CKD and ESRD. Previous work has suggested that therapeutic modification of aortic stiffness may ameliorate CV mortality. Nevertheless, future clinical implementation relies on the ability to accurately and reliably quantify stiffness in renal disease. Pulse wave velocity (PWV) is an indirect measure of stiffness and is the accepted standard for non-invasive assessment of aortic stiffness. It has typically been measured using techniques such as applanation tonometry, which is easy to use but hindered by issues such as the inability to visualize the aorta. Advances in cardiac magnetic resonance imaging now allow direct measurement of stiffness, using aortic distensibility, in addition to PWV. These techniques allow measurement of aortic stiffness locally and are obtainable as part of a comprehensive, multiparametric CV assessment. The evidence cannot yet provide a definitive answer regarding which technique or parameter can be considered superior. This review discusses the advantages and limitations of non-invasive methods that have been used to assess aortic stiffness, the key studies that have assessed aortic stiffness in patients with renal disease and why these tools should be standardized for use in clinical trial work.
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Affiliation(s)
- Sherna F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.,National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Francesca M T Leone
- College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.,John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.,Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
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60
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Sakkas GK, Krase AA, Giannaki CD, Karatzaferi C. Cold dialysis and its impact on renal patients’ health: An evidence-based mini review. World J Nephrol 2017; 6:119-122. [PMID: 28540201 PMCID: PMC5424433 DOI: 10.5527/wjn.v6.i3.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 04/25/2017] [Indexed: 02/06/2023] Open
Abstract
Chronic renal disease is associated with advanced age, diabetes, hypertension, obesity, musculoskeletal problems and cardiovascular disease, the latter being the main cause of mortality in patients receiving haemodialysis (HD). Cooled dialysate (35 °C-36 °C) is recently employed to reduce the incidence of intradialytic hypotension in patients on chronic HD. The studies to date that have evaluated cooled dialysate are limited, however, data suggest that cooled dialysate improves hemodynamic tolerability of dialysis, minimizes hypotension and exerts a protective effect over major organs including the heart and brain. The current evidence-based review is dealing with the protective effect of cold dialysis and the benefits of it in aspects affecting patients’ quality of care and life. There is evidence to suggest that cold dialysis can reduce cardiovascular mortality. However, large multicentre randomized clinical trials are urgently needed to provide further supporting evidence in order to incorporate cold dialysis in routine clinical practice.
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61
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Pajewski R, Gipson P, Heung M. Predictors of post-hospitalization recovery of renal function among patients with acute kidney injury requiring dialysis. Hemodial Int 2017; 22:66-73. [DOI: 10.1111/hdi.12545] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Russell Pajewski
- Department of Internal Medicine; University of Michigan; Ann Arbor Michigan USA
| | - Patrick Gipson
- Department of Internal Medicine; University of Michigan; Ann Arbor Michigan USA
- Division of Nephrology; University of Michigan; Ann Arbor Michigan USA
| | - Michael Heung
- Department of Internal Medicine; University of Michigan; Ann Arbor Michigan USA
- Division of Nephrology; University of Michigan; Ann Arbor Michigan USA
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62
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Abstract
The optimal approach to managing acid-base balance is less well defined for patients receiving hemodialysis than for those receiving peritoneal dialysis. Interventional studies in hemodialysis have been limited and inconsistent in their findings, whereas more compelling data are available from interventional studies in peritoneal dialysis. Both high and low serum bicarbonate levels associate with an increased risk of mortality in patients receiving hemodialysis, but high values are a marker for poor nutrition and comorbidity and are often highly variable from month to month. Measurement of pH would likely provide useful additional data. Concern has arisen regarding high-bicarbonate dialysate and dialysis-induced alkalemia, but whether these truly cause harm remains to be determined. The available evidence is insufficient for determining the optimal target for therapy at this time.
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Affiliation(s)
- Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, and
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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63
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Makar MS, Pun PH. Sudden Cardiac Death Among Hemodialysis Patients. Am J Kidney Dis 2017; 69:684-695. [PMID: 28223004 DOI: 10.1053/j.ajkd.2016.12.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
Hemodialysis patients carry a large burden of cardiovascular disease; most onerous is the high risk for sudden cardiac death. Defining sudden cardiac death among hemodialysis patients and understanding its pathogenesis are challenging, but inferences from the existing literature reveal differences between sudden cardiac death among hemodialysis patients and the general population. Vascular calcifications and left ventricular hypertrophy may play a role in the pathophysiology of sudden cardiac death, whereas traditional cardiovascular risk factors seem to have a more muted effect. Arrhythmic triggers also differ in this group as compared to the general population, with some arising uniquely from the hemodialysis procedure. Combined, these factors may alter the types of terminal arrhythmias that lead to sudden cardiac death among hemodialysis patients, having important implications for prevention strategies. This review highlights current knowledge on the epidemiology, pathophysiology, and risk factors for sudden cardiac death among hemodialysis patients. We then examine strategies for prevention, including the use of specific cardiac medications and device-based therapies such as implantable defibrillators. We also discuss dialysis-specific prevention strategies, including minimizing exposure to low potassium and calcium dialysate concentrations, extending dialysis treatment times or adding sessions to avoid rapid ultrafiltration, and lowering dialysate temperature.
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Affiliation(s)
- Melissa S Makar
- Duke Clinical Research Institute, Durham, NC; Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Patrick H Pun
- Duke Clinical Research Institute, Durham, NC; Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
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64
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Intestinal Barrier Disturbances in Haemodialysis Patients: Mechanisms, Consequences, and Therapeutic Options. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5765417. [PMID: 28194419 PMCID: PMC5282437 DOI: 10.1155/2017/5765417] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/20/2016] [Indexed: 01/01/2023]
Abstract
There is accumulating evidence that the intestinal barrier and the microbiota may play a role in the systemic inflammation present in HD patients. HD patients are subject to a number of unique factors, some related to the HD process and others simply to the uraemic milieu but with common characteristic that they can both alter the intestinal barrier and the microbiota. This review is intended to provide an overview of the current methods for measuring such changes in HD patients, the mechanisms behind these changes, and potential strategies that may mitigate these modifications. Lastly, intradialytic exercise is an increasingly employed intervention in HD patients; however the potential implications that this may have for the intestinal barrier are not known; therefore future research directions are also covered.
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65
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Gray KS, Cohen DE, Brunelli SM. Dialysate temperature of 36 °C: association with clinical outcomes. J Nephrol 2016; 31:129-136. [PMID: 28000088 DOI: 10.1007/s40620-016-0369-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/03/2016] [Indexed: 11/29/2022]
Abstract
Dialysate cooling, either individualized based upon patient body temperature, or to a standardized temperature below 37 °C, has been proposed to minimize hemodynamic insults and improve outcomes among hemodialysis patients. However, low dialysate temperatures (35-35.5 °C) are associated with patient discomfort, and individualized dialysate cooling is difficult to operationalize. Here, we tested whether a standardized dialysate temperature of 36 °C (dT36) was associated with improved clinical outcomes compared to the default temperature of 37 °C (dT37). Because patients with known hemodynamic instability may be selectively prescribed dT36, we minimized selection bias by considering only incident adult in-center hemodialysis patients who, between Jan 2011 and Dec 2013 received their first-ever hemodialysis treatment at a large dialysis organization. Exposure status was based on the treatment order for this first-ever treatment. 313 dT36 patients were identified and propensity-score matched (1:5) to 1565 dT37 controls. Death, hospitalization, and missed hemodialysis treatments were considered from the date of first-ever hemodialysis treatment until the earliest of death, loss to follow-up, crossover (month in which prescribed dialysate temperature was consistent with patient's exposure group for <80% of treatments), or study end (June 2015). During follow-up, rates of death, hospitalization and missed hemodialysis treatments did not differ between the two groups. This study therefor showed no benefit of dT36 vs. dT37 with respect to these clinical outcomes. Our results do not favor conversion to a default dialysate temperature of 36 °C. Individualized dialysate cooling may provide a more reliable approach to achieve the hemodynamic benefits associated with reduced dialysate temperature.
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Affiliation(s)
- Kathryn S Gray
- DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA
| | - Dena E Cohen
- DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA
| | - Steven M Brunelli
- DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA.
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66
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Bourdenx JP, Fartoux L. Place des « outils embarqués » (BVM et BTM) dans la prise en charge de la surcharge hydro-sodée. Nephrol Ther 2016; 12:S17-S19. [DOI: 10.1016/s1769-7255(17)30023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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67
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Buchanan C, Mohammed A, Cox E, Köhler K, Canaud B, Taal MW, Selby NM, Francis S, McIntyre CW. Intradialytic Cardiac Magnetic Resonance Imaging to Assess Cardiovascular Responses in a Short-Term Trial of Hemodiafiltration and Hemodialysis. J Am Soc Nephrol 2016; 28:1269-1277. [PMID: 28122851 DOI: 10.1681/asn.2016060686] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/11/2016] [Indexed: 12/15/2022] Open
Abstract
Hemodynamic stress during hemodialysis (HD) results in recurrent segmental ischemic injury (myocardial stunning) that drives cumulative cardiac damage. We performed a fully comprehensive study of the cardiovascular effect of dialysis sessions using intradialytic cardiac magnetic resonance imaging (MRI) to examine the comparative acute effects of standard HD versus hemodiafiltration (HDF) in stable patients. We randomly allocated 12 patients on HD (ages 32-72 years old) to either HD or HDF. Patients were stabilized on a modality for 2 weeks before undergoing serial cardiac MRI assessment during dialysis. Patients then crossed over to the other modality and were rescanned after 2 weeks. Cardiac MRI measurements included cardiac index, stroke volume index, global and regional contractile function (myocardial strain), coronary artery flow, and myocardial perfusion. Patients had mean±SEM ultrafiltration rates of 3.8±2.9 ml/kg per hour during HD and 4.4±2.5 ml/kg per hour during HDF (P=0.29), and both modalities provided a similar degree of cooling. All measures of systolic contractile function fell during HD and HDF, with partial recovery after dialysis. All patients experienced some degree of segmental left ventricular dysfunction, with severity proportional to ultrafiltration rate and BP reduction. Myocardial perfusion decreased significantly during HD and HDF. Treatment modality did not influence any of the cardiovascular responses to dialysis. In conclusion, in this randomized, crossover study, there was no significant difference in the cardiovascular response to HDF or HD with cooled dialysate as assessed with intradialytic MRI.
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Affiliation(s)
| | - Azharuddin Mohammed
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, United Kingdom
| | | | - Katrin Köhler
- Center of Excellence Medical Europe, Middle East and Africa, Fresenius Medical Care, Bad Homburg, Germany; and
| | - Bernard Canaud
- Center of Excellence Medical Europe, Middle East and Africa, Fresenius Medical Care, Bad Homburg, Germany; and
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, United Kingdom
| | | | - Chris W McIntyre
- Departments of Medicine and .,Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Canada
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68
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Blake PG. Sodium Levels in Peritoneal Dialysis Solution: How Low Should We Go? Am J Kidney Dis 2016; 67:719-21. [PMID: 27091013 DOI: 10.1053/j.ajkd.2016.02.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Peter G Blake
- Western University and London Health Sciences Centre, London, Canada.
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69
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Abstract
Cardiac dysfunction is a key factor in the high morbidity and mortality rates seen in hemodialysis (HD) patients. Much of the dysfunction is manifest as adverse changes in cardiac and vascular structure prior to commencing dialysis. This adverse vascular remodeling arises as a dysregulation between pro- and antiproliferative signaling pathways in response to hemodynamic and nonhemodynamic factors. The HD procedure itself further promotes cardiomyopathy by inducing hypotension and episodic regional cardiac ischemia that precedes global dysfunction, fibrosis, worsening symptoms, and increased mortality. Drug-based therapies have been largely ineffective in reversing HD-associated cardiomyopathy, in part due to targeting single pathways of low yield. Few studies have sought to establish natural history and there is no framework of priorities for future clinical trials. Targeting intradialytic cardiac dysfunction by altering dialysate temperature, composition, or ultrafiltration rate might prevent the development of global cardiomyopathy, heart failure, and mortality through multiple pathways. Novel imaging techniques show promise in characterizing the physiological response to HD that is a unique model of repetitive ischemia-reperfusion injury. Reducing HD-associated cardiomyopathy may need a paradigm shift from empirical delivery of solute clearance to a personalized therapy balancing solute and fluid removal with microvascular protection. This review describes the evidence for intradialytic cardiac dysfunction outlining cardioprotective strategies that extend to multiple organs with potential impacts on exercise tolerance, sleep, cognitive function, and quality of life.
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Affiliation(s)
- Aghogho Odudu
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom. .,Salford Royal Hospital, Salford, United Kingdom.
| | - Christopher W McIntyre
- Division of Nephrology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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70
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Abstract
The heart and the vascular tree undergo major structural and functional changes when kidney function declines and renal replacement therapy is required. The many cardiovascular risk factors and adaptive changes the heart undergoes include left ventricular hypertrophy and dilatation with concomitant systolic and diastolic dysfunction. Myocardial fibrosis is the consequence of impaired angio-adaptation, reduced capillary angiogenesis, myocyte-capillary mismatch, and myocardial micro-arteriopathy. The vascular tree can be affected by both atherosclerosis and arteriosclerosis with both lipid rich plaques and abundant media calcification. Development of cardiac and vascular disease is rapid, especially in young patients, and the phenotype resembles all aspects of an accelerated ageing process and latent cardiac failure. The major cause of left ventricular hypertrophy and failure and the most common problem directly affecting myocardial function is fluid overload and, usually, hypertension. In situations of stress, such as intradialytic hypotension and hypoxaemia, the hearts of these patients are more vulnerable to developing cardiac arrest, especially when such episodes occur frequently. As a result, cardiac and vascular mortality are several times higher in dialysis patients than in the general population. Trials investigating one pharmacological intervention (eg, statins) have shown limitations. Pragmatic designs for large trials on cardio-active interventions are mandatory for adequate cardioprotective renal replacement therapy.
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Affiliation(s)
- Christoph Wanner
- Comprehensive Heart Failure Center and Renal Division, University Hospital of Würzburg, Würzburg, Germany.
| | - Kerstin Amann
- Department of Nephropathology at the Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Tetsuo Shoji
- Department of Geriatrics and Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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71
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Nie Y, Zhang Z, Zou J, Liang Y, Cao X, Liu Z, Shen B, Chen X, Ding X. Hemodialysis-induced regional left ventricular systolic dysfunction. Hemodial Int 2016; 20:564-572. [PMID: 27312507 DOI: 10.1111/hdi.12434] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction Hemodialysis (HD) patients are under observably elevated cardiovascular mortality. Cardiac dysfunction is closely related to death caused by cardiovascular diseases (CVD). In the general population, repetitive myocardial ischemia induced left ventricular (LV) dysfunction may progress to irreversible loss of contraction step by step, and finally lead to cardiac death. In HD patients, to remove water and solute accumulated from 48 or 72 hours of interdialysis period in a 4-hour HD session will induce myocardial ischemia. In this study, we evaluated the prevalence and potential risk factors associated with HD-induced LV systolic dysfunction and provide some evidences for clinical strategies. Methods We recruited 31 standard HD patients for this study from Fudan University Zhongshan hospital. Echocardiography was performed predialysis, at peak stress during HD (15 minutes prior to the end of dialysis), and 30 minutes after HD. Auto functional imaging (AFI) was used to assess the incidence and persistence of HD-induced regional wall motion abnormalities (RWMAs). Blood samples were drawn to measure biochemical variables. Findings Among totally 527 segments of 31 patients, 93.54% (29/31) patients and 51.40% (276/527) segments were diagnosed as RWMAs. Higher cTnT (0.060 ± 0.030 vs. 0.048 ± 0.015 ng/mL, P = 0.023), phosphate (2.07 ± 0.50 vs. 1.49 ± 0.96 mmol/L, P = 0.001), UFR (11.00 ± 3.89 vs. 8.30 ± 2.66 mL/Kg/h, P = 0.039) and lower albumin (37.83 ± 4.48 vs. 38.38 ± 2.53 g/L, P = 0.050) were found in patients with severe RWMAs (RWMAs in more than 50% segments). After univariate and multivariate analysis, interdialytic weight gain (IDWG) was found as independent risk factor of severe RWMAs (OR = 1.047, 95%CI 1.155-4.732, P = 0.038). Discussion LV systolic dysfunction induced by HD is prevalent in conventional HD patients and should be paid attention to. Patients would benefit from better weight control during interdialytic period to reduce ultrafiltration rate.
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Affiliation(s)
- Yuxin Nie
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
| | - Zhen Zhang
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
| | - Jianzhou Zou
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China.,Key Laboratory of Kidney and Blood Purification of Shanghai, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Yixiu Liang
- Division of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Xuesen Cao
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
| | - Zhonghua Liu
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
| | - Bo Shen
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
| | - Xiaohong Chen
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, P. R. China. .,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China. .,Key Laboratory of Kidney and Blood Purification of Shanghai, Zhongshan Hospital, Fudan University, Shanghai, P. R. China.
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72
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Toth-Manikowski SM, Sozio SM. Cooling dialysate during in-center hemodialysis: Beneficial and deleterious effects. World J Nephrol 2016; 5:166-171. [PMID: 26981441 PMCID: PMC4777788 DOI: 10.5527/wjn.v5.i2.166] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/27/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
The use of cooled dialysate temperatures first came about in the early 1980s as a way to curb the incidence of intradialytic hypotension (IDH). IDH was then, and it remains today, the most common complication affecting chronic hemodialysis patients. It decreases quality of life on dialysis and is an independent risk factor for mortality. Cooling dialysate was first employed as a technique to incite peripheral vasoconstriction on dialysis and in turn reduce the incidence of intradialytic hypotension. Although it has become a common practice amongst in-center hemodialysis units, cooled dialysate results in up to 70% of patients feeling cold while on dialysis and some even experience shivering. Over the years, various studies have been performed to evaluate the safety and efficacy of cooled dialysate in comparison to a standard, more thermoneutral dialysate temperature of 37 °C. Although these studies are limited by small sample size, they are promising in many aspects. They demonstrated that cooled dialysis is safe and equally efficacious as thermoneutral dialysis. Although patients report feeling cold on dialysis, they also report increased energy and an improvement in their overall health following cooled dialysis. They established that cooling dialysate temperatures improves hemodynamic tolerability during and after hemodialysis, even in patients prone to IDH, and does so without adversely affecting dialysis adequacy. Cooled dialysis also reduces the incidence of IDH and has a protective effect over major organs including the heart and brain. Finally, it is an inexpensive measure that decreases economic burden by reducing necessary nursing intervention for issues that arise on hemodialysis such as IDH. Before cooled dialysate becomes standard of care for patients on chronic hemodialysis, larger studies with longer follow-up periods will need to take place to confirm the encouraging outcomes mentioned here.
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73
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McIntyre C, Crowley L. Dying to Feel Better: The Central Role of Dialysis-Induced Tissue Hypoxia. Clin J Am Soc Nephrol 2016; 11:549-51. [PMID: 26936947 DOI: 10.2215/cjn.01380216] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Christopher McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Lisa Crowley
- Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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74
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Sherman RA. Briefly Noted. Semin Dial 2016. [DOI: 10.1111/sdi.12447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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75
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Daugirdas JT. Lower cardiovascular mortality with high-volume hemodiafiltration: a cool effect? Nephrol Dial Transplant 2015; 31:853-6. [PMID: 26687900 DOI: 10.1093/ndt/gfv412] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- John T Daugirdas
- Medicine/Nephrology, University of Illinois at Chicago, Chicago, IL, USA
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76
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Clark EG, Zimmerman DL. Dialysate Calcium in Limbo: How Low Can You Go? Am J Kidney Dis 2015; 66:558-60. [PMID: 26408235 DOI: 10.1053/j.ajkd.2015.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 06/14/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Edward G Clark
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Deborah L Zimmerman
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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77
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Roumelioti ME, Unruh ML. Lower Dialysate Temperature in Hemodialysis: Is It a Cool Idea? Clin J Am Soc Nephrol 2015. [PMID: 26195504 DOI: 10.2215/cjn.06920615] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
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