151
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Sun M, Cao X, Guo Y, Tan X, Dong L, Pan C, Shu X. Long-term impacts of hemodialysis on the right ventricle: Assessment via 3-dimensional speckle-tracking echocardiography. Clin Cardiol 2018; 41:87-95. [PMID: 29363796 DOI: 10.1002/clc.22857] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/06/2017] [Accepted: 11/21/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is a major cause of death in patients undergoing maintenance hemodialysis (MHD). We used 3-dimensional speckle-tracking echocardiography (3DSTE) to evaluate long-term impacts of MHD on RV function. HYPOTHESIS In this study, RV dysfunction in MHD patients will be revealed and studied in depth by 3DSTE. METHODS Echocardiography was performed on 110 consecutively enrolled individuals: 30 controls and 80 patients with MHD. Conventional echocardiographic parameters and 3DSTE parameters were obtained and compared between groups. Univariate and multivariate logistic regression analysis identified independent predictors of intradialytic hypotension (IDH). RESULTS Compared with the control group, RV end-diastolic volume (RVEDV) was markedly enlarged (46.1 ± 11.8 mL/m2 vs 42.3 ± 8.6 mL/m2 ; P = 0.047), whereas RV ejection fraction (RVEF) was significantly lower in the MHD group (50.6% ± 5.8% vs 55.2% ± 3.7%; P < 0.001). RV global, septal, and lateral wall longitudinal strains were also decreased in the MHD group (-18.2 ± 3.6 vs -22.6 ± 4.3%; -13.1 ± 3.8 vs -17.5 ± 5.5%; and -23.4 ± 4.7 vs -27.7 ± 4.0%, respectively; all P < 0.001). RVEF (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.51 to 1.01, P = 0.038) and history of diabetes (OR: 11.14, 95% CI: 1.16 to 106.71, P = 0.036) were 2 independent predictors of IDH. Ultrafiltration rate was an independent factor associated with RVEF (β = -0.01, 95% CI: -0.019 to 0.001, P = 0.039). CONCLUSIONS RVEF by 3DSTE could be an important predictor of IDH in MHD patients, and lower ultrafiltration rate was protective for RVEF. 3DSTE may have potential in RV evaluation and risk stratification in MHD patients.
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Affiliation(s)
- Minmin Sun
- Department of Echocardiography, Zhongshan Hospital of Fudan University, Shanghai, China; Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xuesen Cao
- Department of Nephrology, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Yao Guo
- Department of Echocardiography, Zhongshan Hospital of Fudan University, Shanghai, China; Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xiao Tan
- Department of Nephrology, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Lili Dong
- Department of Echocardiography, Zhongshan Hospital of Fudan University, Shanghai, China; Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Cuizhen Pan
- Department of Echocardiography, Zhongshan Hospital of Fudan University, Shanghai, China; Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital of Fudan University, Shanghai, China; Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
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152
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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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153
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Wu TK, Lim PS, Jin JS, Wu MY, Chen CH. Impaired Gut Epithelial Tight Junction Expression in Hemodialysis Patients Complicated with Intradialytic Hypotension. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2670312. [PMID: 29581966 PMCID: PMC5822862 DOI: 10.1155/2018/2670312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/30/2017] [Accepted: 11/22/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND There is accumulating evidence pointing to uremia-induced impairment of the intestinal epithelial barrier structure in advanced chronic kidney disease (CKD) and hemodialysis (HD) patients. In this study, the impact of intradialytic hypotension on intestinal barrier integrity is being explored. METHODS Immunohistochemical staining was used to detect the expression of 4 types of tight junction (TJ) proteins such as occludin, zonula occludens-1 (ZO-1), claudin-1, and claudin-4, in colonic samples of a group of patients receiving segmental colectomy. Five patients with nondialysis CKD (group 2), 5 HD patients with intradialytic hypotension (group 3), and 5 non-CKD subjects (group 1) were examined. RESULTS Both patients' groups 2 and 3 demonstrated significantly reduced expression of occludin as compared to group 1 (p < 0.05 and p < 0.01, resp.). Except for claudin-4, expression of all markers of TJ proteins was significantly reduced in patients' group 3 as compared to control (p < 0.01). In addition, decreased expressions of claudin-1 and ZO-1 were also more pronounced in group 3 when compared to group 2. CONCLUSIONS This study extends the earlier finding by demonstrating that dialysis-related hypotension caused even marked depletion of the key protein constituents of the epithelial TJ.
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Affiliation(s)
- Tsai-Kun Wu
- Division of Renal Medicine, Tungs' Metroharbor Hospital, Taichung, Taiwan
- Department of Rehabilitation, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Paik-Seong Lim
- Division of Renal Medicine, Tungs' Metroharbor Hospital, Taichung, Taiwan
- Department of Rehabilitation, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Jong-Shiaw Jin
- Department of Pathology, Tungs' Metroharbor Hospital, Taichung, Taiwan
| | - Ming-Ying Wu
- Division of Renal Medicine, Tungs' Metroharbor Hospital, Taichung, Taiwan
| | - Chang-Hsu Chen
- Division of Renal Medicine, Tungs' Metroharbor Hospital, Taichung, Taiwan
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154
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Scotland G, Cruickshank M, Jacobsen E, Cooper D, Fraser C, Shimonovich M, Marks A, Brazzelli M. Multiple-frequency bioimpedance devices for fluid management in people with chronic kidney disease receiving dialysis: a systematic review and economic evaluation. Health Technol Assess 2018; 22:1-138. [PMID: 29298736 PMCID: PMC5776406 DOI: 10.3310/hta22010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition requiring treatment such as conservative management, kidney transplantation or dialysis. To optimise the volume of fluid removed during dialysis (to avoid underhydration or overhydration), people are assigned a 'target weight', which is commonly assessed using clinical methods, such as weight gain between dialysis sessions, pre- and post-dialysis blood pressure and patient-reported symptoms. However, these methods are not precise, and measurement devices based on bioimpedance technology are increasingly used in dialysis centres. Current evidence on the role of bioimpedance devices for fluid management in people with CKD receiving dialysis is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of multiple-frequency bioimpedance devices versus standard clinical assessment for fluid management in people with CKD receiving dialysis. DATA SOURCES We searched major electronic databases [e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Science Citation Index and Cochrane Central Register of Controlled Trials (CENTRAL)] conference abstracts and ongoing studies. There were no date restrictions. Searches were undertaken between June and October 2016. REVIEW METHODS Evidence was considered from randomised controlled trials (RCTs) comparing fluid management by multiple-frequency bioimpedance devices and standard clinical assessment in people receiving dialysis, and non-randomised studies evaluating the use of the devices for fluid management in people receiving dialysis. One reviewer extracted data and assessed the risk of bias of included studies. A second reviewer cross-checked the extracted data. Standard meta-analyses techniques were used to combine results from included studies. A Markov model was developed to assess the cost-effectiveness of the interventions. RESULTS Five RCTs (with 904 adult participants) and eight non-randomised studies (with 4915 adult participants) assessing the use of the Body Composition Monitor [(BCM) Fresenius Medical Care, Bad Homburg vor der Höhe, Germany] were included. Both absolute overhydration and relative overhydration were significantly lower in patients evaluated using BCM measurements than for those evaluated using standard clinical methods [weighted mean difference -0.44, 95% confidence interval (CI) -0.72 to -0.15, p = 0.003, I2 = 49%; and weighted mean difference -1.84, 95% CI -3.65 to -0.03; p = 0.05, I2 = 52%, respectively]. Pooled effects of bioimpedance monitoring on systolic blood pressure (SBP) (mean difference -2.46 mmHg, 95% CI -5.07 to 0.15 mmHg; p = 0.06, I2 = 0%), arterial stiffness (mean difference -1.18, 95% CI -3.14 to 0.78; p = 0.24, I2 = 92%) and mortality (hazard ratio = 0.689, 95% CI 0.23 to 2.08; p = 0.51) were not statistically significant. The economic evaluation showed that, when dialysis costs were included in the model, the probability of bioimpedance monitoring being cost-effective ranged from 13% to 26% at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. With dialysis costs excluded, the corresponding probabilities of cost-effectiveness ranged from 61% to 67%. LIMITATIONS Lack of evidence on clinically relevant outcomes, children receiving dialysis, and any multifrequency bioimpedance devices, other than the BCM. CONCLUSIONS BCM used in addition to clinical assessment may lower overhydration and potentially improve intermediate outcomes, such as SBP, but effects on mortality have not been demonstrated. If dialysis costs are not considered, the incremental cost-effectiveness ratio falls below £20,000, with modest effects on mortality and/or hospitalisation rates. The current findings are not generalisable to paediatric populations nor across other multifrequency bioimpedance devices. FUTURE WORK Services that routinely use the BCM should report clinically relevant intermediate and long-term outcomes before and after introduction of the device to extend the current evidence base. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041785. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Elisabet Jacobsen
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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155
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Dasgupta I, Keane D, Lindley E, Shaheen I, Tyerman K, Schaefer F, Wühl E, Müller MJ, Bosy-Westphal A, Fors H, Dahlgren J, Chamney P, Wabel P, Moissl U. Validating the use of bioimpedance spectroscopy for assessment of fluid status in children. Pediatr Nephrol 2018; 33:1601-1607. [PMID: 29869117 PMCID: PMC6061658 DOI: 10.1007/s00467-018-3971-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/31/2018] [Accepted: 04/27/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bioimpedance spectroscopy (BIS) with a whole-body model to distinguish excess fluid from major body tissue hydration can provide objective assessment of fluid status. BIS is integrated into the Body Composition Monitor (BCM) and is validated in adults, but not children. This study aimed to (1) assess agreement between BCM-measured total body water (TBW) and a gold standard technique in healthy children, (2) compare TBW_BCM with TBW from Urea Kinetic Modelling (UKM) in haemodialysis children and (3) investigate systematic deviation from zero in measured excess fluid in healthy children across paediatric age range. METHODS TBW_BCM and excess fluid was determined from standard wrist-to-ankle BCM measurement. TBW_D2O was determined from deuterium concentration decline in serial urine samples over 5 days in healthy children. UKM was used to measure body water in children receiving haemodialysis. Agreement between methods was analysed using paired t test and Bland-Altman method comparison. RESULTS In 61 healthy children (6-14 years, 32 male), mean TBW_BCM and TBW_D2O were 21.1 ± 5.6 and 20.5 ± 5.8 L respectively. There was good agreement between TBW_BCM and TBW_D2O (R2 = 0.97). In six haemodialysis children (4-13 years, 4 male), 45 concomitant measurements over 8 months showed good TBW_BCM and TBW_UKM agreement (mean difference - 0.4 L, 2SD = ± 3.0 L). In 634 healthy children (2-17 years, 300 male), BCM-measured overhydration was - 0.1 ± 0.7 L (10-90th percentile - 0.8 to + 0.6 L). There was no correlation between age and OH (p = 0.28). CONCLUSIONS These results suggest BCM can be used in children as young as 2 years to measure normally hydrated weight and assess fluid status.
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Affiliation(s)
| | - David Keane
- Departments of Renal Medicine and Medical Physics, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Elizabeth Lindley
- Departments of Renal Medicine and Medical Physics, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ihab Shaheen
- Department of Children's Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kay Tyerman
- Department of Children's Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Franz Schaefer
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Elke Wühl
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Manfred J Müller
- Institute for Human Nutrition and Food Science, Christian-Albrecht University, Kiel, Germany
| | | | - Hans Fors
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jovanna Dahlgren
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Paul Chamney
- Global R&D, Fresenius Medical Care, Bad Homburg, Germany
| | - Peter Wabel
- Global R&D, Fresenius Medical Care, Bad Homburg, Germany
| | - Ulrich Moissl
- Global R&D, Fresenius Medical Care, Bad Homburg, Germany
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156
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Miskulin DC, Gassman J, Schrader R, Gul A, Jhamb M, Ploth DW, Negrea L, Kwong RY, Levey AS, Singh AK, Harford A, Paine S, Kendrick C, Rahman M, Zager P. BP in Dialysis: Results of a Pilot Study. J Am Soc Nephrol 2017; 29:307-316. [PMID: 29212839 DOI: 10.1681/asn.2017020135] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 08/28/2017] [Indexed: 01/13/2023] Open
Abstract
The optimal BP target for patients receiving hemodialysis is unknown. We randomized 126 hypertensive patients on hemodialysis to a standardized predialysis systolic BP of 110-140 mmHg (intensive arm) or 155-165 mmHg (standard arm). The primary objectives were to assess feasibility and safety and inform the design of a full-scale trial. A secondary objective was to assess changes in left ventricular mass. Median follow-up was 365 days. In the standard arm, the 2-week moving average systolic BP did not change significantly during the intervention period, but in the intensive arm, systolic BP decreased from 160 mmHg at baseline to 143 mmHg at 4.5 months. From months 4-12, the mean separation in systolic BP between arms was 12.9 mmHg. Four deaths occurred in the intensive arm and one death occurred in the standard arm. The incidence rate ratios for the intensive compared with the standard arm (95% confidence intervals) were 1.18 (0.40 to 3.33), 1.61 (0.87 to 2.97), and 3.09 (0.96 to 8.78) for major adverse cardiovascular events, hospitalizations, and vascular access thrombosis, respectively. The intensive and standard arms had similar median changes (95% confidence intervals) in left ventricular mass of -0.84 (-17.1 to 10.0) g and 1.4 (-11.6 to 10.4) g, respectively. Although we identified a possible safety signal, the small size and short duration of the trial prevent definitive conclusions. Considering the high risk for major adverse cardiovascular events in patients receiving hemodialysis, a full-scale trial is needed to assess potential benefits of intensive hypertension control in this population.
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Affiliation(s)
- Dana C Miskulin
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jennifer Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Ronald Schrader
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico
| | - Ambreen Gul
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David W Ploth
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Lavinia Negrea
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Raymond Y Kwong
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Ajay K Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Antonia Harford
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico.,Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Susan Paine
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico
| | - Cynthia Kendrick
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip Zager
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico; .,Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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157
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Continuous monitoring of blood pressure by analyzing the blood flow sound of arteriovenous fistula in hemodialysis patients. Clin Exp Nephrol 2017; 22:677-683. [DOI: 10.1007/s10157-017-1499-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/16/2017] [Indexed: 01/01/2023]
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158
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Chou JA, Kalantar-Zadeh K, Mathew AT. A brief review of intradialytic hypotension with a focus on survival. Semin Dial 2017; 30:473-480. [PMID: 28661565 PMCID: PMC5738929 DOI: 10.1111/sdi.12627] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intradialytic hypotension (IDH), a common complication of ultrafiltration during hemodialysis therapy, is associated with high mortality and morbidity. IDH, defined as a nadir systolic blood pressure of less than 90 mm Hg on more than 30% of treatments, is a relevant definition and is correlated with mortality. Risk factors for IDH include patient demographics, anti-hypertensive medication use, larger interdialytic weight gain, and dialysis prescription features as dialysate sodium, high ultrafiltration rate, and dialysate temperature. A high frequency of IDH events carries a substantial death risk. An ultrafiltration rate >10 mL/h/kg, and even more so >13 mL/h/kg, is highly predictive of cardiovascular and all-cause mortality. Evidence suggests that IDH causes acute reversible segmental myocardial hypoperfusion and contractile dysfunction (myocardial stunning), which can result in long-term loss of myocardial contractility, leading to premature death. IDH also has negative end-organ effects on the brain and gut, contributing to mortality through stroke, and endotoxin translocation with associated inflammation and protein-energy wasting. Given strong association of IDH and dialysis mortality, a paradigm shift to its approach is urgently needed. Randomized controlled trials are required to prospectively test drugs and monitoring devices which may reduce IDH.
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Affiliation(s)
- Jason A Chou
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles, CA, USA
- Fielding School of Public Health at UCLA, Los Angeles, CA, USA
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
| | - Anna T Mathew
- Division of Nephrology, Northwell Health, Great Neck, NY, USA
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159
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Abstract
Intradialytic hypotension (IDH) is a common and often distressful complication of hemodialysis. However, despite its clinical significance, there is no consensus, evidence-based medical definition for the condition. Over the years, numerous definitions have been implemented in both the clinical and research settings. Definition inconsistencies have hindered data synthesis and the development of evidence-based guidelines for the prevention and treatment of IDH, as well as prevented accurate estimation of the population burden of IDH and patient risk assessment. Most existing IDH definitions are comprised of one or more of the following components: (1) intradialytic BP criteria (requisite BP declines or minimum BP thresholds), (2) the provision of interventions aimed at restoring effective arterial volume, and/or (3) patient-reported symptoms. Remarkably, there are insufficient data to inform IDH definition construction, and it remains unknown if a single, universal definition can adequately capture the condition across patient subgroups, and in clinical and research settings.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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160
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Steinwandel U, Gibson N, Towell A, Rippey JJR, Rosman J. Can a renal nurse assess fluid status using ultrasound on the inferior vena cava? A cross-sectional interrater study. Hemodial Int 2017; 22:261-269. [DOI: 10.1111/hdi.12606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ulrich Steinwandel
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Western Australia Australia
| | - Nicholas Gibson
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Western Australia Australia
| | - Amanda Towell
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Western Australia Australia
| | - James J. R. Rippey
- Sir Charles Gairdner Hospital; Perth Western Australia Australia
- Department of Emergency Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Johan Rosman
- School of Medicine, Faculty of Health Sciences; Curtin University Perth; Perth Western Australia Australia
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161
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Chan L, Zhang H, Meyring-Wösten A, Campos I, Fuertinger D, Thijssen S, Kotanko P. Intradialytic Central Venous Oxygen Saturation is Associated with Clinical Outcomes in Hemodialysis Patients. Sci Rep 2017; 7:8581. [PMID: 28819317 PMCID: PMC5561134 DOI: 10.1038/s41598-017-09233-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/17/2017] [Indexed: 01/20/2023] Open
Abstract
Central venous oxygen saturation (ScvO2) in the superior vena cava is predominantly determined by cardiac output, arterial oxygen content, and oxygen consumption by the upper body. While abnormal ScvO2 levels are associated with morbidity and mortality in non-uremic populations, ScvO2 has received little attention in hemodialysis patients. From 1/2012 to 8/2015, 232 chronic hemodialysis patients with central venous catheters as vascular access had their ScvO2 monitored during a 6-month baseline period and followed for up to 36 months. Patients were stratified into upper and lower two tertiles by a ScvO2 of 61.1%. Survival analysis employed Kaplan-Meier curves and adjusted Cox proportional hazards models. Patients in the lower tertiles of ScvO2 were older, had longer hemodialysis vintage, lower systolic blood pressure, lower ultrafiltration rates, higher leukocyte counts and neutrophil-to-lymphocyte ratios. Kaplan-Meier analysis indicated a shorter survival time in the lower tertiles of ScvO2 (P = 0.005, log-rank test). In adjusted Cox analysis, a 1 percent point decrease in mean ScvO2 was associated with a 4% increase in mortality (HR 1.04 [95% CI 1.01-1.08], P = 0.044), indicating that low ScvO2 is associated with poor outcomes. Research on the relative contributions of cardiac output and other factors is warranted to further elucidate the pathophysiology underlying this novel finding.
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Affiliation(s)
- Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | - Peter Kotanko
- Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Renal Research Institute, New York, NY, USA.
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162
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Ibarra-Sifuentes HR, Del Cueto-Aguilera Á, Gallegos-Arguijo DA, Castillo-Torres SA, Vera-Pineda R, Martínez-Granados RJ, Atilano-Díaz A, Cuellar-Monterrubio JE, Pezina-Cantú CO, Martínez-Guevara EDJ, Ortiz-Treviño JF, Delgado-García GR, Martínez-Jiménez JG, Cruz-Valdez J, Sánchez-Martínez C. Levocarnitine Decreases Intradialytic Hypotension Episodes: A Randomized Controlled Trial. Ther Apher Dial 2017; 21:459-464. [PMID: 28805348 DOI: 10.1111/1744-9987.12553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/01/2017] [Accepted: 04/13/2017] [Indexed: 11/28/2022]
Abstract
Intradialytic hypotension is common complication in stage 5 chronic kidney disease patients on hemodialysis. Incidence ranges from 15 to 30%. These patients have levocarnitine deficiency. A randomized, placebo-controlled quadruple-blinded trial was designed to demonstrate the levocarnitine efficiency on intradialytic hypotension prevention. Patients were randomized into four groups, to receive levocarnitine or placebo. During the intervention period, levocarnitine and placebo was administered 0 and 30 min before each hemodialysis session, respectively. During the trial, 33 patients received 1188 hemodialysis sessions. We identified 239 (21.3%) intradialytic hypotension episodes. The intradialytic hypotension episodes were less frequent in the levocarnitine group (9.3%, 60 IH events) (P < 0.001). Hemodialysis is frequently perplexed by intradialytic hypotension episodes. Levocarnitine supplementation before each hemodialysis session efficiently diminishes the intradialytic hypotension episodes. This is a new application method that must be considered and explored.
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Affiliation(s)
- Héctor Raúl Ibarra-Sifuentes
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | - Ángel Del Cueto-Aguilera
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | | | | | - Raymundo Vera-Pineda
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | | | - Alexandro Atilano-Díaz
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | | | | | | | | | | | - José Guadalupe Martínez-Jiménez
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | - Jesús Cruz-Valdez
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | - Concepción Sánchez-Martínez
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
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163
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Ignacak E, Cieniawski D, Bętkowska-Prokop A, Osuch C, Kuźniewski M, Sułowicz W. Beneficial effect of kidney transplantation from a deceased donor on severe chronic refractory intradialytic hypotension - a case report. BMC Nephrol 2017; 18:248. [PMID: 28728576 PMCID: PMC5520388 DOI: 10.1186/s12882-017-0662-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 07/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic refractory hypotension (IDH, intradialytic hypotension) is a rare but serious problem encountered in patients on hemodialysis. Patients with chronic hypotension are often disqualified by transplant teams from renal transplantation. This is due to the possibility of an enormous risk of ischemic complications. CASE PRESENTATION We describe a 44-year old female patient with severe refractory hypotension (mean BP 60/30 mmHg, the lowest 48/28 mmHg), which appeared after bilateral laparoscopic nephrectomy of the infected kidneys. The kidney transplantation from a deceased donor, with infusion of the two pressor amines (dopamine, dobutamine) was performed without technical complications and the blood pressure measurements were 100-120/70-80 mmHg. The immunosuppression regimen was tacrolimus (TAC) + mycophenolate mophetil (MMF) and steroids (GS). Pressor amines were discontinued on the 18th day after the transplantation. Because of delayed graft function, 4 hemodialysis treatments were performed. The patient was discharged from the hospital on the 22nd day with good function of the transplanted kidney (the concentration of serum creatinine 117 μmol/l). During one-year follow-up, the patient has been remaining stable with a very good graft function (serum creatinine 84 μmol/l) and normal blood pressure (115/70 mmHg). CONCLUSIONS Proper preparation and adequate perioperative treatment allowed for safely performing kidney transplantation in the patient with severe IDH.
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Affiliation(s)
- Ewa Ignacak
- Department of Nephrology, Jagiellonian University, ul. Kopernika 15C, 31-501, Krakow, Poland
| | - Dominik Cieniawski
- Department of Nephrology, Jagiellonian University, ul. Kopernika 15C, 31-501, Krakow, Poland.
| | - Alina Bętkowska-Prokop
- Department of Nephrology, Jagiellonian University, ul. Kopernika 15C, 31-501, Krakow, Poland
| | - Czesław Osuch
- First Department of Surgery, Jagiellonian University, ul. Kopernika 40, 31-501, Krakow, Poland
| | - Marek Kuźniewski
- Department of Nephrology, Jagiellonian University, ul. Kopernika 15C, 31-501, Krakow, Poland
| | - Władysław Sułowicz
- Department of Nephrology, Jagiellonian University, ul. Kopernika 15C, 31-501, Krakow, Poland
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164
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Ansari S, Molaei S, Oldham K, Heung M, Ward KR, Najarian K. An extended Kalman filter with inequality constraints for real-time detection of intradialytic hypotension. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:2227-2230. [PMID: 29060339 DOI: 10.1109/embc.2017.8037297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Intradialytic hypotension (IDH) is the most common complication of hemodialysis, affecting 15-50% of all dialysis sessions. Previously, we had presented a non-invasive Polyvinylidene Fluoride (PVDF) based sensor in the form of a ring to measure vascular tone and we showed that the morphology of the signal can be utilized to predict IDH. This paper presents an approach for analyzing the PVDF signal using extended Kalman filter (EKF) and a synthetic model that has previously been used to model the ECG signal with Gaussian functions. Moreover, a novel approach for incorporating state inequality constraints into the EKF process using a gradient projection method is introduced. The taut string algorithm was first used to estimate the outline of the signal and remove it to highlight the reflection waves. Then, the EKF was used to characterize the morphology of the signal using Gaussian functions. The amplitudes of the Gaussian functions were used as features to train a classifier. The results indicated that the PPV and NPV for the prediction were 83.33% and 100%, respectively.
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165
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Hussein WF, Arramreddy R, Sun SJ, Reiterman M, Schiller B. Higher Ultrafiltration Rate Is Associated with Longer Dialysis Recovery Time in Patients Undergoing Conventional Hemodialysis. Am J Nephrol 2017; 46:3-10. [PMID: 28554180 DOI: 10.1159/000476076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/19/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Increased mortality and morbidity are reported in association with high ultrafiltration rate (UFR) and with long dialysis recovery time (DRT). We studied the association between UFR and DRT. METHODS This is a cross-sectional, observational study was conducted. Patients on thrice-weekly hemodialysis (HD) with self-reported DRT between August and December 2014 were included. We examined the association of 30-day average UFR with recovery time. RESULTS The total number of patients included in this study was 2,689. DRT in categories of immediate recovery, >0-≤2, >2-≤6, >6-≤12, and >12 h, were reported in 27, 28, 17, 9, and 20% of the patients respectively. In multivariable analysis, longer DRT was associated with female gender, non-black race, higher body weight, lower serum albumin, chronic heart failure, cerebrovascular disease, missed dialysis sessions, higher pre-dialysis systolic blood pressure, and larger UF volume. Compared to UFR of <10, UFR ≥13 mL/kg/h was associated with longer DRT, OR of 1.16 (95% CI 0.99-1.36), and 1.28 (95% CI 1.06-1.54) in the unadjusted and the adjusted analyses respectively. Intradialytic hypotension was also associated with longer DRT in the unadjusted (per 10% higher frequency, OR 1.04 [95% CI 1.01-1.07]) and adjusted analyses (OR 1.03 [95% CI 1.00-1.07]). CONCLUSION Long recovery time is common after HD. Rapid fluid removal is associated with longer DRT.
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Affiliation(s)
- Wael F Hussein
- Department of Medicine, Division of Nephrology, Stanford University, Palo Alto, CA, USA
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166
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Nakai K, Fujii H, Kono K, Goto S, Nishi S. Hypertension Induced by Tyrosine-Kinase Inhibitors for the Treatment of Renal Cell Carcinoma in Hemodialysis Patients: A Single-Center Experience and Review of the Literature. Ther Apher Dial 2017; 21:320-325. [DOI: 10.1111/1744-9987.12537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Kentaro Nakai
- Division of Nephrology and Kidney Center; Kobe University Graduate School of Medicine; Kobe Japan
- Department of Nephrology and Kidney Center; Kakogawa Central City Hospital; Kakogawa Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center; Kobe University Graduate School of Medicine; Kobe Japan
| | - Keiji Kono
- Division of Nephrology and Kidney Center; Kobe University Graduate School of Medicine; Kobe Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center; Kobe University Graduate School of Medicine; Kobe Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center; Kobe University Graduate School of Medicine; Kobe Japan
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167
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Morena M, Jaussent A, Chalabi L, Leray-Moragues H, Chenine L, Debure A, Thibaudin D, Azzouz L, Patrier L, Maurice F, Nicoud P, Durand C, Seigneuric B, Dupuy AM, Picot MC, Cristol JP, Canaud B. Treatment tolerance and patient-reported outcomes favor online hemodiafiltration compared to high-flux hemodialysis in the elderly. Kidney Int 2017; 91:1495-1509. [PMID: 28318624 DOI: 10.1016/j.kint.2017.01.013] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/09/2016] [Accepted: 01/05/2017] [Indexed: 12/18/2022]
Abstract
Large cohort studies suggest that high convective volumes associated with online hemodiafiltration may reduce the risk of mortality/morbidity compared to optimal high-flux hemodialysis. By contrast, intradialytic tolerance is not well studied. The aim of the FRENCHIE (French Convective versus Hemodialysis in Elderly) study was to compare high-flux hemodialysis and online hemodiafiltration in terms of intradialytic tolerance. In this prospective, open-label randomized controlled trial, 381 elderly chronic hemodialysis patients (over age 65) were randomly assigned in a one-to-one ratio to either high-flux hemodialysis or online hemodiafiltration. The primary outcome was intradialytic tolerance (day 30-day 120). Secondary outcomes included health-related quality of life, cardiovascular risk biomarkers, morbidity, and mortality. During the observational period for intradialytic tolerance, 85% and 84% of patients in high-flux hemodialysis and online hemodiafiltration arms, respectively, experienced at least one adverse event without significant difference between groups. As exploratory analysis, intradialytic tolerance was also studied, considering the sessions as a statistical unit according to treatment actually received. Over a total of 11,981 sessions, 2,935 were complicated by the occurrence of at least one adverse event, with a significantly lower occurrence in online hemodiafiltration with fewer episodes of intradialytic symptomatic hypotension and muscle cramps. By contrast, health-related quality of life, morbidity, and mortality were not different in both groups. An improvement in the control of metabolic bone disease biomarkers and β2-microglobulin level without change in serum albumin concentration was observed with online hemodiafiltration. Thus, overall outcomes favor online hemodiafiltration over high-flux hemodialysis in the elderly.
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Affiliation(s)
- Marion Morena
- Laboratoire de Biochimie, CHU de Montpellier, Montpellier, France; Institut de Recherche et de Formation en Dialyse, Montpellier, France; PhyMedExp, INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Audrey Jaussent
- Département de l'Information Médicale, CHU de Montpellier, Montpellier, France
| | - Lotfi Chalabi
- Association pour l'Installation à Domicile des Epurations Rénales (AIDER), Montpellier, France
| | | | - Leila Chenine
- Service de Néphrologie, CHU de Montpellier, Montpellier, France
| | | | - Damien Thibaudin
- Service de Néphrologie, CHU de Saint Etienne, Saint-Etienne, France
| | - Lynda Azzouz
- Association Régionale pour le Traitement de l'Insuffisance Rénale Chronique, Saint-Priest-en-Jarez, France
| | | | | | | | | | | | - Anne-Marie Dupuy
- Laboratoire de Biochimie, CHU de Montpellier, Montpellier, France
| | | | - Jean-Paul Cristol
- Laboratoire de Biochimie, CHU de Montpellier, Montpellier, France; Institut de Recherche et de Formation en Dialyse, Montpellier, France; PhyMedExp, INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France.
| | - Bernard Canaud
- Institut de Recherche et de Formation en Dialyse, Montpellier, France; Université de Montpellier, Néphrologie, Montpellier, France
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168
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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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169
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Tsujimoto Y, Tsujimoto H, Nakata Y, Kataoka Y, Kimachi M, Shimizu S, Ikenoue T, Fukuma S, Yosuke Y, Fukuhara S. Dialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical Center; Hospital Care Research Unit; Higashi-Naniwa-Cho 2-17-77 Amagasaki Hyogo Japan 606-8550
| | - Yukihiko Nakata
- Shimane University; Department of Mathematics; 1060 Nishikawatsu cho Matsue 690-8504 Japan
| | - Yuki Kataoka
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Miho Kimachi
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Sayaka Shimizu
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Tatsuyoshi Ikenoue
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Shingo Fukuma
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Yamamoto Yosuke
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Shunichi Fukuhara
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
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170
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Wong MM, McCullough KP, Bieber BA, Bommer J, Hecking M, Levin NW, McClellan WM, Pisoni RL, Saran R, Tentori F, Tomo T, Port FK, Robinson BM. Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2017; 69:367-379. [DOI: 10.1053/j.ajkd.2016.08.030] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 08/13/2016] [Indexed: 11/11/2022]
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Association of Triiodothyronine Levels with Left Ventricular Function, Cardiovascular Events, and Mortality in Hemodialysis Patients. Int J Artif Organs 2017; 40:60-66. [PMID: 28315504 DOI: 10.5301/ijao.5000569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 11/20/2022]
Abstract
Background Hemodialysis (HD) patients have altered free triiodothyronine (fT3) levels. A low fT3 level is a strong and inverse mortality predictor in HD patients. However, little is known about the relationship between fT3 and left ventricular function in HD patients. Methods A total of 128 maintenance HD patients were enrolled in this study. A thyroid function test with blood sampling and echocardiography was conducted. Low-T3 syndrome was defined as fT3 level <3.62 pmol/L and normal thyroid stimulating hormone (TSH). Overall mortality and rate of cardiovascular (CV) events were assessed during 48 months of follow-up. Results Low-T3 syndrome was detected in 57 (44.5%) of the 128 patients. Patients with low-T3 syndrome had a shorter duration of HD (49.1 vs. 73.3, p = 0.01), and lower serum albumin (35.1 vs. 40.4 g/L, p<0.001), left ventricular ejection fraction (LVEF; 54.7% vs. 63.9%, p<0.001), and fractional shortening at endocardial levels (endoFS; 29.3% vs. 34.8%, p = 0.001) compared to those with normal fT3 levels. In multivariate linear regression, LVEF, albumin, and duration of HD were independently correlated with fT3 levels. In addition, fT3 was also correlated with LVEF. During the study period, 13 (10.1%) patients died, CV events occurred in 15 (11.7%) patients. In Cox regression analysis, low fT3 level and elevated high-sensitivity C-reactive protein (hs-CRP) were associated with mortality and CV events. Conclusions In HD patients, fT3 level is positively correlated with LVEF. Low fT3 level and elevated hs-CRP predicted all-cause mortality and CV events.
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172
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Trinh E, Weber C. The Dialysis Sodium Gradient: A Modifiable Risk Factor for Fluid Overload. NEPHRON EXTRA 2017; 7:10-17. [PMID: 28413417 PMCID: PMC5346930 DOI: 10.1159/000453674] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/17/2016] [Indexed: 12/15/2022]
Abstract
Background Fluid overload in patients on conventional hemodialysis is a frequent complication, associated with increased cardiovascular morbidity and mortality. The dialysate sodium prescription is a potential modifiable risk factor. Our primary objective was to describe associations between dialysate-to-serum sodium gradient and parameters of fluid status. A secondary objective was to evaluate the 6-month risk of hospitalization and mortality in relation to sodium gradient. Methods We performed a cross-sectional study of 110 prevalent conventional hemodialysis patients at a single center. The associations of sodium gradient with interdialytic weight gain index (IDWG%), ultrafiltration (UF) rate, and blood pressure (BP) were analyzed. Results The mean serum sodium gradient was 4.6 ± 3.6 mEq/L. There was a direct correlation between sodium gradient and IDWG% (r = 0.48, p < 0.01) as well as UF rate (r = 0.44, p < 0.01). In a logistic regression model, a 1 mEq/L higher sodium gradient was associated with increased risk of IDWG% >3% (OR 1.33, p < 0.01) and increased risk of UF rate >10 mL/kg/h (OR 1.16, p = 0.03), but there were no associations with intradialytic hypotension, intradialytic hypertension or BP. No significant differences were found with 6-month hospitalization or mortality risk in relation to sodium gradient. Conclusion A higher sodium gradient was associated with significant increases in IDWG and UF rates, known to be associated with poor outcomes, but was not associated with intradialytic hypotension. Individualizing the dialysate sodium prescription to minimize sodium gap may lead to less fluid overload in conventional hemodialysis patients.
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Weber
- Division of Nephrology, McGill University Health Centre, Montreal, QC, Canada
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173
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Kim JK, Song YR, Park G, Kim HJ, Kim SG. Impact of rapid ultrafiltration rate on changes in the echocardiographic left atrial volume index in patients undergoing haemodialysis: a longitudinal observational study. BMJ Open 2017; 7:e013990. [PMID: 28148536 PMCID: PMC5294025 DOI: 10.1136/bmjopen-2016-013990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Optimal fluid management is essential when caring for a patient on haemodialysis (HD). However, if the fluid removal is too rapid, the resultant higher ultrafiltration rate (UFR) disadvantageously promotes haemodynamic instability and cardiac injury. We evaluated the effects of a rapid UFR on changes in the echocardiographic left atrial volume index (LAVI) over a period of time. DESIGN Longitudinal observational study. SETTING AND PARTICIPANTS A total of 124 new patients on HD. INTERVENTIONS Echocardiography was performed at baseline and repeated after 19.7 months (range 11.3-23.1 months). Changes in LAVI (ΔLAVI/year, mL/m2/year) were calculated. The UFR was expressed in mL/hour/kg, and we used the mean UFR over 30 days (∼12-13 treatments). MAIN OUTCOME MEASURES The 75th centile of the ΔLAVI/year distribution was regarded as a 'pathological' increment. RESULTS The mean interdialytic weight gain was 1.73±0.94 kg, and the UFR was 8.01±3.87 mL/hour/kg. The significant pathological increment point in ΔLAVI/year was 4.89 mL/m2/year. Correlation analysis showed that ΔLAVI/year was closely related to the baseline blood pressure, haemoglobin level, residual renal function and UFR. According to the receiver operating characteristics curve, the 'best' cut-off value of UFR for predicting the pathological increment was 10 mL/hour/kg, with an area under the curve of 0.712. In multivariate analysis, systolic blood pressure, a history of coronary artery disease, haemoglobin <10 g/dL and high UFR were significant predictors. An increase of 1 mL/hour/kg in the UFR was associated with a 22% higher risk of a worsening LAVI (OR 1.22, 95% CI 1.05 to 1.41). CONCLUSIONS An increased haemodynamic load could affect left atrial remodelling in incident patients on HD. Thus, close monitoring and optimal control of UFR are needed.
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Affiliation(s)
- Jwa-Kyung Kim
- Department of Internal Medicine and Kidney Research
Institute, Hallym University Sacred Heart Hospital,
Anyang, Korea
- Department of Clinical Immunology,
Hallym University Sacred Heart Hospital,
Anyang, Korea
| | - Young Rim Song
- Department of Internal Medicine and Kidney Research
Institute, Hallym University Sacred Heart Hospital,
Anyang, Korea
| | - GunHa Park
- Department of Internal Medicine and Kidney Research
Institute, Hallym University Sacred Heart Hospital,
Anyang, Korea
| | - Hyung Jik Kim
- Department of Internal Medicine and Kidney Research
Institute, Hallym University Sacred Heart Hospital,
Anyang, Korea
| | - Sung Gyun Kim
- Department of Internal Medicine and Kidney Research
Institute, Hallym University Sacred Heart Hospital,
Anyang, Korea
- Department of Clinical Immunology,
Hallym University Sacred Heart Hospital,
Anyang, Korea
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174
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Milani GP, Groothoff JW, Vianello FA, Fossali EF, Paglialonga F, Edefonti A, Agostoni C, Consonni D, van Harskamp D, van Goudoever JB, Schierbeek H, Oosterveld MJS. Bioimpedance and Fluid Status in Children and Adolescents Treated With Dialysis. Am J Kidney Dis 2017; 69:428-435. [PMID: 28089477 DOI: 10.1053/j.ajkd.2016.10.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/09/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Assessment of hydration status in patients with chronic kidney failure treated by dialysis is crucial for clinical management decisions. Dilution techniques are considered the gold standard for measurement of body fluid volumes, but they are unfit for day-to-day care. Multifrequency bioimpedance has been shown to be of help in clinical practice in adults and its use in children and adolescents has been advocated. We investigated whether application of multifrequency bioimpedance is appropriate for total-body water (TBW) and extracellular water (ECW) measurement in children and adolescents on dialysis therapy. STUDY DESIGN A study of diagnostic test accuracy. SETTING & PARTICIPANTS 16 young dialysis patients (before a hemodialysis session or after peritoneal dialysis treatment) from the Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy, and the Emma Children's Hospital-Academic Medical Center, Amsterdam, the Netherlands. INDEX TEST TBW and ECW volumes assessed by multifrequency bioimpedance. REFERENCE TESTS TBW and ECW volumes measured by deuterium and bromide dilution, respectively. RESULTS Mean TBW volumes determined by multifrequency bioimpedance and deuterium dilution were 19.2±8.7 (SD) and 19.3±8.3L, respectively; Bland-Altman analysis showed a mean bias between the 2 methods of -0.09 (95% limits of agreement, -2.1 to 1.9) L. Mean ECW volumes were 8.9±4.0 and 8.3±3.3L measured by multifrequency bioimpedance and bromide dilution, respectively; mean bias between the 2 ECW measurements was +0.6 (95% limits of agreement, -2.3 to 3.5). LIMITATIONS Participants ingested the deuterated water at home without direct supervision by investigators, small number of patients, repeated measurements in individual patients were not performed. CONCLUSIONS Multifrequency bioimpedance measurements were unbiased but imprecise in comparison to dilution techniques. We conclude that multifrequency bioimpedance measurements cannot precisely estimate TBW and ECW in children receiving dialysis.
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Affiliation(s)
- Gregorio P Milani
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Jaap W Groothoff
- Pediatric Nephrology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Federica A Vianello
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emilio F Fossali
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Paglialonga
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Edefonti
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Agostoni
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dewi van Harskamp
- Pediatrics, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Johannes B van Goudoever
- Pediatrics, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands; Pediatrics VU University Medical Center, Amsterdam, the Netherlands
| | - Henk Schierbeek
- Pediatrics, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Michiel J S Oosterveld
- Pediatric Nephrology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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175
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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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176
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Borzou SR, Mahdipour F, Oshvandi K, Salavati M, Alimohammadi N. Effect of Mealtime During Hemodialysis on Patients' Complications. J Caring Sci 2016; 5:277-286. [PMID: 28032072 PMCID: PMC5187548 DOI: 10.15171/jcs.2016.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 04/20/2016] [Indexed: 01/06/2023] Open
Abstract
Introduction: Food intake during hemodialysis increases the risk of problems such as hypotension, nausea, and vomiting in patients undergoing hemodialysis. This study aimed to determine the effect of mealtime during dialysis on the patients' complications. Methods: This is a quasi-experimental study consisted of all eligible hemodialysis patients in Hamadan teaching hospitals. All of 48 patients were selected through census method. The research was conducted in two sessions. At both sessions, patients were kept fasting prior to hemodialysis. In the first session, after one hour and in the second session after two hours of hemodialysis, a meal containing 350 kcal of energy was given to the patients. Blood pressure and intensity of nausea and vomiting was measured and recorded immediately before the start of hemodialysis, and then every half an hour before the termination of the hemodialysis. Results: The results showed that in both sessions, food intake caused a drop in the systolic and diastolic blood pressure, but changes in the mealtime had no effect on the systolic and diastolic blood pressure. Also, statistical test showed that changes in the mealtime had no significant impact on the intensity of nausea and vomiting. Conclusion: Food intake during hemodialysis had no effect on the nausea and vomiting, but caused a drop in the systolic and diastolic blood pressure, the drop continued for one hour and one and a half hour after the meal. It is suggested, mealtime in the early hours of hemodialysis could be better managed during the hemodialysis process.
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Affiliation(s)
- Seyed Reza Borzou
- Department of Nursing, Member of Chronic Disease (Home Care) Research Center, Nursing & Midwifery Faculty, Hamadan University of Medical Sciences, Hamadan, IRAN
| | - Fahimeh Mahdipour
- Department of Operating Room, Para medicine Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Khodayar Oshvandi
- Department of Nursing, Member of Research Center for Child and Maternity Care, Nursing & Midwifery Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mohsen Salavati
- Department of Nursing, Nursing & Midwifery Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Neda Alimohammadi
- Department of Nursing, Nursing & Midwifery Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
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177
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Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA, Komenda P. Intensive Hemodialysis and Treatment Complications and Tolerability. Am J Kidney Dis 2016; 68:S43-S50. [DOI: 10.1053/j.ajkd.2016.05.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 11/11/2022]
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178
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Ma TL, Chang RY, Chen HJ, Liu CY, Hsu CC, Hsu YH. Risk of acute coronary syndrome after parathyroidectomy in patients with end-stage renal disease: A population-based cohort study in Taiwan. Nephrology (Carlton) 2016; 23:139-147. [PMID: 27790808 PMCID: PMC5817232 DOI: 10.1111/nep.12958] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 11/29/2022]
Abstract
Aim Patients with end‐stage renal disease (ESRD) who received parathyroidectomy (PTX) had persistently reduced levels of parathyroid hormone. This study investigated the risk of acute coronary syndrome (ACS) in patients with ESRD who underwent PTX using a nationwide health insurance claims database. Methods Of all ESRD patients, we selected 1047 individuals who had undergone PTX between 2000 and 2008 as the PTX group and 4188 patients who did not undergo PTX (non‐PTX group) matched by propensity score. Multivariable Cox proportional hazards regression analysis was conducted for assessing the excess ACS risk for the PTX group compared to the non‐PTX group. Results The mean follow‐up periods were 4.63 and 4.04 years for the PTX and non‐PTX groups, respectively. A significant reduction in the risk of ACS (adjusted hazard ratio = 0.74, 95% confidence interval = 0.57–0.96) was observed for the ESRD patients after PTX. Conclusions Parathyroidectomy is associated with reduced risk of ACS in patients with ESRD. From a national health insurance claims database, this study matched patients receiving dialysis who had a parathyroidectomy to patients who did not, using a propensity score method. They demonstrate that patients who had a parathyroidectomy were less likely to experience an acute coronary syndrome in the ensuing 4 years.
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Affiliation(s)
- Tsung Liang Ma
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Rei Yeuh Chang
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan.,Chung Jen Junior College of Nursing, Health Sciences and Management, Chiayi, Taiwan.,Department of Beauty and Health Care, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
| | - Hsuan Ju Chen
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,Department of College of Medicine, China Medical University, Taichung, Taiwan
| | - Chun Yi Liu
- Department of Public Health and Department of Health Services Administration, China Medical University, Taichung, Taiwan.,Department of Education, China Medical University Hospital, Taichung, Taiwan
| | - Chih Cheng Hsu
- Department of Health Services Administration, China Medical University, Taichung, Taiwan.,Institute of Population Health Sciences, National Health Research Institutes, Zhunane, Miaoli, Taiwan
| | - Yueh Han Hsu
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan.,Department of Medical Research, China Medical University Hospital and China Medical University, Taichung, Taiwan.,Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
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179
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Block GA, Rosenbaum DP, Leonsson-Zachrisson M, Stefansson BV, Rydén-Bergsten T, Greasley PJ, Johansson SA, Knutsson M, Carlsson BC. Effect of Tenapanor on Interdialytic Weight Gain in Patients on Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1597-1605. [PMID: 27340281 PMCID: PMC5012484 DOI: 10.2215/cjn.09050815] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 05/02/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Interdialytic weight gain in patients on hemodialysis is associated with adverse cardiovascular outcomes and increased mortality. The degree of interdialytic weight gain is influenced by sodium intake. We evaluated the effects of tenapanor (AZD1722 and RDX5791), a minimally systemically available inhibitor of the sodium/hydrogen exchanger isoform 3, on interdialytic weight gain in patients with CKD stage 5D treated with hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This phase 2, randomized, double-blind study (NCT01764854; conducted January to September of 2013) enrolled adults on maintenance hemodialysis with interdialytic weight gain ≥3.0% of postdialysis weight and ≥2 kg. Patients were randomly assigned (1:1) to receive tenapanor or placebo. The primary end point was change in mean interdialytic weight gain (percentage of baseline postdialysis weight) from baseline (mean across a 2-week run-in period) to week 4. In a subgroup of inpatients, 24-hour stool sodium and stool weight were assessed for 1 week. RESULTS Sixteen patients received 1 week of inpatient treatment (tenapanor, eight; placebo, eight), and 72 patients received 4 weeks of treatment in an outpatient setting (tenapanor, 37; placebo, 35; completers: tenapanor, 31; placebo, 33). In the outpatient cohort, no significant effect on interdialytic weight gain was detected; least squares mean changes in relative interdialytic weight gain from baseline to week 4 were tenapanor, -0.26% (95% confidence interval, -0.57% to 0.06%) and placebo, -0.23% (95% confidence interval, -0.54% to 0.07%; P=0.46). During week 1 (inpatient cohort only), compared with placebo, tenapanor treatment resulted in higher stool sodium content (mean [±SD]: tenapanor, 36.6 [±21.8] mmol/d; placebo, 2.8 [±2.7] mmol/d; P<0.001) and higher stool weight (tenapanor, 172.5 [±68.1] g/d; placebo, 86.3 [±30.0] g/d; P<0.01). A similar safety profile was observed across treatment groups with the exception of diarrhea, which occurred more frequently with tenapanor treatment. CONCLUSIONS Tenapanor treatment increased stool sodium and weight over placebo in patients undergoing hemodialysis. However, over 4 weeks of treatment, there was no difference in interdialytic weight gain between patients treated with tenapanor and those receiving placebo.
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180
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Huang WH, Hsu CW, Hu CC, Yen TH, Weng CH. Predialysis hypotension is not a predictor for mortality in long-term hemodialysis patients: insight from a single-center observational study. Ther Clin Risk Manag 2016; 12:1285-92. [PMID: 27601912 PMCID: PMC5005003 DOI: 10.2147/tcrm.s111635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Predialysis hypotension has been noted to be a predictor of mortality in hemodialysis (HD) patients. Previous studies evaluating the impact of predialysis hypotension on the mortality of HD patients did not exclude patients with diabetes mellitus (DM) or cardiovascular disease. Methods Eight hundred and sixty-six patients on maintenance HD were recruited. Clinical parameters were recorded and subjected to the analysis of predictors of predialysis hypotension and mortality. Results Multivariate logistic regression analyses indicated that DM (odds ratio [OR]: 0.439, P=0.002), hypertension history (OR: 0.634, P=0.022), Kt/V Daugirdas (OR: 2.545, P=0.001), anuria (OR: 2.313, P=0.002), serum phosphate (OR: 0.833, P=0.010), and serum triglyceride (OR: 1.002, P=0.012) were associated with predialysis hypotension. Multivariate Cox regression analysis showed that age (P<0.001), male sex (P=0.029), anuria (P=0.004), and DM (P=0.011) were associated with higher probability of 24- and 36-month mortality. Predialysis hypotension was not associated with higher probability of 12-, 24-, and 36-month mortality. Conclusion Predialysis hypotension is not a predictor of 12-, 24-, and 36-month survival in patients without DM and with higher dialysis adequacy.
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Affiliation(s)
- Wen-Hung Huang
- Department of Nephrology, Division of Clinical Toxicology, Chang Gung Memorial Hospital, Linkou Medical Center, Gueishan, Taiwan, Republic of China; Department of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Ching-Wei Hsu
- Department of Nephrology, Division of Clinical Toxicology, Chang Gung Memorial Hospital, Linkou Medical Center, Gueishan, Taiwan, Republic of China; Department of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Ching-Chih Hu
- Department of Hepatogastroenterology and Liver Research Unit, Chang Gung Memorial Hospital, Keelung, Taiwan, Republic of China
| | - Tzung-Hai Yen
- Department of Nephrology, Division of Clinical Toxicology, Chang Gung Memorial Hospital, Linkou Medical Center, Gueishan, Taiwan, Republic of China; Department of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Cheng-Hao Weng
- Department of Nephrology, Division of Clinical Toxicology, Chang Gung Memorial Hospital, Linkou Medical Center, Gueishan, Taiwan, Republic of China; Department of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
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181
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Flythe JE. Ultrafiltration Rate Clinical Performance Measures: Ready for Primetime? Semin Dial 2016; 29:425-434. [DOI: 10.1111/sdi.12529] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer E. Flythe
- Department of Medicine; Division of Nephrology and Hypertension; UNC School of Medicine; University of North Carolina Kidney Center; Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
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182
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Rapid ultrafiltration rates and outcomes among hemodialysis patients: re-examining the evidence base. Curr Opin Nephrol Hypertens 2016; 24:525-30. [PMID: 26371525 DOI: 10.1097/mnh.0000000000000174] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This review critically summarizes the evidence linking ultrafiltration rates to adverse outcomes among hemodialysis patients and provides research recommendations to address knowledge gaps. RECENT FINDINGS Growing evidence suggests that fluid-related factors play important roles in hemodialysis patient outcomes. Ultrafiltration rate - the rate of fluid removal during hemodialysis - is one such factor. Existing observational data suggest a robust association between greater ultrafiltration rates and adverse cardiovascular outcomes, and such findings are supported by plausible physiologic rationale. Potential mechanistic pathways include ultrafiltration-related ischemia to the heart, brain, and gut, and volume overload-precipitated cardiac stress from reactive measures to ultrafiltration-induced hemodynamic instability. Inter-relationships among ultrafiltration rates and other fluid measures, such as interdialytic weight gain and chronic volume expansion, render the specific role of ultrafiltration rates in adverse outcomes difficult to study. Randomized trials must be conducted to confirm epidemiologic findings and examine the effect of ultrafiltration rate reduction on clinical and patient-centered outcomes. SUMMARY Compelling observational data demonstrate an association between more rapid ultrafiltration rates and adverse clinical outcomes. Before translating these findings into clinical practice, randomized trials are needed to verify observational data results and to identify effective strategies to mitigate ultrafiltration-related risk.
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183
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Flythe JE, Assimon MM, Wenger JB, Wang L. Ultrafiltration Rates and the Quality Incentive Program: Proposed Measure Definitions and Their Potential Dialysis Facility Implications. Clin J Am Soc Nephrol 2016; 11:1422-1433. [PMID: 27335126 PMCID: PMC4974895 DOI: 10.2215/cjn.13441215] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/04/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Rapid ultrafiltration rates are associated with adverse outcomes among patients on hemodialysis. The Centers for Medicare and Medicaid Services is considering an ultrafiltration rate quality measure for the ESRD Quality Incentive Program. Two measure developers proposed ultrafiltration rate measures with different selection criteria and specifications. We aimed to compare the proposed ultrafiltration rate measures and quantify dialysis facility operational burden if treatment times were extended to lower ultrafiltration rates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were taken from the 2012 database of a large dialysis organization. Analyses of the Centers for Medicare and Medicaid Services measure considered 148,950 patients on hemodialysis, and analyses of the Kidney Care Quality Alliance measure considered 151,937 patients. We described monthly patient and facility ultrafiltration rates and examined differences in patient characteristics across ultrafiltration rate thresholds and differences in facilities across ultrafiltration rate measure scores. We computed the additional treatment time required to lower ultrafiltration rates <13 ml/h per kilogram. RESULTS Ultrafiltration rates peaked in winter and nadired in summer. Patients with higher ultrafiltration rates were younger; more likely to be women, nonblack, Hispanic, and lighter in weight; and more likely to have histories of heart failure compared with patients with lower ultrafiltration rates. Facilities had, on average, 20.8%±10.3% (July) to 22.8%±10.6% (February) of patients with ultrafiltration rates >13 ml/h per kilogram by the Centers for Medicare and Medicaid Services monthly measure. Facilities had, on average, 15.8%±8.2% of patients with ultrafiltration rates ≥13 ml/h per kilogram by the Kidney Care Quality Alliance annual measure. Larger facilities (>100 patients) would require, on average, 33 additional treatment hours per week to lower all facility ultrafiltration rates <13 ml/h per kilogram when total treatment time is capped at 4 hours. CONCLUSIONS Ultrafiltration rates vary seasonally and across clinical subgroups. Extension of treatment time as a strategy to lower ultrafiltration rates may pose facility operational challenges. Prospective studies of ultrafiltration rate threshold implementation are needed.
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Affiliation(s)
- Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina; and
| | - Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Julia B. Wenger
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lily Wang
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina; and
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
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184
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Kim SY, Hong YA, Yoon HE, Chang YK, Yang CW, Kim SY, Hwang HS. Vascular calcification and intradialytic hypotension in hemodialysis patients: Clinical relevance and impact on morbidity and mortality. Int J Cardiol 2016; 217:156-60. [DOI: 10.1016/j.ijcard.2016.04.183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/22/2016] [Accepted: 04/30/2016] [Indexed: 10/21/2022]
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Abstract
While oral diuretics are commonly used in patients with chronic kidney disease for the management of volume and blood pressure, they are often discontinued upon initiation of dialysis. We suggest that diuretics are considerably underutilized in peritoneal dialysis and haemodialysis patients despite numerous potential benefits and few side effects. Moreover, when diuretics are used, optimal doses are not always prescribed. In peritoneal dialysis, the use of diuretics can improve volume status and minimize the need for higher glucose-containing solutions. In patients on haemodialysis, diuretics can help lessen interdialytic weight gain, resulting in decreased ultrafiltration rates and fewer episodes of intradialytic hypotension. This paper will review the mechanism of action of diuretics in patients with renal insufficiency, quantify the risk of side effects and elaborate on the potential advantages of diuretic use in peritoneal dialysis and hemodialysis patients with residual kidney function.
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada.
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186
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Midodrine Dependence: Transplantation Barrier or Opportunity? Transplantation 2016; 100:977-8. [PMID: 26950717 DOI: 10.1097/tp.0000000000001114] [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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187
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Kuipers J, Oosterhuis JK, Krijnen WP, Dasselaar JJ, Gaillard CAJM, Westerhuis R, Franssen CFM. Prevalence of intradialytic hypotension, clinical symptoms and nursing interventions--a three-months, prospective study of 3818 haemodialysis sessions. BMC Nephrol 2016; 17:21. [PMID: 26922795 PMCID: PMC4769826 DOI: 10.1186/s12882-016-0231-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 02/14/2016] [Indexed: 12/02/2022] Open
Abstract
Background Intradialytic hypotension (IDH) is considered one of the most frequent complications of haemodialysis with an estimated prevalence of 20–50 %, but studies investigating its exact prevalence are scarce. A complicating factor is that several definitions of IDH are used. The goal of this study was, to assess the prevalence of IDH, primarily in reference to the European Best Practice Guideline (EBPG) on haemodynamic instability: A decrease in systolic blood pressure (SBP) ≥20 mmHg or in mean arterial pressure (MAP) ≥10 mmHg associated with a clinical event and the need for nursing intervention. Methods During 3 months we prospectively collected haemodynamic data, clinical events, and nursing interventions of 3818 haemodialysis sessions from 124 prevalent patients who dialyzed with constant ultrafiltration rate and dialysate conductivity. Patients were considered as having frequent IDH if it occurred in >20 % of dialysis sessions. Results Decreases in SBP ≥20 mmHg or MAP ≥10 mmHg occurred in 77.7 %, clinical symptoms occurred in 21.4 %, and nursing interventions were performed in 8.5 % of dialysis sessions. Dialysis hypotension according to the full EBPG definition occurred in only 6.7 % of dialysis sessions. Eight percent of patients had frequent IDH. Conclusions The prevalence of IDH according to the EBPG definition is low. The dominant determinant of the EBPG definition was nursing intervention since this was the component with the lowest prevalence. IDH seems to be less common than indicated in the literature but a proper comparison with previous studies is complicated by the lack of a uniform definition. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0231-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johanna Kuipers
- Dialysis Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.
| | - Jurjen K Oosterhuis
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wim P Krijnen
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Judith J Dasselaar
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carlo A J M Gaillard
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ralf Westerhuis
- Dialysis Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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188
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Wright E, Fischbach M, Zaloszyc A, Paglialonga F, Aufricht C, Dufek S, Bakkaloğlu S, Klaus G, Zurowska A, Ekim M, Ariceta G, Holtta T, Jankauskiene A, Schmitt CP, Stefanidis CJ, Walle JV, Vondrak K, Edefonti A, Shroff R. Hemodialysis in children with ventriculoperitoneal shunts: prevalence, management and outcomes. Pediatr Nephrol 2016; 31:137-43. [PMID: 26386590 DOI: 10.1007/s00467-015-3204-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/13/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemodialysis (HD) in children with a concomitant ventriculoperitoneal shunt (VPS) is rare. Registry data suggest that peritoneal dialysis with a VPS is safe, but little is known about HD in the presence of a VPS. METHODS We performed a 10-year survey to determine the prevalence of a VPS, complications and outcome in children with a VPS on HD in 15 dialysis units from the 13 countries participating in the European Pediatric Dialysis Working Group. RESULTS Eleven cases of HD with a VPS were reported (prevalence 1.33 %; 328 patient-months) and compared with prospective Registry data. The median age at start of dialysis was 9.6 [inter-quartile range (IQR) 1.0-15.0] years and median HD vintage was 2.4 (IQR 1.7-3.0) years. Dialysis was performed through a central venous line (CVL) and through an arteriovenous fistula in six and five children, respectively. Three CVL infections occurred in two children, but these children did not develop VPS infections or meningitis. Symptoms of hemodynamic instability were reported in six (55 %) children at least once per week, with hypotension or hypertension occurring in four of these children and nausea, vomiting and headaches occurring in two; four other children reported less frequent symptoms. Seizures on dialysis occurred in two children, at a frequency of less than once per month, with one child also experiencing visual disturbances. During follow-up (median 4.0; IQR 0.38-7.63 years), three children remained on HD and eight had a functioning transplant. No patients were switched to PD. CONCLUSIONS Hemodialysis in children with a VPS is safe, but associated with frequent symptoms of hemodynamic instability. No episodes of VPS infection or meningitis were seen among the children in the survey, not even in those with CVL sepsis.
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Affiliation(s)
- Elizabeth Wright
- Nephro-Urology Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Stephanie Dufek
- Nephro-Urology Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | | | | | | | | | - Gema Ariceta
- University Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | | | | | - Alberto Edefonti
- Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Rukshana Shroff
- Nephro-Urology Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK.
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189
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Ito K, Ookawara S, Ueda Y, Miyazawa H, Yamada H, Goto S, Ishii H, Shindo M, Kitano T, Hirai K, Yoshida M, Kaku Y, Hoshino T, Nabata A, Mori H, Yoshida I, Kakei M, Morishita Y, Tabei K. A Higher Cardiothoracic Ratio Is Associated with 2-Year Mortality after Hemodialysis Initiation. NEPHRON EXTRA 2015; 5:100-10. [PMID: 26951636 PMCID: PMC4777940 DOI: 10.1159/000442591] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED A high cardiothoracic ratio (CTR) is indicative of a cardiac disorder. However, few reports have revealed an association between the CTR and mortality in patients starting hemodialysis (HD). METHODS Patients with HD initiation (n = 387; mean age, 66.7 ± 12.7 years) were divided into the following three groups according to their CTR at HD initiation: CTR <50%, 50% ≤ CTR < 55%, and CTR ≥55%. Kaplan-Meier analysis was performed to compare 2-year all-cause mortality among these groups. Furthermore, we investigated the factors affecting their 2-year mortality using a Cox proportional hazard regression analysis. RESULTS Sixty-five patients (17%) died within 2 years after HD initiation. Kaplan-Meier analysis showed that patients with CTR ≥55% had a higher mortality rate than those in the other groups. Cox proportional hazard regression analysis was performed using parameters with p values <0.1 among these three groups [sex, age, presence or absence of ischemic heart disease, hemoglobin levels, serum albumin levels, CTR, body mass index (BMI)] and confounding factors [presence or absence of diabetes mellitus, and estimated glomerular filtration rate (eGFR)]. Age, eGFR, BMI, and CTR ≥55% at HD initiation were identified as factors influencing 2-year mortality. CONCLUSION CTR >55% is one of the most important independent factors to affect 2-year all-cause mortality. Thus, confirming the cardiac condition of patients at HD initiation with a CTR >55% may improve their survival.
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Affiliation(s)
- Kiyonori Ito
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuichiro Ueda
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hodaka Yamada
- Endocrinology and Metabolism, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Sawako Goto
- Division of Clinical Nephrology and Rheumatology, Niigata University Medical and Dental Hospital, Japan
| | - Hiroki Ishii
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsutoshi Shindo
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masashi Yoshida
- Endocrinology and Metabolism, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshio Kaku
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Aoi Nabata
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Honami Mori
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | - Masafumi Kakei
- Endocrinology and Metabolism, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshiyuki Morishita
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaoru Tabei
- Divisions of Nephrology, Saitama Medical Center, Jichi Medical University, Saitama, Japan; Minami-Uonuma City Hospital, Niigata, Japan
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190
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Assimon MM, Flythe JE. Intradialytic Blood Pressure Abnormalities: The Highs, The Lows and All That Lies Between. Am J Nephrol 2015; 42:337-50. [PMID: 26584275 PMCID: PMC4761237 DOI: 10.1159/000441982] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Frequent blood pressure (BP) measurements are necessary to ensure patient safety during hemodialysis treatments. Intradialytic BPs are not optimal tools for hypertension diagnosis and cardiovascular risk stratification, but they do have critical clinical and prognostic significance. We present evidence associating intradialytic BP phenomena including fall, rise and variability with adverse clinical outcomes and review related pathophysiologic mechanisms and potential management strategies. SUMMARY Observational studies demonstrate associations between intradialytic hypotension, hypertension and BP variability and mortality. Lack of consensus regarding diagnostic criteria has hampered data synthesis, and prospective studies investigating optimal management strategies for BP phenomena are lacking. Mechanistic data suggest that cardiac, gut, kidney and brain ischemia may lie on the causal pathway between intradialytic hypotension and mortality, and endothelial cell dysfunction, among other factors, may be an important mediator of intradialytic hypertension and adverse outcomes. These plausible pathophysiologic links present potential therapeutic targets for future inquiry. The phenomenon of intradialytic BP variability has not been adequately studied, and practical clinical measures and treatment strategies are lacking. KEY MESSAGES Intradialytic BP phenomena have important prognostic bearing. Clinical practice guidelines for both intradialytic hypotension and hypertension exist, but their underlying evidence is weak overall. Further research is needed to develop consensus diagnostic criteria for intradialytic hypotension, hypertension and BP variability and to elucidate optimal treatment and prevention strategies for each BP manifestation.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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191
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Brunelli SM, Sibbel S, Do TP, Cooper K, Bradbury BD. Facility Dialysate Calcium Practices and Clinical Outcomes Among Patients Receiving Hemodialysis: A Retrospective Observational Study. Am J Kidney Dis 2015; 66:655-65. [DOI: 10.1053/j.ajkd.2015.03.038] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 03/24/2015] [Indexed: 11/11/2022]
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192
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Boriani G, Savelieva I, Dan GA, Deharo JC, Ferro C, Israel CW, Lane DA, La Manna G, Morton J, Mitjans AM, Vos MA, Turakhia MP, Lip GY. Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making-a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace 2015; 17:1169-96. [PMID: 26108808 PMCID: PMC6281310 DOI: 10.1093/europace/euv202] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Giuseppe Boriani
- Corresponding author. Giuseppe Boriani, Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S.Orsola-Malpighi University Hospital, Via Massarenti 9, 40138 Bologna, Italy. Tel: +39 051 349858; fax: +39 051 344859. E-mail address:
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193
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Frequency of intradialytic hypotensive episodes: old problem, new insights. ACTA ACUST UNITED AC 2015; 9:763-768. [PMID: 26316015 DOI: 10.1016/j.jash.2015.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/07/2015] [Accepted: 07/18/2015] [Indexed: 11/24/2022]
Abstract
Symptomatic intradialytic hypotension (IDH) continues to be an important complication of hemodialysis treatment. There is some evidence that besides an IDH episode, repeated episodes could represent an even more important independent risk factor for mortality in hemodialysis patients. A retrospective cross-sectional study was performed to study 18 dialysis treatments in 43 patients during 6 weeks. Relationships of IDH episodes with baseline variables were examined using a Poisson regression model (generalized linear model). IDH was frequent (93% of patients) and highly variable by patient (0%-100%). Multivariate analysis showed that patients who experienced frequent hypotensive episodes had a lower dry weight (90% confidence interval [CI]: 0.95-0.99), higher phosphorus levels (90% CI: 1.07-1.47), greater prevalence of diabetes mellitus (90% CI: 1.11-2.71), and hypertension (90% CI: 1.04-2.45). Dry weight, hypertension, and phosphorus levels are modifiable risk factors to possibly reduce the rate of IDH episodes. The potential protective role of phosphorus warrants further investigation.
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195
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Cabrera C, Brunelli SM, Rosenbaum D, Anum E, Ramakrishnan K, Jensen DE, Stålhammar NO, Stefánsson BV. A retrospective, longitudinal study estimating the association between interdialytic weight gain and cardiovascular events and death in hemodialysis patients. BMC Nephrol 2015. [PMID: 26197758 PMCID: PMC4510887 DOI: 10.1186/s12882-015-0110-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Greater interdialytic weight gain (IDWG) is associated with risk of all-cause mortality and hospitalization. Dialysis patients are also at greater risk of cardiovascular (CV) events than patients without kidney disease. This retrospective study examined the potential association between IDWG and specific types of CV events. METHODS Data were obtained from United States Renal Data System claims and the electronic health records of Medicare patients who initiated hemodialysis between 01 January 2007 and 31 December 2008 at a large dialysis organization. Absolute IDWG was defined as predialysis weight minus postdialysis weight from the prior treatment, and relative IDWG was calculated as percentage of postdialysis weight with mean values for each, calculated over dialysis days 91 to 180. Patient outcomes were considered beginning on day 181, continuing until death, discontinuation of care, censoring, or study end (31 December 2009). Outcomes included all-cause mortality, CV mortality, hospitalization for nonfatal heart failure/volume overload, hospitalization for nonfatal myocardial infarction, MACE (a composite measure of nonfatal myocardial infarction, nonfatal ischemic stroke, or CV death), and MACE+ (events comprising MACE as well as arrhythmia, nonfatal hemorrhagic stroke, or hospitalization for heart failure). Associations between IDWG and outcomes over the exposure period were estimated using proportional hazards regression and adjusted for baseline characteristics. RESULTS 39,256 patients qualified for analysis. In general, associations of relative IDWG with outcomes were more potent, consistent, and monotonic than those for absolute IDWG. Relative IDWG > 3.5 % body weight was independently associated with all outcomes studied: point estimates ranged from 1.18 (myocardial infarction) to 1.26 (CV mortality) and were consistent among patients with and without diabetes, and with and without baseline heart failure. Absolute IDWG > 3 kg was associated with outcomes other than myocardial infarction: point estimates ranged from 1.11 (MACE) to 1.20 (heart failure). CONCLUSIONS Greater IDWG is associated with an increased risk of CV morbid events. Strategies that mitigate IDWG may improve CV health and survival among hemodialysis patients.
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196
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Sherman RA. Briefly Noted. Semin Dial 2015. [DOI: 10.1111/sdi.12353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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197
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Schiller B, Arramreddy R, Hussein W. What are the Consequences of Volume Expansion in Chronic Dialysis Patients? Semin Dial 2015; 28:233-5. [DOI: 10.1111/sdi.12356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Brigitte Schiller
- Satellite Healthcare; San Jose California
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto California
| | - Rohini Arramreddy
- Satellite Healthcare; San Jose California
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto California
| | - Wael Hussein
- Satellite Healthcare; San Jose California
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto California
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198
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Weiner DE, Brunelli SM. In Reply to ‘More Evidence Needed Before Lower Dialysate Sodium Concentrations Can Be Recommended’. Am J Kidney Dis 2015; 65:520. [DOI: 10.1053/j.ajkd.2014.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/12/2014] [Indexed: 11/11/2022]
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199
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Flythe JE, Brookhart MA. Fluid management: the challenge of defining standards of care. Clin J Am Soc Nephrol 2014; 9:2033-5. [PMID: 25376766 PMCID: PMC4255411 DOI: 10.2215/cjn.10341014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Jennifer E Flythe
- University of North Carolina Kidney Center and Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, and
| | - M Alan Brookhart
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
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