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Zhou M, Ficociello LH, Mullon C, Mooney A, Williamson D, Anger MS. Real-World Performance of High-Flux Dialyzers in Patients With Hypoalbuminemia. ASAIO J 2022; 68:96-102. [PMID: 34172639 PMCID: PMC8700293 DOI: 10.1097/mat.0000000000001511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is little research on factors that influence the choice of dialyzer in patients undergoing hemodialysis. In patients at risk for poorer outcomes, including those with hypoalbuminemia, understanding how this choice impacts clinical parameters could inform patient management. The objective of this real-world analysis was to evaluate the use and performance of four single-use (i.e., nonreuse [NR]), high-flux Optiflux dialyzers with varying surface areas (F160NR [1.5 m2], F180NR [1.7 m2], F200NR [1.9 m2], and F250NR [2.5 m2]) in patients (N = 271) with baseline hypoalbuminemia (≤3.5 g/dl) receiving hemodialysis at a medium-sized dialysis organization. Thrice weekly, in-center dialysis was delivered for 6 months without adjustments to the hemodialysis prescription. Larger dialyzers were more frequently used in men, patients with higher body mass indices, and those with diabetes. Increases in serum albumin from baseline (month 1) to month 6 (p < 0.05) were observed with all dialyzer sizes. A mean increase in hemoglobin of 0.31 g/dl was also observed (p < 0.001). Among patients exhibiting increased serum albumin levels (n = 177), reductions in the neutrophil-to-lymphocyte ratio, a marker of inflammation, were observed (mean: 0.90; p < 0.001). These results support the use of high-flux dialyzers in patients with hypoalbuminemia.
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Affiliation(s)
- Meijiao Zhou
- From the Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
| | - Linda H. Ficociello
- From the Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
| | - Claudy Mullon
- From the Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
| | - Ann Mooney
- American Renal Associates, Beverly, Massachusetts
| | | | - Michael S. Anger
- From the Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
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2
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Ding L, Johnston J, Pinsk MN. Monitoring dialysis adequacy: history and current practice. Pediatr Nephrol 2021; 36:2265-2277. [PMID: 33399992 DOI: 10.1007/s00467-020-04816-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 09/17/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022]
Abstract
Dialysis adequacy for pediatric patients has largely followed the trends in adult dialysis by judging the success or adequacy of peritoneal or hemodialysis with urea kinetic modeling. While this provides a starting point to establish a dose of dialysis, it is clear that urea is only part of the picture. Many clinical parameters and interventions now have been identified that are just as impactful on mortality and morbidly as urea clearance. As such, our concept of adequacy is evolving to include non-urea parameters and assessing the impact that following an "adequate therapy" has on patient lives. As we move to a new era, we consider the impact these therapies have on patients and how it affects the quality of their lives; we must take these factors into consideration to achieve a therapy that is not just adequate, but livable.
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Affiliation(s)
- Linda Ding
- Department of Pediatrics and Child Health, University of Manitoba, Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - James Johnston
- Department of Pediatrics and Child Health, University of Manitoba, Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Maury N Pinsk
- Department of Pediatrics and Child Health, University of Manitoba, Rady College of Medicine, Winnipeg, Manitoba, Canada.
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3
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Teehan BP, Schleifer CR, Brown J. Assessment of Dialysis Adequacy and Nutrition by Urea Kinetic Modeling. Perit Dial Int 2020. [DOI: 10.1177/089686089401403s19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brendan P. Teehan
- Lankenau Hospital/Lankenau Medical Research Center, Wynnewood, Pennsylvania, U.S.A
| | - Charles R. Schleifer
- Lankenau Hospital/Lankenau Medical Research Center, Wynnewood, Pennsylvania, U.S.A
| | - Joan Brown
- Lankenau Hospital/Lankenau Medical Research Center, Wynnewood, Pennsylvania, U.S.A
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Abstract
Objective Although important enhancements to continuous ambulatory peritoneal dialysis (CAPD) have occurred since its inception, few studies have explicitly evaluated trends over time in CAPD technique failure rates. To assist in quantifying the net benefit of improvements to CAPD for patient outcomes, we examined trends in technique failure rates among Canadian CAPD patients. Patients Patients initiating renal replacement therapy on CAPD ( n = 7110) between 1981 and 1997. Main Outcome Measures Technique failure ( i.e., switch to hemodialysis). Results Total follow-up was 12 831 patient-years (pt-yr). There were 1976 technique failures, for a crude CAPD failure rate of 154.0/1000 pt-yr. Technique failure rate ratios (RR) estimated using Poisson regression and adjusted for age, gender, race, province, primary renal diagnosis, and follow-up time, were significantly reduced for the 1990–93 [RR = 0.75, 95% confidence interval (CI) = (0.68, 0.83)], 1994–95 [RR = 0.83, CI (0.75, 0.93)], and 1996–97 [RR = 0.78, CI (0.70, 0.87)] calendar periods relative to 1981–89 (RR = 1, reference). Among cause-specific technique failure rates, the greatest improvement was observed for peritonitis-attributable technique failure, with RR = 0.46, CI (0.41, 0.50) for 1990–97 relative to 1981–89. However, rates of technique failure due to inadequate dialysis were significantly elevated for the 1990–97 period [RR = 1.68, CI (1.44, 1.96)]. Conclusions The collection of more detailed data on practice patterns would enable future studies to elucidate the cause-and-effect relationship between CAPD descriptors and technique failure, and hence assist in clinical decision-making.
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Affiliation(s)
- Douglas E. Schaubel
- Department of Biostatistics, School of Public Health, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Peter G. Blake
- Division of Nephrology, London Health Sciences Centre, London
| | - Stanley S.A. Fenton
- Faculty of Medicine, University of Toronto
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Adequacy of Hemodialysis and Its Associated Factors among Patients Undergoing Chronic Hemodialysis in Dar es Salaam, Tanzania. Int J Nephrol 2020; 2020:9863065. [PMID: 32095287 PMCID: PMC7035558 DOI: 10.1155/2020/9863065] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 12/30/2019] [Accepted: 01/20/2020] [Indexed: 12/03/2022] Open
Abstract
The worldwide prevalence of maintenance hemodialysis continues to rise. An adequate delivery of hemodialysis dose as measured by Kt/V or urea reduction ratio is a crucial determinant of clinical outcome for chronic hemodialysis patients. The aim of this study was to assess the adequacy of hemodialysis and its associated factors among patients undergoing chronic hemodialysis in Dar es Salaam. This was a cross-sectional study done on patients undergoing chronic hemodialysis in four dialysis centers in Dar es Salaam. Sociodemographic information and treatment characteristics were collected. Urea reduction rate and single-pool Kt/V were calculated to determine the adequacy of hemodialysis. The data were analyzed and any associated factors for inadequate hemodialysis were determined using a chi-square test and a logistic regression analysis. A total of 143 patients participated in the study. Males represented 65.7% of the study population. The mean age (±SD) was 51.7 ± 1.2 years. Only 34.3% (based on urea reduction ratio (URR)) and 40.6% (based on Kt/V) of patients received adequate hemodialysis. The univariate analysis showed that males were more likely to have inadequate dialysis (65.6% versus 48.0%, p=0.048 based on Kt/V). Patients using hemodialyzers with dialyzer surface area less than 1.4 m2 received significantly less hemodialysis dose than those with more than 1.4 m2 (69.0% versus 41.2%, p=0.02, by URR) (62.7% versus 35.3%, p=0.03, by Kt/V criteria). Patients who had hemoglobin <10 g/dl received significantly inadequate hemodialysis dose as compared to patients with hemoglobin ≥10 g/dl by Kt/V criteria (69.8% versus 51.3%, p=0.03). None of the factors acquired significance in the multivariate analysis. The proportion of patients receiving an adequate hemodialysis dose is low (34.3% based on URR and 40.6% based on Kt/V). Male gender, dialyzer surface area of <1.4 m2, and hemoglobin level of <10 g/dl were associated with an inadequate delivered dose of hemodialysis in the univariate analysis but not in the multivariate analysis. This study can increase awareness about the importance of measuring hemodialysis adequacy and giving the correct hemodialysis dose to achieve the intended benefit.
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Bellomo R, Ronco C. Adequacy of Dialysis in the Acute Renal Failure of the Critically ILL: The Case for Continuous Therapies. Int J Artif Organs 2018. [DOI: 10.1177/039139889601900217] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- R. Bellomo
- Department of Anaesthesia and Intensive Care, Austin Hospital, Melbourne, Victoria - Australia
| | - C. Ronco
- Divisione di Nefrologia, Ospedale San Bortolo, Vicenza - Italy
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Charra B, Terrat JC, Vanel T, Chazot C, Jean G, Hurot JM, Lorriaux C. Long Thrice Weekly Hemodialysis: The Tassin Experience. Int J Artif Organs 2018; 27:265-83. [PMID: 15163061 DOI: 10.1177/039139880402700403] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- B Charra
- Centre de Rein Artificiel de Tassin, Tassin, France.
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Vlassopoulos DA, Hadjiyannakos DK, Koutala KG, Iliopoulos AN, Diamantopoulou NV, Marioli SI. Hemoglobin Normalization Results in Lower Dialysis Dose, Despite High Dialysate Flow. Single Needle Offers Inadequate Dialysis. Int J Artif Organs 2018; 27:467-72. [PMID: 15291077 DOI: 10.1177/039139880402700604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anemia correction by erythropoietin favorably affects dialysis outcome but may also reduce dialysis efficiency increasing morbidity and mortality. Single needle dialysis (SN) and high dialysate flow (DF) are dialysis variations. We studied the effect of hemoglobin (Hb) normalization on dialysis adequacy under high DF. We also compared double needle (DN) and SN dialysis efficiency. Seventeen stable anuric patients (13 M, 4 F), aged 62 (40–90), on hemodialysis for 48 months (8–204), were studied in two, 6 months apart, periods of low (A) and high Hb (B), during a midweek 4 h dialysis with DN and SN. DF was 500 in A and 800ml/min in B. Rebound urea samples, 20 min post dialysis, were used for computer calculated double pool urea kinetics. Hb levels were 128±8 g/L (B) vs. 119±14 g/L (A), P<0.03. Despite the use of higher DF less dialysis was delivered in B vs. A, under DN or SN (DN: URR 64.8±5.8 vs. 69.7±5.2%, Kt/Vequil. 1.09±0.19 vs. 1.26±0.21, nPCR 1.37±0.29 vs. 1.60±0.36g/kg/day, changes <0.001, SN: URR 49.7±7.5% vs. 52.6±8.8%, Kt/Vequil. 0.74±0.16 vs. 0.82±0.23, nPCR 1.05±0.33 vs. 1.20±0.31, changes NS). SN was found significantly (P<0.001) less efficient than DN in A and B. Serum creatinine drop was significantly (P<0.001) less in both periods with SN vs. DN. Hb (SN in B) correlated inversely to Kt/V (r = –0.5705, P<0.02) and URR (r = –0.6432, P=0.005). Hb correction to normality is associated with a decrease in dialysis efficiency. The use of high dialysate flow does not compensate for this loss. SN delivers inadequate dialysis independently of dialysate flow or hemoglobin concentration.
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Nemati E, Khosravi A, Einollahi B, Meshkati M, Taghipour M, Abbaszadeh S. The relationship between dialysis adequacy and serum uric acid in dialysis patients; a cross-sectional multi-center study in Iranian hemodialysis centers. J Renal Inj Prev 2016; 6:142-147. [PMID: 28497092 PMCID: PMC5423283 DOI: 10.15171/jrip.2017.28] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/02/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction: Uric acid is one of the most significant uremic toxins accumulating in chronic renal failure patients treated with standard dialysis. Its clearance has not any exact relation with urea and creatinine clearance.
Objectives: The aim of this study was to investigate the relationship between adequacy of dialysis and serum level of uric acid in dialysis patients of some dialysis centers in Iran.
Patients and Methods: In this study 1271 hemodialysis patients who have been treated for more than 3 months were evaluated. Their information and examinations from their files in all over the country were gathered and analyzed using SPSS versin18.0.
Results: In this study, a significant relationship between dialysis duration and serum level of uric acid was not detected, however, a significant relationship between patients Kt/V and uric acid (R=0.43, P=0.029) was seen. Patients who had higher adequacy of dialysis had a higher level of plasma uric acid.
Conclusion: For better controlling of plasma uric acid level of hemodialysis patients, increasing of the adequacy of dialysis or its duration is not effective. Other modalities of decreasing of serum uric acid like, changing diet or lifestyle or medical therapy may be necessary.
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Affiliation(s)
- Eghlim Nemati
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Arezoo Khosravi
- Atherosclrosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Behzad Einollahi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehdi Meshkati
- Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taghipour
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Shahin Abbaszadeh
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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10
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Lee J, Choi JY, Kwon YK, Lee D, Jung HY, Ryu HM, Cho JH, Ryu DH, Kim YL, Hwang GS. Changes in serum metabolites with the stage of chronic kidney disease: Comparison of diabetes and non-diabetes. Clin Chim Acta 2016; 459:123-131. [DOI: 10.1016/j.cca.2016.05.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/02/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
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11
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Gura V, Rivara MB, Bieber S, Munshi R, Smith NC, Linke L, Kundzins J, Beizai M, Ezon C, Kessler L, Himmelfarb J. A wearable artificial kidney for patients with end-stage renal disease. JCI Insight 2016; 1:86397. [PMID: 27398407 DOI: 10.1172/jci.insight.86397] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stationary hemodialysis machines hinder mobility and limit activities of daily life during dialysis treatments. New hemodialysis technologies are needed to improve patient autonomy and enhance quality of life. METHODS We conducted a FDA-approved human trial of a wearable artificial kidney, a miniaturized, wearable hemodialysis machine, based on dialysate-regenerating sorbent technology. We aimed to determine the efficacy of the wearable artificial kidney in achieving solute, electrolyte, and volume homeostasis in up to 10 subjects over 24 hours. RESULTS During the study, all subjects remained hemodynamically stable, and there were no serious adverse events. Serum electrolytes and hemoglobin remained stable over the treatment period for all subjects. Fluid removal was consistent with prescribed ultrafiltration rates. Mean blood flow was 42 ± 24 ml/min, and mean dialysate flow was 43 ± 20 ml/min. Mean urea, creatinine, and phosphorus clearances over 24 hours were 17 ± 10, 16 ± 8, and 15 ± 9 ml/min, respectively. Mean β2-microglobulin clearance was 5 ± 4 ml/min. Of 7 enrolled subjects, 5 completed the planned 24 hours of study treatment. The trial was stopped after the seventh subject due to device-related technical problems, including excessive carbon dioxide bubbles in the dialysate circuit and variable blood and dialysate flows. CONCLUSION Treatment with the wearable artificial kidney was well tolerated and resulted in effective uremic solute clearance and maintenance of electrolyte and fluid homeostasis. These results serve as proof of concept that, after redesign to overcome observed technical problems, a wearable artificial kidney can be developed as a viable novel alternative dialysis technology. TRIAL REGISTRATION ClinicalTrials.gov NCT02280005. FUNDING The Wearable Artificial Kidney Foundation and Blood Purification Technologies Inc.
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Affiliation(s)
- Victor Gura
- Cedars-Sinai Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine at UCLA, UCLA, Los Angeles, California, USA
| | - Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Scott Bieber
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Raj Munshi
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington, USA
| | - Nancy Colobong Smith
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,University of Washington Medical Center, Seattle, Washington, USA
| | - Lori Linke
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - John Kundzins
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Masoud Beizai
- Blood Purification Technologies Inc., Beverly Hills, California, USA
| | - Carlos Ezon
- Blood Purification Technologies Inc., Beverly Hills, California, USA
| | - Larry Kessler
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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12
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Vartia A. Urea concentration and haemodialysis dose. ISRN NEPHROLOGY 2013; 2013:341026. [PMID: 24967223 PMCID: PMC4045420 DOI: 10.5402/2013/341026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 09/17/2012] [Indexed: 11/30/2022]
Abstract
Background. Dialysis dose is commonly defined as a clearance scaled to some measure of body size, but the toxicity of uraemic solutes is probably associated more to their concentrations than to their clearance. Methods. 619 dialysis sessions of 35 patients were modified by computer simulations targeting a constant urea clearance or a constant urea concentration. Results. Urea generation rate G varied widely in dialysis patients, rather independently of body size. Dialysing to eKt/V 1.2 in an unselected patient population resulted in great variations in time-averaged concentration (TAC) and average predialysis concentration (PAC) of urea (5.9–40.2 and 8.6–55.8 mmol/L, resp.). Dialysing to equal clearance targets scaled to urea distribution volume resulted in higher concentrations in women. Dialysing to the mean HEMO-equivalent TAC or PAC (17.7 and 25.4 mmol/L) required extremely short or long treatment times in about half of the sessions. Conclusions. The relation between G and V varies greatly and seems to be different in women and men. Dialysing to a constant urea concentration may result in unexpected concentrations of other uraemic toxins and is not recommended, but high concentrations may justify increasing the dose despite adequate eKt/V, std EKR, or std K/V.
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Affiliation(s)
- Aarne Vartia
- Dialysis Unit, Savonlinna Central Hospital, Keskussairaalantie 6, P.O. Box 111, 57101 Savonlinna, Finland
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Kusek JW, Agodoa LY, Jones CA. Morbidity and Mortality Among Hemodialysis Patients: A Plan for Action. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1993.tb00263.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kondepati VR, Damm U, Heise HM. Infrared transmission spectrometry for the determination of urea in microliter sample volumes of blood plasma dialysates. APPLIED SPECTROSCOPY 2006; 60:920-5. [PMID: 16925929 DOI: 10.1366/000370206778062066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Application of mid-infrared spectroscopy for the determination of urea in blood plasma dialysates of microliter sample volumes using a transmission microcell was investigated. Infrared spectra of the dialysates of plasma samples collected from 75 different patients using CMA 60 microdialysis catheters were evaluated with multivariate partial least squares regression. Using the absorbance spectral data from 1520-1420 cm(-1) and 1220-1120 cm(-1), a minimum standard error of prediction (SEP) of 0.88 mg/dL (0.14 mM) was achieved with spectral variable selection. Our findings suggest the feasibility of developing a mid-infrared sensor in combination with micro-fluidics for on-line monitoring of urea in patients undergoing dialysis treatment.
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Affiliation(s)
- Venkata Radhakrishna Kondepati
- ISAS-Institute for Analytical Sciences at the University of Dortmund, Bunsen-Kirchhoff-Strasse 11, D-44139 Dortmund, Germany
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16
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Affiliation(s)
- Gerald Schulman
- Department of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Abstract
Multiple lines of evidence have indicated that the dose of hemodialysis impacts upon patient outcome. Among these outcome measures, nutrition is inextricably linked to the adequacy of the treatment. All of the methods of determining dialysis adequacy are based on assessing the removal of toxic substances retained in renal failure, the majority of which are derivatives of protein metabolism. Urea kinetics, employing urea as a surrogate for quantifying the elimination of small molecular weight nitrogenous substances, is the method that has been most thoroughly validated to date as defining a dose range for thrice-weekly hemodialysis: Both inadequate and optimal levels of hemodialysis dose have been identified by prospective, randomized clinic trials utilizing Kt/V(urea) as the index of adequacy. The impact of urea kinetics on nutritional status during thrice-weekly hemodialysis is discussed. Recently, in an attempt to improve outcome beyond that achievable with thrice-weekly hemodialysis, alternative regimens, consisting of daily treatments, have received increasing interest. In order to compare the dose of hemodialysis associated with these regimens with conventional thrice-weekly regimens in terms of removal of small molecular weight substances, standard Kt/V(urea), a parameter that combines treatment dose with treatment frequency, and thus allows for various intermittent therapies to be compared to continuous therapy, must be used. In addition, membrane flux and middle molecule removal, factors that have not yet been well defined as parameters of adequacy during thrice-weekly regimens, may be shown to be important indices with longer hemodialysis treatments, particularly daily nocturnal hemodialysis. The impact that these alternative regimens have had on nutritional status in hemodialysis patients and how they compare to conventional therapy are important considerations.
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Affiliation(s)
- Gerald Schulman
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Clinical Trials Center, 215 Medical Arts Building, Nashville, TN 37232, USA.
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18
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Vaithilingam I, Polkinghorne KR, Atkins RC, Kerr PG. Time and exercise improve phosphate removal in hemodialysis patients. Am J Kidney Dis 2004; 43:85-9. [PMID: 14712431 DOI: 10.1053/j.ajkd.2003.09.016] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Control of serum phosphate remains a difficult clinical issue in most hemodialysis (HD) patients. This study examines 2 nonpharmacological approaches to improving phosphate control in HD patients. METHODS First, 9 stable HD patients underwent dialysis in random fashion for either 4 hours 3 times weekly or 5 hours 3 times weekly. Adjustments were made to blood flow rates such that Kt/V was the same for all sessions, thus allowing independent assessment of the influence of time. The primary end point was weekly dialysate phosphate removal. In the second study, 12 different patients underwent an exercise program in which they pedaled a bicycle ergometer either immediately before or during dialysis. Again, weekly dialysate phosphate removal was measured. RESULTS In the time study, urea reduction ratio (69% +/- 0.02% versus 68% +/- 0.07, 4 versus 5 hours) and weekly urea removal were no different between the 2 groups. However, weekly phosphate removal (3,007 +/- 641 versus 3,400 +/- 647 mg; P < 0.02) significantly improved with longer dialysis duration. Serum phosphate levels improved, but did not reach statistical significance in this short-term study. In the exercise study, weekly phosphate removal improved with exercise, but did not reach significance (2,741 +/- 715 [no exercise] versus 2,917 +/- 833 [exercise predialysis] versus 2,992 +/- 852 mg [exercise during dialysis]; P = 0.055), although comparing only exercise during dialysis with no exercise reached significance (P = 0.02). There was no significant difference in serum phosphate levels. CONCLUSION Both increased dialysis time and exercise result in increased dialytic removal of phosphate and could be expected in the long term to improve phosphate control.
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Lindberg JS. Hyperphosphatemia Management. Semin Dial 2002. [DOI: 10.1046/j.1525-139x.2002.00826.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jill S. Lindberg
- Department of Internal Medicine, Section on Nephrology, Ochsner Clinic Foundation, New Orleans, Louisiana
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Greene T, Beck GJ, Gassman JJ, Gotch FA, Kusek JW, Levey AS, Levin NW, Schulman G, Eknoyan G. Design and statistical issues of the hemodialysis (HEMO) study. CONTROLLED CLINICAL TRIALS 2000; 21:502-25. [PMID: 11018567 DOI: 10.1016/s0197-2456(00)00062-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The Hemodialysis Study is a multicenter clinical trial of hemodialysis prescriptions for patients with end stage renal disease. Participants from over 65 dialysis facilities associated with 15 clinical centers in the United States are randomized in a 2 x 2 factorial design to dialysis prescriptions targeted to a standard dose or a high dose, and to either low or high flux membranes. The primary outcome variable is mortality; major secondary outcomes are defined based on hospitalizations due to cardiovascular or infectious complications, and on the decline of serum albumin. The Outcome Committee, consisting of study investigators, uses a blinded review system to classify causes of death and hospitalizations related to the major secondary outcomes. The dialysis dose intervention is directed by the Data Coordinating Center using urea kinetic modeling programs that analyze results from dialysis treatments to monitor adherence to the study targets, adjust suggested dialysis prescriptions, and assist in trouble-shooting problems with the delivery of dialysis. The study design has adequate power to detect reductions in mortality rate equal to 25% of the projected baseline mortality rate for both of the interventions.
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Affiliation(s)
- T Greene
- Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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23
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Abstract
Uremia is characterized by gross contamination of body water with a wide spectrum of retained solutes normally excreted by the kidney. The rationale for dialysis therapy is that these retained solutes have concentration-dependent toxicity, which can be ameliorated through removal by dialysis. Apart from the well-established clinical consequences of abnormalities in fluid, electrolyte, acid base metabolism, and retained beta 2-microglobulin (beta 2 m), there is very little understanding of solute-specific uremic toxicity. Evidence is reviewed to demonstrate the following: (1) Many aspects of the uremic syndrome are controlled by adequate dialysis of low molecular weight solutes. (2) Urea can serve as a generic molecule to quantitate the fractional clearance of body water by dialysis (Kt/V) of retained low molecular weight solutes. (3) Urea has no concentration-dependent toxicity, and the generation rate of putative toxic low molecular weight solutes is not proportional to urea generation. The major clinical consequences and controversies stemming from these interrelationships are reviewed. Kinetic approaches to determine Kt/V dose equivalency between intermittent and continuous dialysis therapy are reviewed. We conclude that Kt/V can and will be generalized to describe the kinetics of other solutes such as beta2m as our knowledge of uremic toxicity grows, and hence, it is predicted that it will goeth and goeth and goeth.
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Affiliation(s)
- F A Gotch
- Quantitative Medical Systems, Emeryville, California, USA.
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24
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ING TS, CHENG YL, SHEK CC, WONG KM, YANG VL, KJELLSTRAND CM, LI CS. Observations on urea kinetic modeling and adequacy of hemodialysis. Int J Organ Transplant Med 2000. [DOI: 10.1016/s1561-5413(09)60026-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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25
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Rutledge C, McMahon LP. Relationship between dialysis and nutritional adequacy in haemodialysis patients. Nephrology (Carlton) 2000. [DOI: 10.1046/j.1440-1797.2000.00510.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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26
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Kumano K, Kawaguchi Y. Multicenter cross-sectional study for dialysis dose and physician's subjective judgment in Japanese peritoneal dialysis patients. Group for the Water and Electrocyte Balance Study in CAPD. Am J Kidney Dis 2000; 35:515-25. [PMID: 10692279 DOI: 10.1016/s0272-6386(00)70206-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to investigate the state of dialysis and nutrition among Japanese peritoneal dialysis (PD) patients. Two hundred thirty-nine Japanese PD patients from 21 centers, 79 female and 160 male, were evaluated to determine their status of dialysis and nutrition. Mean age of the patients was 50 years; mean duration on PD, 4.2 years; mean body weight, 58 kg; and body surface area (BSA), 1.61 m(2). Sixty-three percent of the patients had no residual renal function. Mean daily delivered volume was 6.9 L for female continuous ambulatory peritoneal dialysis (CAPD), 8.1 L for male CAPD, 10.5 L for female automated peritoneal dialysis (APD), and 10.7 L for male APD. Total (dialysis and kidney) mean weekly values for creatinine clearance (Ccr), Kt/V, and beta2 microglobulin (beta2MG) clearance were 56 L/1.75 m(2), 1.80, and 11 L/1.73 m(2), respectively. Fifty percent of the patients who had no residual renal function (RRF) and 17% of the patients with RRF did not achieve 50 L/wk/1.73 m(2) of Ccr. With regard to nutritional parameters, mean values for plasma total protein, serum albumin, and normalized protein catabolic rate (nPCR) were 6.5 g/dL, 3.6 g/dL, and 0.97 g/kg BW/d. Mean daily protein loss was 5.8 g. Although a significant number of patients did not achieve 50 or 60 L/wk/1.73 m(2) of Ccr, the physicians determined that 72% of the patients received adequate dialysis and 71% were well nourished according to clinical and laboratory features. In conclusion, the daily prescribed volume and the delivered dialysis dose were lower than expected. The discrepancy between the actual delivered dialysis dose and the physicians' evaluation should be explored in the future.
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Affiliation(s)
- K Kumano
- Kitasato University School of Medicine, Japan
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27
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Navarro JF, Mora C, León C, Martín-Del Río R, Macía ML, Gallego E, Chahin J, Méndez ML, Rivero A, García J. Amino acid losses during hemodialysis with polyacrylonitrile membranes: effect of intradialytic amino acid supplementation on plasma amino acid concentrations and nutritional variables in nondiabetic patients. Am J Clin Nutr 2000; 71:765-73. [PMID: 10702171 DOI: 10.1093/ajcn/71.3.765] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malnutrition is highly prevalent in hemodialysis patients. Amino acid (AA) losses during the dialysis procedure may be a contributing factor. OBJECTIVES The objectives of this study were 1) to prospectively evaluate AA losses and their effect on plasma AA concentrations during dialysis with polyacrylonitrile at baseline and after administration of AAs by intradialysis and 2) to investigate the effects of intradialytic AA supplementation on nutritional status. DESIGN Seventeen stable patients without diabetes who were receiving hemodialysis were studied. In the first phase, AA losses were evaluated over 2 wk in 10 patients randomly assigned to receive AA supplementation. AA losses were analyzed during the first week without supplementation and during the second week with AA administration. In the second phase, the patients' nutritional status was investigated after 3 mo of AA supplementation and was compared with those in 7 patients not receiving AAs. RESULTS Mean +/- SD) AA losses during a 4-h dialysis session were 12 +/- 2 g; there was a significant decrease in plasma AA concentrations (386 +/- 298 micromol/L for essential and 902 +/- 735 micromol/L for nonessential AAs). After administration of AAs, the losses increased to 28 +/- 4 g. However, this procedure produced a positive net balance of AAs (10.6 +/- 5.6 g for total AAs), preventing a reduction in plasma concentrations. After 3 mo of AA administration, there was a significant increase in protein catabolic rate and serum albumin and transferrin. This improvement occurred without any change in the dialysis dose, ruling out the possibility that an increase in dialysis efficiency played a role. CONCLUSIONS Intradialysis adequately provides AA supplements, prevents reductions in plasma AA concentrations, and favorably affects the nutritional status of patients receiving hemodialysis.
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Affiliation(s)
- J F Navarro
- Departments of Nephrology and Biochemistry and the Research Unit, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, Spain
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28
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Sanlidag C, Ccedil;avdar C, Sifil A, Hastaoglu S, üretmen P, çamsari T. Comparison of Two Different Kt/V Methods in Continuous Ambulatory Peritoneal Dialysis Patients. Perit Dial Int 1999. [DOI: 10.1177/089686089901902s87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dialysis adequacy has gained particular interest for the assessment of the quality of dialysis in patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD). Kt/V is used as a test of dialysis adequacy in HD and CAPD patients. The aim of this study was to compare two different Kt/V methods in CAPD patients. A practical method for the calculation of Kt/V will be suggested at the end of this prospective study. The study group included 28 patients. Each patient received CAPD therapy four times per day. During the study, CAPD dialysate samples for a period of 24 hours were obtained by two different methods. One is a modified method for obtaining samples by the patient at home; the other is the conventional method. For study purposes only, we told the patients using the modified method to bring all the bags to the center (contrary to the aim of the modified method). In the first method (modified method), CAPD patients collected 24-hour dialysate and urine samples at home and brought all of the materials to the hospital. A 10 mm3 dialysate sample was drawn from each CAPD dialysate bag, and then a total of 40 mm3 dialysate was mixed in a beaker. A sample of 10 mm3 of dialysate was taken from the mixture in the beaker, and then this dialysate sample, urine, and 5 mm3 venous blood were sent to the laboratory for urea nitrogen (UN) and creatinine level determinations. In addition to these tests, 24-hour dialysate and urine volumes and the patients’ weight and height were measured, and Kt/V values were calculated. In the second method (classic method), all the bags from the 24-hour period were collected and mixed in a big bucket, and then a 10 mm3 sample was taken. The remaining procedures were the same as for the first method. Mean Kt/V values were calculated separately for the two methods and were found to be 2.48 by the modified method and 2.52 by the classic method. The results of the two methods were compared with the Wilcoxon paired t-test, which showed no statistically significant difference (p = 0.5228). In conclusion, two different Kt/V methods can be used in CAPD patients. However, the modified method is easily performed, and CAPD patients can collect and take the dialysate and urine samples at home, and bring these materials to the renal unit without transportation problems.
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Affiliation(s)
- Canan Sanlidag
- CAPD Center, Department of Nephrology; Dokuz EylüI University Hospital, Izmir, Turkey
| | - Caner Ccedil;avdar
- CAPD Center, Department of Nephrology; Dokuz EylüI University Hospital, Izmir, Turkey
| | - Aykut Sifil
- CAPD Center, Department of Nephrology; Dokuz EylüI University Hospital, Izmir, Turkey
| | - Sadiye Hastaoglu
- CAPD Center, Department of Nephrology; Dokuz EylüI University Hospital, Izmir, Turkey
| | - Pinar üretmen
- CAPD Center, Department of Nephrology; Dokuz EylüI University Hospital, Izmir, Turkey
| | - Taner çamsari
- CAPD Center, Department of Nephrology; Dokuz EylüI University Hospital, Izmir, Turkey
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29
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30
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Argilés A, Ficheux A, Thomas M, Bosc JY, Kerr PG, Lorho R, Flavier JL, Stec F, Adelé C, Leblanc M, Garred LJ, Canaud B, Mion H, Mion CM. Precise quantification of dialysis using continuous sampling of spent dialysate and total dialysate volume measurement. Kidney Int 1997; 52:530-7. [PMID: 9264013 DOI: 10.1038/ki.1997.364] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The "gold standard" method to evaluate the mass balances achieved during dialysis for a given solute remains total dialysate collection (TDC). However, since handling over 100 liter volumes is unfeasible in our current dialysis units, alternative methods have been proposed, including urea kinetic modeling, partial dialysate collection (PDC) and more recently, monitoring of dialysate urea by on-line devices. Concerned by the complexity and costs generated by these devices, we aimed to adapt the simple "gold standard" TDC method to clinical practice by diminishing the total volumes to be handled. We describe a new system based on partial dialysate collection, the continuous spent sampling of dialysate (CSSD), and present its technical validation. Further, and for the first time, we report a long-term assessment of dialysis dosage in a dialysis clinic using both the classical PDC and the new CSSD system in a group of six stable dialysis patients who were followed for a period of three years. For the CSSD technique, spent dialysate was continuously sampled by a reversed automatic infusion pump at a rate of 10 ml/hr. The piston was automatically driven by the dialysis machine: switched on when dialysis started, off when dialysis terminated and held during the by pass periods. At the same time the number of production cycles of dialysate was monitored and the total volume of dialysate was calculated by multiplying the volume of the production chamber by the number of cycles. Urea and creatinine concentrations were measured in the syringe and the masses were obtained by multiplying this concentration by the total volume. CSSD and TDC were simultaneously performed in 20 dialysis sessions. The total mass of urea removed was calculated as 58038 and 60442 mmol/session (CSSD and TDC respectively; 3.1 +/- 1.2% variation; r = 0.99; y = 0.92x -28.9; P < 0.001). The total mass of creatinine removed was 146,941,143 and 150,071,195 mumol/session (2.2 +/- 0.9% variation; r = 0.99; y = 0.99x + 263; P < 0.001). To determine the long-term clinical use of PDC and CSSD, all the dialysis sessions monitored during three consecutive summers with PDC (during 1993 and 1994) and with CSSD (1995) in six stable dialysis patients were included. The clinical study comparing PDC and CSSD showed similar urea removal: 510 +/- 59 during the first year with PDC and 516 +/- 46 mmol/dialysis session during the third year, using CSSD. Protein catabolic rate (PCR) could be calculated from total urea removal and was 1.05 +/- 0.11 and 1.05 +/- 0.09 g/kg/day with PDC and CSSD for the same periods. PCR values were clearly more stable when calculated from the daily dialysate collections than when obtained with urea kinetic modeling performed once monthly. We found that CSSD is a simple and accurate method to monitor mass balances of urea or any other solute of clinical interest. With CSSD, dialysis efficacy can be monitored at every dialysis session without the need for bleeding a patient. As it is external to the dialysis machine, it can be attached to any type of machine with a very low cost. The sample of dialysate is easy to handle, since it is already taken in a syringe that is sent directly to the laboratory. The CSSD system is currently in routine use in our unit and has demonstrated its feasibility, low cost and high clinical interest in monitoring dialysis patients.
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Affiliation(s)
- A Argilés
- UDSA-AIDER, CRBM-CNRS, Université Montpellier I, France
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31
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Goldsmith DJ, Covic AC, Venning MC, Ackrill P. Ambulatory blood pressure monitoring in renal dialysis and transplant patients. Am J Kidney Dis 1997; 29:593-600. [PMID: 9100050 DOI: 10.1016/s0272-6386(97)90343-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Blood pressure (BP) elevation and left ventricular hypertrophy are important factors in the high cardiovascular mortality rate in patients on the renal replacement program. Ambulatory BP monitoring is widely regarded as superior to random BP monitoring in predicting end-organ damage from elevated BP. One hundred seventeen patients (60 on hemodialysis [35 with long sessions and 25 with short sessions], 29 on continuous ambulatory peritoneal dialysis, and 28 transplant recipients) underwent ambulatory BP monitoring, with target organ assessment by electrocardiography. Mean 24-hour BP for the patients with the long hemodialysis sessions (LHD) was 115.5/66.6 mm Hg, without the regular use of antihypertensive drugs. The parathormone (PTH) level was the major determinant of BP on ambulatory BP monitoring analysis, with interdialytic weight gain and age each having weaker associations. The BPs of the other three patient cohorts were much higher (short hemodialysis session [SHD], 143.2/82.1 mm Hg; continuous ambulatory peritoneal dialysis, 137.1/76.8 mm Hg; transplant recipients, 135.9/79.2 mm Hg). Overall, two thirds of the patients had reduced diurnal BP variability. Electrocardiogram voltage criteria for left ventricular hypertrophy were exceeded in approximately one third to one half of the patients. Our findings show that good control of BP is possible without recourse to antihypertensive drugs in the context of dialysis with slow ultrafiltration.
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Affiliation(s)
- D J Goldsmith
- Withington Hospital Artificial Kidney Unit, Withington Hospital, Manchester, UK
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32
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Charytan C, Gupta B, Meindel N, Spinowitz B. Fractional direct dialysis quantification: a new approach for prescription and monitoring hemodialysis therapy. Kidney Int 1996; 50:1845-9. [PMID: 8943465 DOI: 10.1038/ki.1996.504] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We describe a new methodology, fractional direct dialysis quantification (FDDQ) utilizing the Fresinius Dialysate Sampling Module (DSM), for quantitating total solute removal during hemodialysis (HD). Our data demonstrate that this technique and Direct Dialysis Quantification (DDQ) yield virtually identical results. FDDQ, however, obviates the practical obstacles that have limited the applicability of DDQ. We discuss the theoretical and practical advantages of this methodology, as compared to urea kinetic modeling (UKM) with Kt/V, for prescribing and monitoring dialysis therapy. FDDQ provides reliable and accurate quantitative data of dialysis function and protein catabolic rate (PCR) independent of questionable theoretical assumptions and parameters required for UKM with Kt/V. It is simple to comprehend and apply. It permits easy comparison of standard and rapid high efficiency dialyses. It also facilitates the quantitative comparison of HD and continuous therapies (peritoneal dialysis and various types of continuous hemofiltration). FDDQ permits the use of other solutes, in place of or in addition to urea, for the quantitation of HD. Because of its simplicity and probable low cost, it can be used with each HD session. It will thus provide accurate data on delivered versus prescribed therapy. These features should permit more accurate monitoring and lead to a clearer understanding of the relationship of outcomes versus delivered dialysis dose, and consequently more effective adjustment of dialysis therapy.
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Affiliation(s)
- C Charytan
- New York Hospital Medical Center of Queens, Flushing, USA
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33
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Kopple JD, Jones MR, Keshaviah PR, Bergström J, Lindsay RM, Moran J, Nolph KD, Teehan BP. A proposed glossary for dialysis kinetics. Am J Kidney Dis 1995; 26:963-81. [PMID: 7503074 DOI: 10.1016/0272-6386(95)90064-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Quantification of the dialysis dose and assessment of nutritional status and response to nutritional therapy have become standard parts of the management of the chronic dialysis patient. Although advances in these areas have led to a more rational basis for therapy, certain misconceptions and points of confusion appear to have occurred. Recognizing the importance of a standard nomenclature to the development of concepts and the communication of research findings, we have attempted to compile a list of terms that are commonly used in the field of dialysis. New terms have been proposed for current ones that do not seem adequate. In addition, we have discussed potential methodologies for obtaining more accurate data for dialysis kinetics and for precise monitoring of nutritional intake and status. It is hoped that this glossary will stimulate discussion that will lead to refinements in terminology and concepts that will, in turn, improve research and practice in nephrology. It is anticipated that many of these definitions and recommendations will be modified or superseded as the management of patients with renal failure continues to advance.
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34
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Burkart J, Zeigler N, Chaffee D, Hutchens M, Davis L, Poole D, Briley K. The importance of monitoring dialysis adequacy in chronic peritoneal dialysis. ADVANCES IN RENAL REPLACEMENT THERAPY 1995; 2:349-61. [PMID: 8591126 DOI: 10.1016/s1073-4449(12)80033-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The case of a patient who was noted to be malnourished but improved after his dialysis dose was increased is presented. This case and the discussion that follows emphasize the importance of proactively monitoring peritoneal dialysis adequacy and nutritional intake, supporting the notion that the dose of peritoneal dialysis is a major determinant of appetite and, consequently, of nutritional status. In the clinical setting, this influence is best indicated by changes in the serum albumin level and ultimately in long-term patient survival. The case discussion reviews the major principles and supporting literature, describing how we target peritoneal dialysis delivery and optimize nutritional status in an effort to reduce morbidity and mortality.
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Affiliation(s)
- J Burkart
- Department of Nephrology, Bowman Gray School of Medicine/Wake Forest University, Winston-Salem, NC 27157-1053, USA
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35
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Affiliation(s)
- H Haller
- Virchow Klinikum, Franz-Volhard-Klinik, Berlin, Germany
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36
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Keen M, Schulman G. Current standards for dialysis adequacy. ADVANCES IN RENAL REPLACEMENT THERAPY 1995; 2:287-94. [PMID: 8591120 DOI: 10.1016/s1073-4449(12)80027-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Multiple lines of evidence suggest that inadequately prescribed or delivered dosage of hemodialysis is associated with increased morbidity and mortality. Conversely, retrospective studies indicate that increased levels of hemodialysis reverse this trend of poor outcome. The results of the National Cooperative Dialysis Study (NCDS), a prospective and randomized trial, suggested that urea kinetic modeling was a valid method of quantifying the dose of hemodialysis delivered and also identified a level of treatment below which a number of adverse events occurred. In the ensuing years, urea kinetic modeling has been increasingly applied to quantitate dialysis. The application of the NCDS results as well as the limitations of the study are reviewed, and the modifications in applying urea kinetic modeling due to urea rebound are discussed. To assess the impact of newer membranes and higher levels of dialysis on an older hemodialysis population with more comorbid conditions than the subjects studied in the NCDS, a 5-year, multicenter, prospective and randomized trial, the HEMO Study, has recently been initiated.
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Affiliation(s)
- M Keen
- AMGEN, Inc, Thousand Oaks, CA, USA
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37
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Panzetta G. Urea Monitoring in the Dialysis Patient. Int J Artif Organs 1995. [DOI: 10.1177/039139889501800910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- G. Panzetta
- Division Of Nephrology And Dialysis, Ospedale Maggiore, Trieste - Italy
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39
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Teehan BP, Schleifer CR, Brown J. Adequacy of continuous ambulatory peritoneal dialysis: morbidity and mortality in chronic peritoneal dialysis. Am J Kidney Dis 1994; 24:990-101. [PMID: 7985681 DOI: 10.1016/s0272-6386(12)81074-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Mortality for hemodialysis patients tends to be in excess of 20% per year, and it is generally agreed that outcome for continuous ambulatory peritoneal dialysis patients is comparable. Several investigators have suggested recently that continuous ambulatory peritoneal dialysis, as commonly practiced, may not provide adequate therapy, especially for larger patients and for those with no residual renal function. Unfortunately, a dose-response curve relating the amount of dialysis delivered and clinical outcome for continuous ambulatory peritoneal dialysis patients has not been constructed. Several methods of quantifying the dose of peritoneal dialysis are described. Both cross-sectional and longitudinal studies are reviewed. The conclusions of these studies are of limited value, however, because of their retrospective nature and the limited number of patients enrolled. Nevertheless, in aggregate, these studies suggest that survival may be improved by higher doses of dialysis. They also suggest that while malnutrition is relatively common in this patient population, higher doses of Kt/V are associated with higher protein intake (as measured by protein catabolic rate). Serum albumin is recognized as a strong predictor of clinical outcome and the protein catabolic rate may correlate directly with Kt/V, but there are studies that support and others that refute a correlation between Kt/V and serum albumin. Definitive answers to these questions are likely to be available in the near future. Two large multicenter studies are currently under way. Preliminary results may be available in the near future.
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Affiliation(s)
- B P Teehan
- Division of Nephrology, Lankenau Hospital/Lankenau Medical Research Center, Wynnewood, PA 19096
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40
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Himmelfarb J, Holbrook D, McMonagle E, Robinson R, Nye L, Spratt D. Kt/V, nutritional parameters, serum cortisol, and insulin growth factor-1 levels and patient outcome in hemodialysis. Am J Kidney Dis 1994; 24:473-9. [PMID: 8079972 DOI: 10.1016/s0272-6386(12)80904-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Despite many technical advances in dialysis care, morbidity and mortality in chronic hemodialysis patients in the United States remains high. In this study, we analyzed the effects of Kt/V, nutritional parameters (serum albumin level, triceps skin-fold thickness, mid-arm muscle circumference, and normalized protein catabolic rate), and predialysis serum cortisol and insulin growth factor-1 levels on predicting morbidity and mortality. The cohort studied consisted of 52 patients recruited from a single outpatient dialysis facility. Cox proportional hazards modeling indicated that only Kt/V predicted subsequent mortality (P = 0.02), while both predialysis cortisol levels (P = 0.03) and Kt/V (P = 0.03) predicted hospitalization. Kaplan-Meier analysis demonstrated that the ability of cortisol levels to predict hospitalization was largely confined to the group with values greater than 22 micrograms/dL predialysis. High serum cortisol levels were correlated with low serum albumin levels and a trend toward low triceps skin-fold thickness and higher normalized protein catabolic rate, suggesting a catabolic state. Both predialysis serum cortisol and insulin growth factor-1 levels were higher than those in age- and sex-matched normal human controls. These results demonstrate the importance role of Kt/V in predicting subsequent hospitalization rates and mortality, and that high predialysis serum cortisol levels correlate with a high hospitalization rate.
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Affiliation(s)
- J Himmelfarb
- Division of Nephrology, Maine Medical Center, Portland 04102
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41
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Parker TF, Husni L, Huang W, Lew N, Lowrie EG. Survival of hemodialysis patients in the United States is improved with a greater quantity of dialysis. Am J Kidney Dis 1994; 23:670-80. [PMID: 8172209 DOI: 10.1016/s0272-6386(12)70277-9] [Citation(s) in RCA: 186] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The mortality rate for hemodialysis patients in the United States is higher than in other industrialized countries. Some attribute this to insufficient quantities of prescribed and delivered dialysis. A multicenter study in Dallas dialysis centers (Dallas Nephrology Associates) was begun in 1989 to assess the impact of increasing the delivered quantity of dialysis on mortality in subsequent years. Dialysis dose was measured by urea kinetic modeling. Kt/V, reflecting the fractional volume of body water clearance of urea during a dialysis treatment, was purposefully increased from 1.18 starting in 1989 to 1.46 in 1992. Additionally, the dialysis dose measured by the urea reduction ratio, the fractional reduction of blood urea nitrogen concentration caused by a dialysis treatment, increased from 63.0% to 69.6% between 1990 and 1992. Outcome analytical methods included both crude and standardized mortality rates and mortality ratios standardized to large end-stage renal disease databases at the United States Renal Data System and at National Medical Care, Inc. Crude mortality rates at Dallas Nephrology Associates decreased from 22.5% in 1989 to 18.1% in 1992. In comparison, between 1990 and 1992 the urea reduction ration in National Medical Care facilities increased from 57.1% to 62.5%. During that time crude mortality rates decreased from 21.8% to 19.5%. Crude mortality in the United States remained essentially unchanged in the same time period. By 1992, Dallas Nephrology Associates and National Medical Care had standardized mortality ratios of 0.77 and 0.74, respectively, compared with the US dialysis population, indicating almost 30% fewer observed deaths than expected. Monitoring dialysis dose by urea kinetic modeling or urea reduction ratio are equally effective in predicting improvement in patient survival. Improved survival is possible in the US end-stage renal disease program with greater amounts of dialysis. This strategy can save an estimated 8,000 to 16,000 lives per year.
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42
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Roth SL, Cornell C. Health care in Canada and the United States. N Engl J Med 1993; 329:964-5; author reply 965-6. [PMID: 8123103 DOI: 10.1056/nejm199309233291314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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43
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Honkanen E. Individualized use of hemodialysis and peritoneal dialysis. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1993; 27:289-93. [PMID: 8290905 DOI: 10.3109/00365599309180436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Over the past few years it has better been realized how individual the needs for the effectiveness ("dose") of dialytic therapy are and which treatment related factors affect the morbidity and mortality of dialysis patients. Although the role of urea, a marker of small molecular weight uremic toxins, has been challenged, most studies have been based on kinetics of urea during and between dialyses. The dose of dialysis affects also the nutritional status and a special role for "middle" molecules as anorectic factors has been suggested. This article gives an in-depth view of some factors which affect the needs for the effectiveness of dialytic therapy, a summary of the goals of the treatment, and some practical guidelines how to reach them.
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Phillips LH, Williams FH. Are nerve conduction studies useful for monitoring the adequacy of renal dialysis? Muscle Nerve 1993; 16:970-4. [PMID: 8355729 DOI: 10.1002/mus.880160914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
When hemodialysis was first used clinically, a peripheral neuropathy frequently emerged. The discovery that sufficient dialysis time would prevent the emergence of symptomatic neuropathy led to the routine use of nerve conduction studies (NCS) to monitor the "adequacy" of dialysis. Modern dialysis practice has evolved since then, and the patient population is markedly different. This report addresses the question of whether there is evidence to indicate that routine use of NCS is helpful to monitor the adequacy of present-day dialysis. A critical review of the available literature reveals that there is insufficient evidence to allow one to answer the question.
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Affiliation(s)
- L H Phillips
- Department of Neurology, University of Virginia School of Medicine, Charlottesville 22908
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Iseki K, Kawazoe N, Osawa A, Fukiyama K. Survival analysis of dialysis patients in Okinawa, Japan (1971-1990). Kidney Int 1993; 43:404-9. [PMID: 8441236 DOI: 10.1038/ki.1993.59] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We analyzed longitudinal data obtained from the initiation of chronic dialysis in Okinawa, Japan. A total of 1,982 patients (824 females and 1,158 males) were registered in the Okinawa Dialysis Study (OKIDS) up to the end of 1990. The number of patients dying, undergoing renal transplantation, or being transferred was 605 (30.5%), 75 (3.8%), and 23 (1.2%), respectively. The mean acceptance rate per million population increased from 19.7 in 1971 to 1975 to 157.4 in 1986 to 1990. The percentage of diabetic patients and the annual gross mortality rate were, respectively 0% and 0.52 (1971 to 1975), 7.3% and 0.12 (1976 to 1980), 14.4% and 0.06 (1981 to 1985), and 24.6% and 0.07 (1986 to 1990). Cox proportional hazard analysis was used to determine the relative risk (RR) for sex, primary renal disease, age at entry, and the year of starting dialysis. The RR for males was 1.09 (1.00 for females) and the 95% confidence interval (CI) was 0.93 to 1.28. The RR for diabetics was 1.88 (95% CI; 1.55 to 2.28) when that for nondiabetics was set at 1.00. The RR (95% CI) for starting dialysis in 1976 to 1980, 1981 to 1985, and 1986 to 1990 was 0.65 (0.59 to 0.72), 0.43 (0.35 to 0.52), and 0.28 (0.20 to 0.38), respectively, when the RR in 1971 to 1975 was taken as 1.00. During the last two decades, the survival of chronic dialysis patients in Okinawa has continued to improve despite the large increase in acceptance rate, the older age of the new patients, and the increase in diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K Iseki
- Third Department of Internal Medicine and Urology, School of Medicine, University of The Ryukyus, Okinawa, Japan
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Abstract
Despite technical advances in the delivery of hemodialysis over the past decade, the mortality rate of hemodialysis-dependent, end-stage renal disease (ESRD) patients in the United States remains high. The increase in the number and severity of comorbid conditions of patients entering ESRD is a factor contributing to this high mortality. Nevertheless, there is increasing evidence that the dose of dialysis received by US patients is inadequate and that this plays a major role in the observed high mortality. In this review, we examine some of the parameters used to judge the adequacy of dialysis, as well as factors that can result in differences between prescribed and delivered dose of hemodialysis. Based on available evidence, we propose that for most patients the optimum dose of dialysis, above which further improvement of morbidity and mortality is doubtful, is represented by a delivered dose of dialysis equivalent to a Kt/V of 1.4 or greater, using biocompatible membranes. The prescription of this optimal dose of dialysis must be coupled with an ongoing effort to monitor delivery of the appropriate dose.
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Affiliation(s)
- R M Hakim
- Division of Nephrology, Vanderbilt University, Nashville, TN
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Abstract
Mast cells may be more abundant in the tissues of uremic patients and may contribute to itching via mediator release. Because mast cell (MC) granule release may be inhibited by ultraviolet B (UVB) radiation, we investigated skin MC in the superficial dermis by quantitative histomorphometry before and after whole body UVB for uremic itching. Toluidine blue-stained 3.5 mm punch biopsy specimens were examined with a micrometer grid after separate coding. Upon entry to the study, itching dialysis patients indicated their itching intensity on a visual analog scale (0 to 10). Concurrent study of living, related kidney donors (controls, n = 11) and their recipients (n = 11) showed no differences in MC number per unit area. Compared to controls, skin MC number was not greater in itching dialysis patients (n = 20). MC number decreased after 2 months of UVB from 1.6 +/- 0.6 (standard deviation) to 1.0 +/- 0.7 (n = 11, p = 0.025). Pre-UVB total plasma calcium correlated directly with itching intensity, but not with MC number. Plasma phosphate and intact parathyrin level were not statistically related to itching or MC number. Of the 14 subjects that completed UVB, 8 had objective benefit, and mean itching intensity declined from 7.1/10 to 5.2/10 in the 14 subjects. The conclusion is that although skin MC number may decline with chronic UVB, MC number is not related to uremic itching, and hypercalcemia, but not elevation of parathyrin or plasma phosphate, relates statistically to severe uremic itching.
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Affiliation(s)
- E P Cohen
- Department of Medicine, Medical College of Wisconsin, Milwaukee
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Delmez JA, Slatopolsky E. Hyperphosphatemia: its consequences and treatment in patients with chronic renal disease. Am J Kidney Dis 1992; 19:303-17. [PMID: 1562018 DOI: 10.1016/s0272-6386(12)80446-x] [Citation(s) in RCA: 165] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Control of phosphorus accumulation in chronic renal insufficiency is crucial to the prevention of secondary hyperparathyroidism and metastatic calcification. In early renal failure, calcitriol levels are normal and parathyroid hormone levels are elevated. The phosphorus levels are maintained in the normal range by the phosphaturia induced by hyperparathyroidism. In this situation, dietary phosphorus restriction increases calcitriol levels and suppresses parathyroid hormone secretion. As renal failure progresses into late stages, hyperphosphatemia is evident along with low levels of calcitriol and worsening hyperparathyroidism. Phosphorus restriction will not affect calcitriol concentrations, yet parathyroid levels may decline. During long-term dialysis, urinary excretion of phosphorus is usually minimal. Therefore, phosphorus balance is determined primarily by the net amount absorbed by the bowel and the quantity removed during dialytic therapy. Given an adequate diet, no form of conventional dialysis is able to fully compensate for the gastrointestinal absorption of phosphorus. Hence, compounds that bind phosphorus in the bowel are often necessary. With the realization that the use of phosphorus binders containing aluminum leads to aluminum accumulation and its sequelae: osteomalacia, dementia, myopathy, and anemia, other phosphorus binders have been evaluated. Calcium carbonate has been investigated the most thoroughly and is in wide use. It is inexpensive and contains a high percent of elemental calcium. However, it is only modestly potent in the binding of phosphorus, and large doses are often necessary to attain satisfactory control of phosphorus. This may lead to hypercalcemia. One approach to this problem is to decrease the concentration of calcium in the dialysate. Alternatively, a more effective phosphorus binder may be used. Calcium acetate has been shown in acute studies to have twice the binding capacity of phosphorus per calcium absorbed than calcium carbonate. Whether use of this compound decreases the incidence of hypercalcemia is unproven. Calcium citrate increases the gastrointestinal absorption of aluminum and offers no advantage over calcium carbonate. Other compounds, such as calcium ketoacids and calcium alginate, have not been extensively studied and are not generally available. The use of phosphorus binders containing magnesium in conjunction with a dialysate low in magnesium may be efficacious. Large doses of magnesium will cause diarrhea and thus limit its use as a single agent. Reasons for failure to control hyperphosphatemia include poor compliance, improper prescription of binders, poor dissolution rates seen with some generic brands of calcium carbonate, and the presence of severe hyperparathyroidism. Optimal control of serum phosphorus in dialysis patients should always be viewed in the context of adequate nutrition and protein intake.
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Affiliation(s)
- J A Delmez
- Department of Internal Medicine, Washington University School of Medicine, St Louis, MO 63110
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Delmez JA, Windus DW. Hemodialysis prescription and delivery in a metropolitan community. The St. Louis Nephrology Study Group. Kidney Int 1992; 41:1023-8. [PMID: 1513083 DOI: 10.1038/ki.1992.155] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The National Cooperative Dialysis Study attempted to determine adequacy of hemodialysis based on kinetic modeling of urea. Based on this study, it has been recommended that a dimensionless term quantitating the amount of dialysis delivered (KT/V) be greater than 1.0 to avoid adverse outcomes. With the declining duration of dialysis treatments in the United States, there has been concern that a significant proportion of patients may be receiving inadequate therapy. The purpose of this study was to survey hemodialysis practices and treatment outcomes in our metropolitan area. Sixteen area nephrologists volunteered to study their outpatient hemodialysis patients (N = 617). Demographic data and urea kinetic modeling results were then analyzed at the lead center. The mean length of dialysis was 3.2 +/- 0.4 (SD) hours with dialysis blood flow rates of 333 +/- 74 ml/min. The mean KT/V was 1.03 +/- 0.25 with nearly half of patients failing to attain a KT/V of 1.0. In 55% of patients the reason for a low KT/V was the prescription of an insufficient amount of dialysis treatment. In the remainder, insufficient delivery of prescribed dialysis contributed to the low KT/V. Only 1 of 33 patients undergoing dialysis twice a week achieved the recommended quantity of treatment on a weekly basis. Patients undergoing dialysis in non-profit units had a higher KT/V than those treated in proprietary units (1.1 +/- 0.26 vs. 0.92 +/- 0.22, P less than 0.001). In addition, patients dialyzed in units that performed urea kinetic modeling on all or selected patients had a higher KT/V compared to those in units where urea kinetics were not done (1.12 +/- 0.25 vs. 0.95 +/- 0.23, P less than 0.001). If these findings reflect practices elsewhere in the United States, many hemodialysis patients fail to receive the current recommended quantity of treatment.
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Affiliation(s)
- J A Delmez
- Renal Division, Washington University School of Medicine, St. Louis, Missouri
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