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Lu R, Fang Y, Wu W, Zeng X, Liu T, Qian Y, Xie Y, Zhou Y, Gu L. Hemodiafiltration with endogenous reinfusion for uremic toxin removal in patients undergoing maintenance hemodialysis: a pilot study. Ren Fail 2024; 46:2338929. [PMID: 38632963 PMCID: PMC11028005 DOI: 10.1080/0886022x.2024.2338929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/30/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE To delineate the efficacy and safety profile of hemodiafiltration with endogenous reinfusion (HFR) for uremic toxin removal in patients undergoing maintenance hemodialysis (MHD). METHODS Patients who have been on MHD for a period of at least 3 months were enrolled. Each subject underwent one HFR and one hemodiafiltration (HDF) treatment. Blood samples were collected before and after a single HFR or HDF treatment to test uremic toxin levels and to calculate clearance rate. The primary efficacy endpoint was to compare uremic toxin levels of indoxyl sulfate (IS), λ-free light chains (λFLC), and β2-microglobulin (β2-MG) before and after HFR treatment. Secondary efficacy endpoints was to compare the levels of urea, interleukin-6 (IL-6), P-cresol, chitinase-3-like protein 1 (YKL-40), leptin (LEP), hippuric acid (HPA), trimethylamine N-oxide (TMAO), asymmetric dimethylarginine (ADMA), tumor necrosis factor-α (TNF-α), fibroblast growth factor 23 (FGF23) before and after HFR treatment. The study also undertook a comparative analysis of uremic toxin clearance between a single HFR and HDF treatment. Meanwhile, the lever of serum albumin and branched-chain amino acids before and after a single HFR or HDF treatment were compared. In terms of safety, the study was meticulous in recording vital signs and the incidence of adverse events throughout its duration. RESULTS The study enrolled 20 patients. After a single HFR treatment, levels of IS, λFLC, β2-MG, IL-6, P-cresol, YKL-40, LEP, HPA, TMAO, ADMA, TNF-α, and FGF23 significantly decreased (p < 0.001 for all). The clearance rates of λFLC, β2-MG, IL-6, LEP, and TNF-α were significantly higher in HFR compared to HDF (p values: 0.036, 0.042, 0.041, 0.019, and 0.036, respectively). Compared with pre-HFR and post-HFR treatment, levels of serum albumin, valine, and isoleucine showed no significant difference (p > 0.05), while post-HDF, levels of serum albumin significantly decreased (p = 0.000). CONCLUSION HFR treatment effectively eliminates uremic toxins from the bloodstream of patients undergoing MHD, especially protein-bound toxins and large middle-molecule toxins. Additionally, it retains essential physiological compounds like albumin and branched-chain amino acids, underscoring its commendable safety profile.
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Affiliation(s)
- Renhua Lu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Fang
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wangshu Wu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaojun Zeng
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tingting Liu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yue Qian
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanyuan Xie
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yijun Zhou
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Leyi Gu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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2
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Iman Y, Bamforth R, Ewhrudjakpor R, Komenda P, Gorbe K, Whitlock R, Bohm C, Tangri N, Collister D. The impact of dialysate flow rate on haemodialysis adequacy: a systematic review and meta-analysis. Clin Kidney J 2024; 17:sfae163. [PMID: 38979109 PMCID: PMC11229034 DOI: 10.1093/ckj/sfae163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Indexed: 07/10/2024] Open
Abstract
Background Patients with kidney failure treated with maintenance haemodialysis (HD) require appropriate small molecule clearance. Historically, a component of measuring 'dialysis adequacy' has been quantified using urea kinetic modelling that is dependent on the HD prescription. However, the impact of dialysate flow rate on urea clearance remains poorly described in vivo and its influence on other patient-important outcomes of adequacy is uncertain. Methods We searched Embase, MEDLINE and the Cochrane Library from inception until April 2022 for randomized controlled trials and observational trials comparing a higher dialysate flow rate (800 ml/min) and lower dialysate flow rate (300 ml/min) with a standard dialysis flow rate (500 ml/min) in adults (age ≥18 years) treated with maintenance HD (>90 consecutive days). We conducted a random effects meta-analysis to estimate the pooled mean difference in dialysis adequacy as measured by Kt/V or urea reduction ratio (URR). Results A total of 3118 studies were identified. Of those, nine met eligibility criteria and four were included in the meta-analysis. A higher dialysate flow rate (800 ml/min) increased single-pool Kt/V by 0.08 [95% confidence interval (CI) 0.05-0.10, P < .00001] and URR by 3.38 (95% CI 1.97-4.78, P < .00001) compared with a dialysate flow rate of 500 ml/min. Clinically relevant outcomes including symptoms, cognition, physical function and mortality were lacking and studies were generally at a moderate risk of bias due to issues with randomization sequence generation, allocation concealment and blinding. Conclusion A higher dialysate flow increased urea-based markers of dialysis adequacy. Additional high-quality research is needed to determine the clinical, economic and environmental impacts of higher dialysate flow rates.
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Affiliation(s)
- Yasmin Iman
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Ryan Bamforth
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Ruth Ewhrudjakpor
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- Quanta Dialysis Technologies, Alcester, UK
- University of Manitoba, Rady Faculty of Health Sciences, Department of Internal Medicine, Winnipeg, Manitoba, Canada
| | | | - Reid Whitlock
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Clara Bohm
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- University of Manitoba, Rady Faculty of Health Sciences, Department of Internal Medicine, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- University of Manitoba, Rady Faculty of Health Sciences, Department of Internal Medicine, Winnipeg, Manitoba, Canada
| | - David Collister
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- University of Manitoba, Rady Faculty of Health Sciences, Department of Internal Medicine, Winnipeg, Manitoba, Canada
- University of Alberta, Faculty of Medicine & Dentistry, Department of Medicine, Edmonton, Alberta, Canada
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Pereira M, Tocino MLS, Mas-Fontao S, Manso P, Burgos M, Carneiro D, Ortiz A, Arenas MD, González-Parra E. Dependency and frailty in the older haemodialysis patient. BMC Geriatr 2024; 24:416. [PMID: 38730386 PMCID: PMC11088105 DOI: 10.1186/s12877-024-04973-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Frailty among older adults undergoing hemodialysis is increasingly prevalent, significantly impacting cognitive function, mobility, and social engagement. This study focuses on the clinical profiles of very older adults in hemodialysis, particularly examining the interplay of dependency and frailty, and their influence on dialysis regimens. METHODS In this observational, descriptive study, 107 patients aged over 75 from four outpatient centers and one hospital unit were examined over a year. Patient data encompassed sociodemographic factors, dialysis specifics, analytical outcomes, lifestyle elements, and self-reported post-treatment fatigue. Malnutrition-inflammation scale was used to measure the Nutritional status; MIS scale for malnutrition-inflammation, Barthel index for dependency, Charlson comorbidity index; FRIED scale for frailty and the SF12 quality of life measure. RESULTS The study unveiled that a substantial number of older adults on hemodialysis faced malnutrition (55%), dependency (21%), frailty (46%), and diminished quality of life (57%). Patients with dependency were distinctively marked by higher comorbidity, severe malnutrition, enhanced frailty, nursing home residency, dependency on ambulance transportation, and significantly limited mobility, with 77% unable to walk. Notably, 56% of participants experienced considerable post-dialysis fatigue, correlating with higher comorbidity, increased dependency, and poorer quality of life. Despite varying clinical conditions, dialysis patterns were consistent across the patient cohort. CONCLUSIONS The older adult cohort, averaging over four years on hemodialysis, exhibited high rates of comorbidity, frailty, and dependency, necessitating substantial support in transport and living arrangements. A third of these patients lacked residual urine output, yet their dialysis regimen mirrored those with preserved output. The study underscores the imperative for tailored therapeutic strategies to mitigate dependency, preserve residual renal function, and alleviate post-dialysis fatigue, ultimately enhancing the physical quality of life for these patients.
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Affiliation(s)
- M Pereira
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain
| | - M L Sanchez Tocino
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain
- Facultad de Enfermería, Universidad de Salamanca, Salamanca, Spain
| | - Sebastian Mas-Fontao
- Instituto de Investigación Sanitaria Fundación Jimenez Díaz, Madrid, 28040, Spain.
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain.
- Facultad de Medicina y Biomedicina, Universidad Alfonso X, Villanueva de la Cañada, Spain.
| | - P Manso
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain
| | - M Burgos
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain
| | - D Carneiro
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain
| | - A Ortiz
- Instituto de Investigación Sanitaria Fundación Jimenez Díaz, Madrid, 28040, Spain
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, Spain
| | - M D Arenas
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain
| | - E González-Parra
- Fundación Renal Íñigo Álvarez de Toledo, Madrid, 28003, Spain.
- Instituto de Investigación Sanitaria Fundación Jimenez Díaz, Madrid, 28040, Spain.
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, Spain.
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Krüger T, Dellanna F, Kleophas W, Flader O, McClure C, Caiazzo M, Manfredini S. Safety and performance of the Clearum™ high flux hemodialyzer. Artif Organs 2024; 48:365-374. [PMID: 37962073 DOI: 10.1111/aor.14676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/03/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Clearum™ is a high flux steam sterilized dialyzer for patients with hemodialysis or hemodiafiltration. This study evaluated the safety and performance of the Clearum high flux steam sterilized hemodialyzer in the removal of small and middle-sized toxins. METHODS A prospective, interventional, nonrandomized study enrolled twenty end-stage renal disease patients undergoing hemodialysis. The Clearum high flux steam sterilized dialyzer was compared to Fresenius FX dialyzers for baseline comparison. The duration of the trial was 2 weeks for the FX dialyzer and 6 weeks with the Clearum high flux steam sterilized dialyzer. In vitro studies with dextrans of varying sizes were performed to compare the membrane characteristics and sieving coefficient curves for the two dialyzers. RESULTS The primary objective of a mean urea reduction ratio >65% was met, with no significant difference in mean urea reduction ratio between the Clearum high flux steam sterilized and Fresenius FX-series of dialyzers (p = 0.86). No dialyzer-related adverse events were reported in the study. β-2-microglobulin reduction with the Clearum high flux steam sterilized dialyzer was statistically higher than the FX-series dialyzer (66.5% vs. 53.6%; p < 0.0001). Predialysis interleukin-6 and C-reactive protein concentrations, blood-rest scores (residual blood after blood restitution), and thrombin-anti-thrombin values were comparable. Albumin remained stable during the 6 weeks of Clearum high flux steam sterilized dialyzer use, with no appreciable differences compared to the Fresenius FX-series. CONCLUSION The Clearum high flux steam sterilized dialyzer showed good mid-term effectivity for small and middle molecule removal with no reported dialyzer-related adverse events.
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Affiliation(s)
- Thilo Krüger
- Department of Nephrology, University Clinic of the RWTH Aachen, Aachen, Germany
- MVZ DaVita Geilenkirchen GmbH, Geilenkirchen, Germany
| | | | | | - Ons Flader
- MVZ DaVita Rhein-Ruhr GmbH, Duesseldorf, Germany
| | - Candace McClure
- North American Science Associates, Inc., Northwood, Ohio, USA
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5
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Delgado C, Powe NR, Chertow GM, Grimes B, Johansen KL. Muscle Mass and Serum Creatinine Concentration by Race and Ethnicity among Hemodialysis Patients. J Am Soc Nephrol 2024; 35:66-73. [PMID: 37822022 PMCID: PMC10786608 DOI: 10.1681/asn.0000000000000240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023] Open
Abstract
SIGNIFICANCE STATEMENT Serum creatinine is a product of skeletal muscle metabolism. Differences in serum creatinine concentration between Black and non-Black individuals have been attributed to differences in muscle mass but have not been thoroughly examined. Furthermore, other race and ethnic groups have not been considered. If differences in body composition explain differences in serum concentration by race or ethnicity, then estimates of body composition could be used in eGFR equations rather than race. Adjustment for intracellular water (ICW) as a proxy of muscle mass among patients with kidney failure in whom creatinine clearance should minimally influence serum concentration does not explain race- and ethnicity-dependent differences. BACKGROUND Differences in serum creatinine concentration among groups defined by race and ethnicity have been ascribed to differences in muscle mass. We examined differences in serum creatinine by race and ethnicity in a cohort of patients receiving hemodialysis in whom creatinine elimination by the kidney should have little or no effect on serum creatinine concentration and considered whether these differences persisted after adjustment for proxies of muscle mass. METHODS We analyzed data from 501 participants in the A Cohort Study to Investigate the Value of Exercise in ESKD/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESKD study who had been receiving hemodialysis for >1 year. We examined the independent associations among race and ethnicity (Black, Asian, non-Hispanic White, and Hispanic), serum creatinine, and ICW (L/m 2 ), a proxy for muscle mass, derived by whole-body multifrequency bioimpedance spectroscopy, using multivariable linear regression with adjustment for several demographic, clinical, and laboratory characteristics. We examined the association of race and ethnicity with serum creatinine concentration with and without adjustment for ICW. RESULTS Black, Asian, and Hispanic patients had higher serum creatinine concentrations (+1.68 mg/dl [95% confidence interval (CI), 1.09 to 2.27], +1.61 mg/dl [95% CI, 0.90 to 2.32], and +0.83 [95% CI, 0.08 to 1.57], respectively) than non-Hispanic White patients. Overall, ICW was associated with serum creatinine concentration (0.26 mg/dl per L/m 2 ICW; 95% CI, 0.006 to 0.51) but was not statistically significantly different by race and ethnicity. Black, Asian, and Hispanic race and ethnicity remained significantly associated with serum creatinine concentration after adjustment for ICW. CONCLUSION Among patients receiving dialysis, serum creatinine was higher in Black, Asian, and Hispanic patients than in non-Hispanic White patients. Differences in ICW did not explain the differences in serum creatinine concentration across race groups.
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Affiliation(s)
- Cynthia Delgado
- Division of Nephrology, University of California, San Francisco and Nephrology Section, San Francisco VA Medical Center, San Francisco, California
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco and Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Glenn M. Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University, Palo Alto, California
| | - Barbara Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Kirsten L. Johansen
- Department of Medicine, Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Balsamello C, Rombolà G, Costantino ML, Casagrande G. Can the response to dialysis treatment be predicted by using patient-specific modeling of fluid and solute exchanges? A multicentric evaluation. Artif Organs 2023; 47:1326-1341. [PMID: 36995361 DOI: 10.1111/aor.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/15/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Parametric multipool kinetic models were used to describe the intradialytic trends of electrolytes, breakdown products, and body fluids volumes during hemodialysis. Therapy customization can be achieved by the identification of parameters, allowing patient-specific modulation of mass and fluid balance across dialyzer, capillary, and cell membranes. This study wants to evaluate the possibility to use this approach to predict the patient's intradialytic response. METHODS 6 sessions of 68 patients (DialysIS© project) were considered. Data from the first three sessions were used to train the model, identifying the patient-specific parameters, that, together with the treatment settings and the patient's data at the session start, could be used for predicting the patient's specific time course of solutes and fluids along the sessions. Na+ , K+ , Cl- , Ca2+ , HCO3 - , and urea plasmatic concentrations and hematic volume deviations from clinical data were evaluated. RESULTS nRMSE predictive error is on average equal to 4.76% when describing the training sessions, and only increases by 0.97 percentage points on average in independent sessions of the same patient. CONCLUSIONS The proposed predictive approach represents a first step in the development of tools to support the clinician in tailoring the patient's prescription.
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Affiliation(s)
- Carlo Balsamello
- Department of Chemistry, Materials, and Chemical Engineering, Politecnico di Milano, Milano, Italy
| | - Giuseppe Rombolà
- Nephrology Dialysis and Kidney Transplant Unit, ASST-Settelaghi, Varese, Italy
| | - Maria Laura Costantino
- Department of Chemistry, Materials, and Chemical Engineering, Politecnico di Milano, Milano, Italy
| | - Giustina Casagrande
- Department of Chemistry, Materials, and Chemical Engineering, Politecnico di Milano, Milano, Italy
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Sadaati S, Daneshamouz S, Bahig J, Shoker A, Abdelrasoul A. In-Situ Synchrotron Imaging, Experimental, and Computational Investigations on the Efficiency of Trametes versicolor Laccase on Detoxification of P-Cresyl Sulfate (PCS) Protein Bound Uremic Toxin (PBUT). J Biotechnol 2023; 368:12-30. [PMID: 37004788 DOI: 10.1016/j.jbiotec.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023]
Abstract
Protein bound uremic toxins (PBUTs) are small substances binding to larger proteins, mostly human serum albumin (HSA), and are challenging to remove by hemodialysis (HD). Among different classes of PBUTs, p-cresyl sulfate (PCS) is the most widely used marker molecule and major toxin, as 95% is bound to HSA. PCS has a pro-inflammatory effect and increases both the uremia symptom score and multiple pathophysiological activities. High-flux HD to clear PCS leads to serious loss of HSA, which results in a high mortality rate. The goal of the present study is to investigate the efficacy of PCS detoxification in serum of HD patients using a biocompatible laccase enzyme from Trametes versicolor. Molecular docking was used to gain an in-depth understanding of the interactions between PCS and the laccase to identify the functional group(s) responsible for ligand-protein receptor interactions. UV-Vis spectroscopy and gas chromatography-mass spectrometry (GC-MS) were used to assess the detoxification of PCS. GC-MS was used to identify the detoxification byproducts and their toxicity was assessed using docking commutations. In situ synchrotron radiation micro-computed tomography (SR-µCT) imaging available at the Canadian Light Source (CLS) was conducted to assess HSA binding with PCS before and after detoxification with laccase and undertake the corresponding quantitative analysis. GC-MS analyses confirmed the detoxification of PCS with laccase at a concentration of 500mg/L. The potential pathway of PCS detoxification in the presence of the laccase was identified. Increasing laccase concentration led to the formation of m-cresol, as indicated by the corresponding absorption in the UV-Vis spectra and a sharp peak on the GC-MS spectra. Our analysis provides insight into the general features of PCS binding on Sudlow site II, as well as insights into PCS detoxification product interactions. The average affinity energy for detoxification products was lower than that of PCS. Even though some byproducts showed potential toxicity, the level was lower than for PCS based on toxicity indexes (e.g., LD50/LC50, carcinogenicity, neurotoxicity, mutagenicity). In addition, these small compounds can also be more easily removed by HD compared to PCS. SR-µCT quantitative analysis showed adhesion of the HSA to a significant reduced extent in the presence of the laccase enzyme in bottom sections of the polyarylethersulfone (PAES) clinical HD membrane tested. Overall, this study opens new frontiers for PCS detoxification.
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Sánchez-Tocino ML, Mas-Fontao S, Gracia-Iguacel C, Pereira M, González-Ibarguren I, Ortiz A, Arenas MD, Parra EG. A Sarcopenia Index Derived from Malnutrition Parameters in Elderly Haemodialysis Patients. Nutrients 2023; 15:nu15051115. [PMID: 36904114 PMCID: PMC10005100 DOI: 10.3390/nu15051115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/12/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
(1) Background: Persons with chronic kidney disease may have sarcopenia characterized by the loss of muscle mass and loss of muscle strength. However, EWGSOP2 criteria to diagnose sarcopenia are technically challenging, especially in elderly persons on hemodialysis. Sarcopenia may be associated with malnutrition. We aimed at defining a sarcopenia index derived from malnutrition parameters for use in elderly haemodialysis patients. (2) Methods: A retrospective study of 60 patients aged 75 to 95 years treated with chronic hemodialysis was conducted. Anthropometric and analytical variables, EWGSOP2 sarcopenia criteria and other nutrition-related variables were collected. Binomial logistic regressions were used to define the combination of anthropometric and nutritional parameters that best predict moderate or severe sarcopenia according to EWGSOP2, and performance for moderate and severe sarcopenia was assessed by the area under the curve (AUC) of receiver operating characteristic (ROC) curves. (3) Results: The combination of loss of strength, loss of muscle mass and low physical performance correlated with malnutrition. We developed regression-equation-related nutrition criteria that predicted moderate sarcopenia (elderly hemodialysis sarcopenia index-moderate, EHSI-M) and severe sarcopenia (EHSI-S) diagnosed according to EWGSOP2 with an AUC of 0.80 and 0.866, respectively. (4) Conclusions: There is a close relationship between nutrition and sarcopenia. The EHSI may identify EWGSOP2-diagnosed sarcopenia from easily accessible anthropometric and nutritional parameters.
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Affiliation(s)
| | - S. Mas-Fontao
- Servicio de Nefrología e Hipertensión, Fundación Jiménez Díaz, 28040 Madrid, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), 28029 Madrid, Spain
| | - C. Gracia-Iguacel
- Servicio de Nefrología e Hipertensión, Fundación Jiménez Díaz, 28040 Madrid, Spain
| | - M. Pereira
- Fundación Renal Íñigo Álvarez de Toledo, 28003 Madrid, Spain
| | - I. González-Ibarguren
- Servicio de Geriatría, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain
| | - A. Ortiz
- Servicio de Nefrología e Hipertensión, Fundación Jiménez Díaz, 28040 Madrid, Spain
| | - M. D. Arenas
- Fundación Renal Íñigo Álvarez de Toledo, 28003 Madrid, Spain
| | - E. González Parra
- Servicio de Nefrología e Hipertensión, Fundación Jiménez Díaz, 28040 Madrid, Spain
- Correspondence:
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9
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Aghsaeifard Z, Zendehdel A, Alizadeh R, Salehnasab A. Chronic hemodialysis: Evaluation of dialysis adequacy and mortality. Ann Med Surg (Lond) 2022; 76:103541. [PMID: 35495410 PMCID: PMC9052277 DOI: 10.1016/j.amsu.2022.103541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Dialysis efficacy is one of the important issues in patients undergoing hemodialysis. This study aimed to determine the adequacy of dialysis with mortality and hospital admissions in patients undergoing hemodialysis. Methods This retrospective cohort study was conducted on patients who underwent dialysis. Dialysis adequacy was measured based on the Kt/V criterion. Age, sex, disease etiology, duration of dialysis, and access dialysis were evaluated. Results 128 patients with a mean age of 61.48 ± 13.36 years were included in the study. 8 patients had a history of kidney transplantation. The mean dialysis time in the patients was 4.30 ± 3.39 years. The mean Kt/V in the patients was 1.40 ± 1.8 years. Of the 128 patients, 53 were hospitalized for cardiac or renal reasons. The number of fatalities was 9 cases out of 128. The cause of death in all the cases was heart problems. There was a statistically significant correlation between the adequacy of dialysis in terms of Kt/V and mortality, but it was not associated with hospitalization. Conclusion Inadequate dialysis in terms of Kt/V is likely to increase the rate of mortality among dialysis patients. Dialysis efficacy is one of the important issues in patients undergoing hemodialysis. Inadequate dialysis in terms of Kt/V is likely to increase the rate of mortality among dialysis patient. The findings showed that there was no significant correlation between the dialysis adequacy and hospitalization.
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Affiliation(s)
- Ziba Aghsaeifard
- Department of Internal Medicine, School of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Zendehdel
- Geriatrics Department, Ziaeian Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Family Medicine Department, Ziaeian Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Alizadeh
- Department of Anesthesiology and Intensive Care, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
- Corresponding author. AJA University of Medical Sciences, Tehran, Iran.
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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11
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Siga E, Cusumano C, Garcia M, Cusumano A. Twice-weekly hemodialysis in the time of COVID-19: a multicenter study in prevalent patients. Clin Kidney J 2021; 14:2134-2135. [PMID: 34471527 PMCID: PMC8344675 DOI: 10.1093/ckj/sfab115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Esteban Siga
- Centro de Dialisis Madariaga, Gral Juan Madariaga, Buenos Aires. Argentina
| | - Carlos Cusumano
- Instituto de Nefrologia, Department Hemodialysis, Pergamino, Buenos Aires, Argentina
| | - Mariano Garcia
- Centro de Estudios Nefro-Urológicos, Department Hemodialysis, Trenque Lauquen, Buenos Aires, Argentina
| | - Ana Cusumano
- Instituto de Nefrologia, Department Hemodialysis, Rojas, Buenos Aires, Argentina
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12
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Zou LX, Sun L, Hua RX, Wu Y. Serum Hepcidin-25 and All-Cause Mortality in Patients Undergoing Maintenance Hemodialysis. Int J Gen Med 2021; 14:3153-3162. [PMID: 34262329 PMCID: PMC8274829 DOI: 10.2147/ijgm.s313777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/16/2021] [Indexed: 12/18/2022] Open
Abstract
Background Hepcidin plays an important role in iron homeostasis, inhibits intestinal iron absorption and iron release from hepatocytes and macrophages, while its clinical utility remained unclear. This study aimed to investigate the associations between hepcidin-25 and mortality in MHD patients. Methods This was a prospective observational cohort of 161 MHD patients, with 2-year follow-up. We investigated the relationships between the variables in our dataset, including serum hepcidin-25, demographic characteristics as well as other clinical parameters. Results The median value of baseline serum hepcidin-25 was 31.0 (12.1, 57.3) ng/mL; therefore, the patients were stratified into two groups (low-level hepcidin-25 group, and high-level hepcidin-25 group). The serum iron, serum ferritin, transferrin saturation (TSAT), and hsCRP were higher, pre-dialysis creatinine and albumin were lower, and the scores of health-related qualities of life were worse in the high-level hepcidin-25 group than in the low-level hepcidin-25 group. Maximal information-based nonparametric exploration analysis suggested that serum hepcidin-25 was associated with ferritin, TSAT, and all-cause mortality. The patients with hepcidin-25<31 ng/mL had better survival outcomes than those with hepcidin-25≥31 ng/mL during the 24-month follow-up (Log rank test, P = 0.0017). For per 10ng/mL increase of serum hepcidin-25, the hazard ratio (HR) for all-cause mortality was 1.225 (95% confidence interval [CI]1.085-1.382, P<0.001), which remained significant after multivariate adjustments. Conclusion Serum hepcidin-25 was associated with ferritin and TSAT, and could be an independent predictor for all-cause mortality in MHD patients. Further research with larger sample size and longer-term follow-up is still needed.
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Affiliation(s)
- Lu-Xi Zou
- School of Management, Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Ling Sun
- Department of Nephrology, Xuzhou Central Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Rui-Xue Hua
- XuZhou Clinical School of Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Yu Wu
- XuZhou Clinical School of Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
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13
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Prevention of tunneled cuffed catheter dysfunction with prophylactic use of a taurolidine urokinase lock: A randomized double-blind trial. PLoS One 2021; 16:e0251793. [PMID: 34015014 PMCID: PMC8136626 DOI: 10.1371/journal.pone.0251793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/01/2021] [Indexed: 12/04/2022] Open
Abstract
Background The efficacy and cost-effectiveness of prophylactic thrombolytic locks in hemodialysis patients at high-risk of thrombotic dialysis catheter dysfunction is uncertain. We investigated this question in a double-blinded randomized controlled study. Methods Prevalent hemodialysis patients from 8 Belgian hemodialysis units, with ≥2 separate episodes of thrombotic dysfunction of their tunneled cuffed catheter during the 6 months before inclusion, were randomized to either: taurolidine heparin locks thrice weekly (control arm) or the same locks twice a week combined with taurolidine urokinase locks once a week before the longest interval without HD (TaurolockU arm). The primary efficacy outcome was the incidence rate of catheter thrombotic dysfunction requiring thrombolytic locks to restore function. Results 68 hemodialysis patients (32 controls, 36 urokinase) were followed during 9875 catheter days between May 2015 and June 2017. Incidence rate of thrombotic catheter dysfunction was 4.8 in TaurolockU vs 12.1/1000 catheter days in control group (rate ratio 0.39; 95%CI 0.23–0.64). 15/36 (42%) catheters in the treatment group required at least one therapeutic urokinase lock vs 23/32 (72%) in the control group (P = 0.012). The two groups did not differ significantly in catheter-related bloodstream infection and combined cost of prophylactic and therapeutic catheter locks. The TaurolockU group had a numerically higher number of episodes of refractory thrombosis. Conclusions Prophylactic use of urokinase locks is highly effective in reducing the number of thrombotic catheter dysfunctions in catheters with a history of recurring dysfunction. Prophylactic use of urokinase locks did not reduce the overall costs associated with catheter locks and was associated with a numerically higher number of episodes of refractory thrombosis. Trial registration ClinicalTrials.gov Identifier: NCT02036255.
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14
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François K, De Clerck D, Tonnelier A, Cambier ML, Orlando C, Jochmans K, Cools W, Wissing KM. Dialyzer Performance During Hemodialysis Without Systemic Anticoagulation Using a Heparin-Grafted Dialyzer Combined With a Citrate-Enriched Dialysate: Results of the Randomized Crossover Noninferiority EvoCit Study. Am J Kidney Dis 2021; 79:79-87.e1. [PMID: 33940113 DOI: 10.1053/j.ajkd.2021.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/06/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The EvoCit study was designed to evaluate performance of a heparin-grafted dialyzer during hemodialysis with and without systemic anticoagulation. STUDY DESIGN Randomized, crossover, noninferiority trial. Noninferiority was defined as a difference of≤10% for the primary outcome. SETTING & PARTICIPANTS Single hemodialysis center; 26 prevalent patients treated with 617 hemodialysis sessions. INTERVENTIONS Hemodialysis using a heparin-grafted dialyzer combined with a 1.0mmol/L citrate-enriched dialysate ("EvoCit") without systemic anticoagulation compared with hemodialysis performed with a heparin-grafted dialyzer with systemic heparin ("EvoHep"). Patients were randomly allocated to a first period of 4 weeks and crossed over to the alternative strategy for a second period of 4 weeks. OUTCOMES The primary end point was the difference in Kt/Vurea between EvoCit and EvoHep. Secondary end points were urea reduction ratio, middle molecule removal, treatment time, thrombin generation, and reduction in dialyzer blood compartment volume. RESULTS The estimated difference in Kt/Vurea between EvoCit and EvoHep was-0.03 (95% CI, -0.06 to-0.007), establishing noninferiority with mean Kt/Vurea of 1.47±0.05 (SE) for EvoCit and 1.50±0.05 for EvoHep. Noninferiority was also established for reduction ratios of urea and β2-microglobulin. Premature discontinuation of dialysis was required for 4.2% of sessions among 6 patients during EvoCit and no sessions during EvoHep. Effective treatment time was 236±5 minutes for EvoCit and 238±1 minutes for EvoHep. Thrombin generation was increased and there was greater reduction in dialyzer blood compartment volume after treatments with EvoCit compared with EvoHep. LIMITATIONS The effects of avoiding systemic anticoagulation on clinical outcomes were not evaluated. CONCLUSIONS EvoCit is noninferior to EvoHep with respect to solute clearance but results in a greater number of shortened treatments, more membrane clotting, and greater thrombin generation TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT03887468.
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Affiliation(s)
- Karlien François
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Dieter De Clerck
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Annelies Tonnelier
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Marie-Laure Cambier
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christelle Orlando
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kristin Jochmans
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Wilfried Cools
- Interfaculty Center Data processing & Statistics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Karl Martin Wissing
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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15
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Toth-Manikowski SM, Sirich TL, Meyer TW, Hostetter TH, Hwang S, Plummer NS, Hai X, Coresh J, Powe NR, Shafi T. Contribution of 'clinically negligible' residual kidney function to clearance of uremic solutes. Nephrol Dial Transplant 2020; 35:846-853. [PMID: 30879076 DOI: 10.1093/ndt/gfz042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 02/03/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Residual kidney function (RKF) is thought to exert beneficial effects through clearance of uremic toxins. However, the level of native kidney function where clearance becomes negligible is not known. METHODS We aimed to assess whether levels of nonurea solutes differed among patients with 'clinically negligible' RKF compared with those with no RKF. The hemodialysis study excluded patients with urinary urea clearance >1.5 mL/min, below which RKF was considered to be 'clinically negligible'. We measured eight nonurea solutes from 1280 patients participating in this study and calculated the relative difference in solute levels among patients with and without RKF based on measured urinary urea clearance. RESULTS The mean age of the participants was 57 years and 57% were female. At baseline, 34% of the included participants had clinically negligible RKF (mean 0.7 ± 0.4 mL/min) and 66% had no RKF. Seven of the eight nonurea solute levels measured were significantly lower in patients with RKF than in those without RKF, ranging from -24% [95% confidence interval (CI) -31 to -16] for hippurate, -7% (-14 to -1) for trimethylamine-N-oxide and -4% (-6 to -1) for asymmetric dimethylarginine. The effect of RKF on plasma levels was comparable or more pronounced than that achieved with a 31% higher dialysis dose (spKt/Vurea 1.7 versus 1.3). Preserved RKF at 1-year follow-up was associated with a lower risk of cardiac death and first cardiovascular event. CONCLUSIONS Even at very low levels, RKF is not 'negligible', as it continues to provide nonurea solute clearance. Management of patients with RKF should consider these differences.
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Affiliation(s)
| | - Tammy L Sirich
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Timothy W Meyer
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thomas H Hostetter
- Department of Medicine, Palo Alto Veterans Affairs Health Care System, Stanford University, Palo Alto, CA, USA
| | - Seungyoung Hwang
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Natalie S Plummer
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Xin Hai
- Department of Medicine, Palo Alto Veterans Affairs Health Care System, Stanford University, Palo Alto, CA, USA
| | - Josef Coresh
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Neil R Powe
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tariq Shafi
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
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16
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Rodriguez Cuellar CI, García de la Puente S, Hernández Moraria J, Bojórquez Ochoa A, Filler G, Zaltzman Grishevich S. High depression rates among pediatric renal replacement therapy patients: A cross-sectional study. Pediatr Transplant 2019; 23:e13591. [PMID: 31583800 DOI: 10.1111/petr.13591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/21/2019] [Accepted: 09/05/2019] [Indexed: 01/09/2023]
Abstract
Depression is common in pediatric chronic kidney disease (CKD) patients. Depression is associated with inferior long-term outcomes. There is a paucity of studies that evaluate depression and possible associated factors in children and adolescents requiring renal replacement therapy (RRT). Cross-sectional study using Children`s Depression Inventory in a cohort from a large urban center. Forty-seven pediatric RRT patients (26 female, 12 peritoneal dialysis (PD), 17 hemodialysis (HD), 18 after successful kidney transplantation (KTX)) with a mean age at the time of assessment of 13.9 ± 2.3 years. Symptoms of depression were found in 30 (64%, 11KTX, 11HD, 8PD) patients. We found no association with age, sex, renal function, dialysis adequacy markers, anemia, electrolytes, socioeconomical status, IQ, educational status of the child including school attendance and distance from the house to the hospital among HD patients. Significant differences only applied for age at diagnosis of CKD, RRT vintage and deceased donor for KTX. The group with depression had a higher age at diagnosis of CKD and less time on RRT than the group without depression. There was also a high rate of depression in KTX patients. In this cohort, depression was a common comorbidity of RRT in children and adolescents with RRT and also for KTX patients, even though biomarkers of kidney function and time for RRT are much improved.
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Affiliation(s)
- Carmen Inés Rodriguez Cuellar
- Instituto Nacional de Pediatría, México City, México.,Universidad Autónoma de México, México City, México.,The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, ON, Canada
| | | | | | - Aurora Bojórquez Ochoa
- Instituto Nacional de Pediatría, México City, México.,Universidad Autónoma de México, México City, México
| | - Guido Filler
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, ON, Canada.,Departments of Paediatrics, Medicine, and Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Samuel Zaltzman Grishevich
- Instituto Nacional de Pediatría, México City, México.,Universidad Autónoma de México, México City, México
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17
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Wang M, Obi Y, Streja E, Rhee CM, Chen J, Hao C, Kovesdy CP, Kalantar-Zadeh K. Impact of residual kidney function on hemodialysis adequacy and patient survival. Nephrol Dial Transplant 2019; 33:1823-1831. [PMID: 29688442 DOI: 10.1093/ndt/gfy060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/21/2018] [Indexed: 11/14/2022] Open
Abstract
Background Both dialysis dose and residual kidney function (RKF) contribute to solute clearance and are associated with outcomes in hemodialysis patients. We hypothesized that the association between dialysis dose and mortality is attenuated with greater RKF. Methods Among 32 251 incident hemodialysis patients in a large US dialysis organization (2007-11), we examined the interaction between single-pool Kt/V (spKt/V) and renal urea clearance (rCLurea) levels in survival analyses using multivariable Cox proportional hazards regression model. Results The median rCLurea and mean baseline spKt/V were 3.06 [interquartile range (IQR) 1.74-4.85] mL/min/1.73 m2 and 1.32 ± 0.28, respectively. A total of 7444 (23%) patients died during the median follow-up of 1.2 years (IQR 0.5-2.2 years) with an incidence of 15.4 deaths per 100 patient-years. The Cox model with adjustment for case-mix and laboratory variables showed that rCLurea modified the association between spKt/V and mortality (Pinteraction = 0.03); lower spKt/V was associated with higher mortality among patients with low rCLurea (i.e. <3 mL/min/1.73 m2) but not among those with higher rCLurea. The adjusted mortality hazard ratios (aHRs) and 95% confidence intervals of the low (<1.2) versus high (≥1.2) spKt/V were 1.40 (1.12-1.74), 1.21 (1.10-1.33), 1.06 (0.98-1.14), and 1.00 (0.93-1.08) for patients with rCLurea of 0.0, 1.0, 3.0 and 6.0 mL/min/1.73 m2, respectively. Conclusions Incident hemodialysis patients with substantial RKF do not exhibit the expected better survival at higher hemodialysis doses. RKF levels should be taken into account when deciding on the dose of dialysis treatment among incident hemodialysis patients.
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Affiliation(s)
- Mengjing Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Division of Nephrology, Department of Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Jing Chen
- Division of Nephrology, Department of Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Department of Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA
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18
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Citrate anion improves chronic dialysis efficacy, reduces systemic inflammation and prevents Chemerin-mediated microvascular injury. Sci Rep 2019; 9:10622. [PMID: 31337804 PMCID: PMC6650610 DOI: 10.1038/s41598-019-47040-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/25/2019] [Indexed: 12/04/2022] Open
Abstract
Systemic inflammation and uremic toxins (UT) determine the increased cardiovascular mortality observed in chronic hemodialysis (HD) patients. Among UT, the adipokine Chemerin induces vascular dysfunction by targeting both endothelial and vascular smooth muscular cells (EC and VSMC). As Citrate anion modulates oxidative metabolism, systemic inflammation and vascular function, we evaluated whether citrate-buffered dialysis improves HD efficiency, inflammatory parameters and chemerin-mediated microvascular injury. 45 patients were treated in sequence with acetate, citrate and, again, acetate-buffered dialysis solution (3 months per interval). At study admission and after each treatment switch, we evaluated dialysis efficacy and circulating levels of chemerin and different inflammatory biomarkers. In vitro, we stimulated EC and VSMC with patients’ plasma and we investigated the role of chemerin as UT. Citrate dialysis increased HD efficacy and reduced plasma levels of CRP, fibrinogen, IL6 and chemerin. In vitro, patients’ plasma induced EC and VSMC dysfunction. These effects were reduced by citrate-buffered solutions and paralleled by the decrease of chemerin levels. Consistently, chemerin receptor knockdown reduced EC and VSMC dysfunction. In conclusion, Switching from acetate to citrate improved dialysis efficacy and inflammatory parameters; in vitro, chemerin-induced EC and VSMC injury were decreased by using citrate as dialysis buffer.
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19
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Abstract
Dialyzer clearance of urea multiplied by dialysis time and normalized for urea distribution volume (Kt/Vurea or simply Kt/V) has been used as an index of dialysis adequacy since more than 30 years. This article reviews the flaws of Kt/V, starting with a lack of proof of concept in three randomized controlled hard outcome trials (RCTs), and continuing with a long list of conditions where the concept of Kt/V was shown to be flawed. This information leaves little room for any conclusion other than that Kt/V, as an indicator of dialysis adequacy, is obsolete. The dialysis patient might benefit more if, instead, the nephrology community concentrates in the future on pursuing the optimal dialysis dose that conforms with adequate quality of life and on factors that are likely to affect outcomes more than Kt/V. These include residual renal function, volume status, dialysis length, ultrafiltration rate, the number of intra-dialytic hypotensive episodes, interdialytic blood pressure, serum potassium and phosphate, serum albumin, and C reactive protein.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
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20
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Macías N, Abad S, Aragoncillo I, Hernández A, Torres E, Santos A, López Gómez JM, Luño J, Vega A. Body composition infuences the elimination of protein-bound uremic toxins in online hemodiafiltration. Nefrologia 2019; 39:434-436. [PMID: 30981460 DOI: 10.1016/j.nefro.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 09/03/2018] [Indexed: 12/01/2022] Open
Affiliation(s)
- Nicolás Macías
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España.
| | - Soraya Abad
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
| | - Inés Aragoncillo
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
| | - Andrés Hernández
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
| | - Esther Torres
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
| | - Alba Santos
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
| | | | - José Luño
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
| | - Almudena Vega
- Servicio de Nefrología, Hospital Gregorio Marañón, Madrid, España
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21
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Effect of Serum Hepcidin on Predicting Mortality in Hemodialysis Patients: A Prospective Cohort Study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2019. [DOI: 10.5812/ircmj.87091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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22
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Desai M, Mohamed A, Davenport A. A pilot study investigating the effect of pedalling exercise during dialysis on 6-min walking test and hand grip and pinch strength. Int J Artif Organs 2019; 42:161-166. [DOI: 10.1177/0391398818823761] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Haemodialysis patients are at an increased risk of sarcopenia. Physical inactivity is now recognised as a major cause of muscle wasting in haemodialysis patients. It is unclear as to what and how much exercise is required to show benefit. We therefore performed a pilot study of cycling during haemodialysis. Methods: Patients underwent a progressive submaximal individualised cycling exercise, 3× a week during haemodialysis for 4 months using bed-cycle ergometers. Body composition was measured by multifrequency segmental bioimpedance and muscle function by 6-min walking test, and hand grip strength and pinch strength. Results: In total, 56% of patients in a dialysis centre fulfilled exercise study inclusion criteria and 13 (72.2%) of 18 patients completed the exercise programme, with the mean age of 64.0 ± 16.6 years and 76.9% being male. The 6-min walking test increased following exercise from 349 ± 105 to 398 ± 94.2 m, p < 0.05, as did both hand grip strength and pinch strength, with 20.4 ± 9.1 versus 23.4 ± 9.9 kg, p < 0.01, and 4.3 ± 1.8 versus 5.9 ± 2.4 kg, p < 0.05, respectively. There were no changes in appendicular muscle mass or other body composition detected with bioimpedance in either the exercise group, or 21 control patients, propensity matched for body composition, comorbidity and frailty. Muscle strength did not change in the control group. Haemodialysis sessional Kt/Vurea was greater at the end of the exercise programme compared to controls (1.63 ± 0.63 vs 1.21 ± 0.12, p < 0.01). Conclusion: The majority of dialysis centre patients met our exercise study entry criteria and could potentially benefit from cycling during haemodialysis. We found that muscle function and strength improved after a 4-month, thrice weekly cycling exercise programme.
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Affiliation(s)
- Manasi Desai
- UCL Department of Nephrology, Royal Free Hospital, UCL Medical School, University College London, London, UK
| | - Ahmed Mohamed
- UCL Department of Nephrology, Royal Free Hospital, UCL Medical School, University College London, London, UK
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, UCL Medical School, University College London, London, UK
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23
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Macías N, Vega A, Abad S, Aragoncillo I, García-Prieto AM, Santos A, Torres E, Luño J. Middle molecule elimination in expanded haemodialysis: only convective transport? Clin Kidney J 2018; 12:447-455. [PMID: 31198548 PMCID: PMC6543970 DOI: 10.1093/ckj/sfy097] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/25/2022] Open
Abstract
Background New high-retention onset dialysers have shown improved efficacy in the elimination of uraemic toxins, and their depurative capacity has been compared with high convective volumes of online haemodiafiltration. Haemodialysis (HD) using high-flux membranes leads to convective transport by internal filtration [direct filtration (DF)/backfiltration (BF)] and allows the removal of middle molecules (MMs). The aim of this study was to assess solute transport mechanisms in expanded HD (HDx). Methods In 14 4-h HDx sessions with Theranova-500 dialysers under similar dialysis conditions (blood flow 400 mL/min, dialysate flow 700 mL/min, dialysate temperature 35.5°C), pressures at the inlet and outlet of both dialyser compartments (P bi, P bo, P di and P do) were collected hourly to estimate DF/BF volumes by semi-empirical methods. Uraemic toxins with various molecular weights were measured pre-dialysis, at 1 h (pre-filter and post-filter) and post-dialysis to calculate molecules' reduction over time and dialyser in vivo clearances. Results Ultrafiltration was 1.47 ± 0.9 L and Kt/V 1.74 ± 0.3. Hydrodynamic data (P bi: 259 ± 39, P bo: 155 ± 27, P di: 271 ± 30, P do: 145 ± 29 mmHg and oncotic pressure 22.0 ± 3.5 mmHg) allowed the estimation of DF/BF rates. DF flow ranged from 29.5 ± 4.2 to 31.3 ± 3.9 mL/min and BF flow ranged from 25.1 ± 2.3 to 23.4 ± 2.6 mL/min. The highest calculated DF volume was 7506.8 ± 935.3 mL/session. Diffusive clearances (K d) of all solutes were higher than their convective transport (all P < 0.001) except for prolactin (23 kDa) clearances, which showed no differences. Total clearances of all solutes were correlated with their K d (ρ = 0.899-0.987, all P < 0.001) and Kt/V correlated with all reduction rates (ρ = 0.661-0.941, P = 0.010 to <0.001). DF flow was only associated with urea (ρ = -0.793, P = 0.001), creatinine (ρ = -0.675, P = 0.008) and myoglobin clearance (ρ = 0.653, P = 0.011). Conclusion Results suggest that diffusive transport is a main mechanism of MM elimination in HDx. HDx offers an efficient depuration of MM without the need for high convective volumes.
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Affiliation(s)
- Nicolás Macías
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Alba Santos
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Esther Torres
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jose Luño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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24
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Falke LL, Maas SLN, Rosati S, Logtenberg SJJ. Dialysis associated β2-microglobulin amyloidosis occurs even in the era of high-flux dialyzers. Amyloid 2018; 25:265-266. [PMID: 30661416 DOI: 10.1080/13506129.2018.1531391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Lucas L Falke
- a Department of internal medicine, Diakonessenhuis Utrecht , Utrecht , The Netherlands.,b Department of pathology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Sybren L N Maas
- b Department of pathology , University Medical Center Utrecht , Utrecht , The Netherlands.,c Department of pathology, Diakonessenhuis Utrecht , Utrecht , The Netherlands
| | - Stefano Rosati
- d Department of Pathology , University Medical Center Groningen , Groningen , The Netherlands
| | - Susan J J Logtenberg
- e Department of internal medicine, Diakonessenhuis Utrecht , Bosboomstraat 1 , 3582 KE , Utrecht , The Netherlands.,f Dianet Dialysis Center , Utrecht , The Netherlands
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25
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Vanholder R, Gryp T, Glorieux G. Urea and chronic kidney disease: the comeback of the century? (in uraemia research). Nephrol Dial Transplant 2018; 33:4-12. [PMID: 28407121 DOI: 10.1093/ndt/gfx039] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 02/15/2017] [Indexed: 02/05/2023] Open
Abstract
Urea, a marker of uraemic retention in chronic kidney disease (CKD) and of adequacy of intradialytic solute removal, has traditionally been considered to be biologically inert. However, a number of recent experimental data suggest that urea is toxic at concentrations representative for CKD. First of all, at least five studies indicate that urea itself induces molecular changes related to insulin resistance, free radical production, apoptosis and disruption of the protective intestinal barrier. Second, urea is at the origin of the generation of cyanate, ammonia and carbamylated compounds, which as such all have been linked to biological changes. Especially carbamylation has been held responsible for post-translational protein modifications that are involved in atherogenesis and other functional changes. In observational clinical studies, these carbamylated compounds were associated with cardiovascular and overall morbidity and mortality. These findings shed new light on the validity of Kt/Vurea as a marker of dialysis adequacy. Yet, also the views that the kinetics of urea are not representative of the kinetics of several other uraemic retention solutes, and that urea cannot be held responsible for all complex metabolic and clinical changes responsible for the uraemic syndrome, still remain valid. Future efforts to improve the outcome of patients with CKD might be directed at further improving removal of solutes implied in the uraemic syndrome, including but not restricted to urea, also taking into account the impact of the intestine and (residual) renal function on solute concentration.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Tessa Gryp
- Laboratory for Bacteriology Research, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, Ghent, Belgium
| | - Griet Glorieux
- Laboratory for Bacteriology Research, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, Ghent, Belgium
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26
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Zou LX, Sun L. Forecast post-dialysis blood pressure in hemodialysis patients with intradialytic hypertension. Clin Exp Hypertens 2018; 41:571-576. [PMID: 30325241 DOI: 10.1080/10641963.2018.1523916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Intradialytic hypertension (IDH) is emerging as an important issue in maintenance hemodialysis (MHD) patients. This study aimed to discuss potential factors related to IDH and build forecasting models for post-dialysis blood pressure (BP) in MHD patients with IDH. Methods: A total of 266 MHD patients were enrolled, included 133 (50%) patients with IDH and 133 patients without IDH. The BP and pulse were determined and recorded over six consecutive dialysis treatments. Forecasting models were established by simple and multiple linear regressions. The Pearson correlation coefficient was used to estimate the association between the values of SBP at pre-HD, intra-HD and post-HD. Results: Lower levels of hemoglobin, albumin, folic acid and magnesium, higher levels of high sensitivity C-reactive protein, ferritin, and erythropoiesis-stimulating agents resistance index (ERI) were detected in the IDH patients. The IDH patients also had lower dry weight, ejection fraction of left ventricular (LVEF), higher interdialytic weight gain (IDWG, % post-HD body weight), and ventricular cardiothoracic ratio (CTR) than non-IDH patients. A linear relationship was revealed between intradialytic SBP in IDH patients, indicating that the pre-HD and intra-HD SBP were correlated with post-HD SBP. Furthermore, simple and multiple linear regression models were built to forecast the values of post-HD SBP in IDH patients. Conclusions: The chronic inflammation, poor IDWG control, LV diastolic dysfunction, as well as low serum folic acid and magnesium might be associated with increasing prevalence of IDH in MHD patients. Forecasting models for post-HD SBP could help to control hypertension during HD treatments.
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Affiliation(s)
- Lu-Xi Zou
- a School of Management , Zhejiang University , Hangzhou , Zhejiang , China
| | - Ling Sun
- b Department of Nephrology, Xuzhou Central Hospital , Medical College of Southeast University , Xuzhou , Jiangsu , China
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27
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Daugirdas JT. Eliminating the need for routine monthly postdialysis serum urea nitrogen measurement: A method for monitoring Kt/V and normalized protein catabolic rate using conductivity determined dialyzer clearance. Semin Dial 2018; 31:633-636. [PMID: 30311270 DOI: 10.1111/sdi.12750] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Many dialysis machines can compute dialyzer sodium clearances at multiple time points during a dialysis treatment using conductivity. For a given treatment, the average dialyzer sodium clearance (K), when combined with treatment time (t), and the estimated urea distribution volume (V, usually based on either anthropometry or bioimpedance), can be used to estimate Kt/V, an important measure of hemodialysis adequacy. While this conductivity-derived value for Kt/V correlates moderately with Kt/V calculated from predialysis and postdialysis serum urea nitrogen (SUN) values (urea reduction ratio, URR), the ultrafiltration volume, and session length it is, unfortunately, not sufficiently accurate to replace URR-based Kt/V. Here we underline the potential utility of an alternative method to estimate Kt/V (a variant of a technique originally proposed by Gotch and Levin and their colleagues) using conductivity-derived sodium clearance (K) that does not require routine measurement of the postdialysis SUN but which should closely track Kt/V computed in the usual fashion. The increased accuracy with the new method is explained by the use of a patient-specific value of V, which is an average value calculated from several dialysis sessions where both conductivity dialyzer clearance and predialysis and postdialysis SUN have been measured. Once this patient-specific conductivity/URR-based value for V has been determined, it can be used to calculate Kt/V for subsequent treatments in which conductivity-based dialyzer clearances are measured, but around which predialysis and postdialysis SUN values have not been obtained. (If the predialysis SUN values for such a subsequent treatment are also measured, then a normalized protein catabolic rate that closely tracks the value from conventional urea modeling, can also be determined.) By reducing the number of postdialysis SUN measurements needed to monitor hemodialysis adequacy this new method of estimating Kt/V by conductivity should save staff time and laboratory costs, increase patient and staff safety, and decrease error rates associated with improper postdialysis blood sampling technique.
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Affiliation(s)
- John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
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28
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Atherton JG, Hains DS, Bissler J, Pendley BD, Lindner E. Generation, clearance, toxicity, and monitoring possibilities of unaccounted uremic toxins for improved dialysis prescriptions. Am J Physiol Renal Physiol 2018. [PMID: 29537310 DOI: 10.1152/ajprenal.00106.2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Current dialysis-dosing calculations provide an incomplete assessment of blood purification. They exclude clearances of protein-bound uremic toxins (PB-UTs), such as polyamines, p-cresol sulfate, and indoxyl sulfate, relying solely on the clearance of urea as a surrogate for all molecules accumulating in patients with end-stage renal disease (ESRD). PB-UTs clear differently in dialysis but also during normal renal function. The kidney clears PB toxins via the process of secretion, whereas it clears urea through filtration. Herein, we review the clearance, accumulation, and toxicity of various UTs. We also suggest possible methods for their monitoring toward the ultimate goal of a more comprehensive dialysis prescription. A more inclusive dialysis prescription would retain the kidney-filtration surrogate, urea, and consider at least one PB toxin as a surrogate for UTs cleared through cellular secretion. A more comprehensive assessment of UTs that includes both secretion and filtration is expected to result in a better understanding of ESRD toxicity and consequently, to reduce ESRD mortality.
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Affiliation(s)
- James G Atherton
- Department of Biomedical Engineering, University of Memphis , Memphis, Tennessee.,Le Bonheur Children's Hospital , Memphis, Tennessee
| | | | - John Bissler
- Le Bonheur Children's Hospital , Memphis, Tennessee
| | - Bradford D Pendley
- Department of Biomedical Engineering, University of Memphis , Memphis, Tennessee
| | - Ernő Lindner
- Department of Biomedical Engineering, University of Memphis , Memphis, Tennessee
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29
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Kennedy C, Connaughton DM, Murray S, Ormond J, Butler A, Phelan E, Young J, Durack L, Flavin J, O'Grady M, O'Kelly P, Lavin P, Leavey S, Lappin D, Giblin L, Casserly L, Plant WD, Conlon PJ. Home haemodialysis in Ireland. QJM 2018; 111:225-229. [PMID: 29272506 DOI: 10.1093/qjmed/hcx249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Home haemodialysis (HHD) has the potential to impact positively on patient outcomes and health resource management. There has been rejuvenated international interest in HHD in recent years. AIM We aimed to review the activity and outcomes of the Irish HHD Programme since inception (2009-16). DESIGN Retrospective review. METHODS Patient data were collected using the national electronic Renal Patient database (eMEDRenal version 3.2.1) and individual centre records. All data were recorded in a coded fashion on a Microsoft Excel Spread-sheet and analysed with Stata SE software. RESULTS One hundred and one patients completed training and commenced HHD; a further fourty-five patients were assessed for HHD suitability but did not ultimately dialyse at home. Twenty patients switched to nocturnal HHD when this resource became available. The switch from conventional in-centre dialysis to HHD led to an increase in the mean weekly hours on haemodialysis (HD) and a reduction in medication burden for the majority of patients. The overall rate of arteriovenous fistula (AVF) as primary vascular access was 62%. Most HHD complications were related to access function or access-related infection. Over the 7-years, 29 HHD patients were transplanted and 9 patients died. No deaths resulted directly from a HHD complication or technical issue. CONCLUSIONS Patient and technique survival rates compared favourably to published international reports. However, we identified several aspects that require attention. A small number of patients were receiving inadequate dialysis and require targeted education. Ongoing efforts to increase AVF and self-needling rates in HD units must continue. Psychosocial support is critical during the transition between dialysis modalities.
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Affiliation(s)
- C Kennedy
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - D M Connaughton
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
| | - S Murray
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
| | - J Ormond
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
| | - A Butler
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
| | - E Phelan
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
| | - J Young
- Department of Nephrology, Tallaght Hospital, Dublin, Ireland
| | - L Durack
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - J Flavin
- Department of Nephrology, University Hospital Limerick, Limerick, Ireland
| | - M O'Grady
- Department of Nephrology, University Hospital Waterford, Waterford, Ireland
| | - P O'Kelly
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
| | - P Lavin
- Department of Nephrology, Tallaght Hospital, Dublin, Ireland
| | - S Leavey
- Department of Nephrology, University Hospital Waterford, Waterford, Ireland
| | - D Lappin
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - L Giblin
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - L Casserly
- Department of Nephrology, University Hospital Limerick, Limerick, Ireland
| | - W D Plant
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Health Service Executive Clinical Strategy and Programmes Division, National Renal Office, Ireland
| | - P J Conlon
- Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
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30
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Jones CB, Bargman JM. Should we look beyond Kt/V urea in assessing dialysis adequacy? Semin Dial 2018; 31:420-429. [PMID: 29573025 DOI: 10.1111/sdi.12684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only due to our changing and aging dialysis population but also to our evolving knowledge base. As nephrologists, we strive to achieve both quality and (often) quantity of life for our patients and we feel reassured when we have a quantifiable marker to show for our efforts. However, we suggest that adequate dialysis reaches far beyond the realms of attaining a particular biochemical result. Dialysis adequacy should encompass a more comprehensive assessment of patient well-being. This metric could comprise quality of life and patient-specified goals, sufficient small solute and middle molecule clearance, optimal blood pressure control, and effective bone-mineral balance, all in the context of minimizing mortality and morbidity, and a livable dialysis regimen for the patient.
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Affiliation(s)
- Clare B Jones
- Division of Nephrology, University Health Network, Toronto, Canada
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Canada
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31
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Rivara MB, Ravel V, Streja E, Obi Y, Soohoo M, Cheung AK, Himmelfarb J, Kalantar-Zadeh K, Mehrotra R. Weekly Standard Kt/V urea and Clinical Outcomes in Home and In-Center Hemodialysis. Clin J Am Soc Nephrol 2018; 13:445-455. [PMID: 29326306 PMCID: PMC5967669 DOI: 10.2215/cjn.05680517] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients undergoing hemodialysis with a frequency other than thrice weekly are not included in current clinical performance metrics for dialysis adequacy. The weekly standard Kt/Vurea incorporates treatment frequency, but there are limited data on its association with clinical outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used multivariable regression to examine the association of dialysis standard Kt/Vurea with BP and metabolic control (serum potassium, calcium, bicarbonate, and phosphorus) in patients incidental to dialysis treated with home (n=2373) or in-center hemodialysis (n=109,273). We further used Cox survival models to examine the association of dialysis standard Kt/Vurea with mortality, hospitalization, and among patients on home hemodialysis, transfer to in-center hemodialysis. RESULTS After adjustment for potential confounders, patients with dialysis standard Kt/Vurea <2.1 had higher BPs compared with patients with standard Kt/Vurea 2.1 to <2.3 (3.4 mm Hg higher [P<0.001] for home hemodialysis and 0.9 mm Hg higher [P<0.001] for in-center hemodialysis). There were no clinically meaningful associations between dialysis standard Kt/Vurea and markers of metabolic control, irrespective of dialysis modality. There was no association between dialysis standard Kt/Vurea and risk for mortality, hospitalization, or transfer to in-center hemodialysis among patients undergoing home hemodialysis. Among patients on in-center hemodialysis, dialysis standard Kt/Vurea <2.1 was associated with higher risk (adjusted hazard ratio, 1.11; 95% confidence interval, 1.07 to 1.14) and standard Kt/Vurea ≥2.3 was associated with lower risk (adjusted hazard ratio, 0.97; 95% confidence interval, 0.94 to 0.99) for death compared with standard Kt/Vurea 2.1 to <2.3. Additional analyses limited to patients with available data on residual kidney function showed similar relationships of dialysis and total (dialysis plus kidney) standard Kt/Vurea with outcomes. CONCLUSIONS Current targets for standard Kt/Vurea have limited utility in identifying individuals at increased risk for adverse clinical outcomes for those undergoing home hemodialysis but may enhance risk stratification for in-center hemodialysis.
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Affiliation(s)
- Matthew B. Rivara
- Kidney Research Institute, Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, Washington
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Alfred K. Cheung
- Division of Nephrology & Hypertension, University of Utah, Salt Lake City, Utah
| | - Jonathan Himmelfarb
- Kidney Research Institute, Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, Washington
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Rajnish Mehrotra
- Kidney Research Institute, Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, Washington
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Abstract
For the over 400,000 patients in the United States dependent on hemodialysis, arteriovenous (AV) access thrombosis may lead to missed dialysis sessions, inpatient admissions and the need for placement of temporary dialysis catheters. It is also the leading cause of permanent access loss. Percutaneous declotting is generally preferred over surgical thrombectomy. Various percutaneous approaches can be employed including the lyse-and-wait technique, thromboaspiration, pulse spray aided pharmacomechanical thrombolysis, and use of mechanical thrombectomy device.
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Affiliation(s)
- Keith Bertram Quencer
- Division of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
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Abstract
Hemodialysis treatment time and Kt/V can both be considered to be primary measures of hemodialysis adequacy, because when either goes to zero, mortality is certain in patients without residual kidney function. Treatment time is important, but it needs to be adjusted based on surface-area-normalized Kt/V, residual kidney function, and expected ultrafiltration rate. Rescaling dose of dialysis measured as Kt/V to body surface area prevents ultrashort dialysis in small patients, women, and children with minimal residual kidney function. Most if not all of the observational studies of associations between outcome and dialysis session length are probably confounded by dose targeting bias. Once adequate Kt/V (taking into account body surface area) has been provided, adequate dialysis time probably is most relevant in terms of limiting the need for a high fluid removal rate. The latter may adversely impact survival by causing recurrent ischemia to cardiovascular and other tissues. There is little high-quality evidence at this time to support a minimum 4-hour treatment time for all patients, regardless of body size, solute removal, or residual kidney function. On the other hand, there is little evidence that prolonging weekly treatment time up to 24 hours per week is harmful. The final decision regarding treatment time is best individualized, based on patient acceptability and experience, residual kidney function, body surface-area-normalized Kt/V, and expected ultrafiltration rate.
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Affiliation(s)
- John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Macías N, Santos García A, Vega Martínez A, Abad Estébanez S, Goicoechea Diezhandino M, López Gómez JM. Importance of Body Water in the Efficacy of Convective Solute Transport in Online Hemodiafiltration. Ther Apher Dial 2017; 21:88-95. [DOI: 10.1111/1744-9987.12486] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/21/2016] [Accepted: 08/03/2016] [Indexed: 01/02/2023]
Affiliation(s)
- Nicolás Macías
- Nephrology Department; Hospital Gregorio Marañón; Madrid Spain
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35
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El-Kateb S, Sridharan S, Farrington K, Fan S, Davenport A. A single weekly Kt/Vurea target for peritoneal dialysis patients does not provide an equal dialysis dose for all. Kidney Int 2016; 90:1342-1347. [DOI: 10.1016/j.kint.2016.07.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/11/2016] [Accepted: 07/14/2016] [Indexed: 10/21/2022]
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36
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Greenhall GHB, Davenport A. Screening for muscle loss in patients established on peritoneal dialysis using bioimpedance. Eur J Clin Nutr 2016; 71:70-75. [DOI: 10.1038/ejcn.2016.202] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 07/13/2016] [Accepted: 08/12/2016] [Indexed: 12/27/2022]
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Daugirdas JT. Solute solver ‘what if’ module for modeling urea kinetics. Nephrol Dial Transplant 2016; 31:1934-1937. [DOI: 10.1093/ndt/gfw311] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/04/2016] [Indexed: 11/13/2022] Open
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Lok CE, Perazella MA, Choi MJ. American Society of Nephrology Quiz and Questionnaire 2015: ESRD/RRT. Clin J Am Soc Nephrol 2016; 11:1313-1320. [PMID: 27094608 PMCID: PMC4934831 DOI: 10.2215/cjn.01280216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. During the 2015 meeting, the conference hall was once again overflowing with eager quiz participants. Topics covered by the experts included electrolyte and acid-base disorders, glomerular disease, ESRD and dialysis, and kidney transplantation. Complex cases representing each of these categories together with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of nephrology fellowship programs and nephrology fellows in the United States answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on the same series of case-oriented questions in a quiz. The audience compared their answers in real time using a cellphone application containing the answers of the nephrology fellows and training program directors. The results of the online questionnaire were displayed, and then, the quiz answers were discussed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces selected content of educational value for the readers of the Clinical Journal of the American Society of Nephrology Enjoy the clinical cases and expert discussions.
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Affiliation(s)
- Charmaine E. Lok
- Division of Nephrology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut; and
| | - Michael J. Choi
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
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Meijers B, Vanholder R. HEMO Revisited: Why Kt/Vurea Only Tells Part of the Story. J Am Soc Nephrol 2016; 27:3235-3237. [PMID: 27270443 DOI: 10.1681/asn.2016040417] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Björn Meijers
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium; .,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium; and
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
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Affiliation(s)
- John T. Daugirdas
- Department of Medicine; University of Illinois at Chicago; Chicago Illinois
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