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Wang M, Xiao J, Du Q, Zhang W, Zhang J, Yan Z, Luo J, Yu C, Ye Z, Chen J. Phosphorus balance calculator: an individualized tool for treatment of hyperphosphatemia in hemodialysis patients. Nephrol Dial Transplant 2024; 39:1159-1170. [PMID: 38037501 DOI: 10.1093/ndt/gfad256] [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: 07/29/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Lack of evaluations of the dietary phosphorus and dialysis phosphorus removal in daily clinical practice are common obstacles to assessing phosphorus balance and controlling phosphorus in hemodialysis patients. We aimed to investigate whether individualized therapy using a phosphorus balance calculator improves phosphorus control. METHODS A randomized, open-label, multicenter, 4-week clinical trial was conducted. A total of 119 maintenance hemodialysis patients aged 18-85 years old and with serum phosphorus level >1.45 mmol/L from three university teaching hospitals in Shanghai were enrolled. Patients were randomized in a 1:1 ratio to individualized therapy (n = 60) or conventional therapy (n = 59). The primary outcome was the serum phosphorus concentration after 4-week treatment. Secondary outcomes included the serum calcium and parathyroid hormone (PTH) concentrations, changes in serum phosphorus, calcium and PTH concentrations, and the proportion of patients achieving target ranges of serum phosphorus, calcium and PTH after 4-week treatment. RESULTS Among 119 randomized participants [mean age 62 years; 68 male (57%)], 116 completed the trial. Using the phosphorus balance calculator, the individualized group achieved a better phosphorus balance state and significantly reduced serum phosphorus (1.62 ± 0.45 mmol/L versus 1.85 ± 0.45 mmol/L, P = .006), increased the proportions of patients achieving target serum phosphorus range (41% versus 18%, P = .006) and had greater adjusted mean difference in change in serum phosphorus over the 4 weeks (-0.47 versus -0.23 mmol/L, P = .010) when compared with conventional therapy. No significant changes were observed in serum calcium and PTH levels, the proportion of patients achieving target serum calcium or PTH levels, or the adjusted mean difference of serum calcium and PTH levels over the treatment period. CONCLUSION Phosphorus balance calculator was proved to improve serum phosphorus control in patients undergoing maintenance hemodialysis, offering a new tool for managing hyperphosphatemia.
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Affiliation(s)
- Mengjing Wang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Xiao
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Qiuna Du
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Weichen Zhang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiaying Zhang
- Division of Nutrition, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhenwen Yan
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Chen Yu
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Zhibin Ye
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jing Chen
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Daugirdas JT. Comparison of modeled versus reported phosphate removal and modeled versus postdialysis serum phosphate levels in conventional hemodialysis. Semin Dial 2022. [PMID: 35829668 DOI: 10.1111/sdi.13112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/21/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND We compared predictions of phosphate removal by a 2-pool kinetic model with measured phosphate removal in spent dialysate as reported by others. METHODS Twenty-six studies were identified that reported phosphate removal in 35 groups of patients. In almost all studies, patients were dialyzed for close to 4 h (range 3 to 6 h). For each study, group mean values of predialysis serum phosphate, body size, dialyzer K0 A urea, blood and dialysate flow rates, and session lengths were input into the kinetic model. Predictions of group mean phosphate removal and postdialysis serum phosphate were compared with reported measured values. RESULTS Mean (by patient group) predicted phosphate removal was 931 ± 170 mg/treatment, somewhat higher (p < 0.001) than the reported measured value, 900 mg ± 287. The ratio of predicted/measured removal averaged 1.15 ± 0.427. In 5/35 patient groups (3/26 studies) the predicted/measured phosphate removal was greater than 1.50. If these groups were excluded, the mean measured phosphate removal was 990 mg versus 966 predicted, with a ratio of predicted/measured removal averaging 0.993. Measured group mean postdialysis serum phosphate values (reported in 25/35) were 2.64 ± 0.54, not significantly different from predicted (2.60 ± 0.24 mg/dl, p = NS). CONCLUSIONS For conventional 4-h dialysis treatments, phosphate removal and postdialysis serum phosphate values predicted by a 2-pool kinetic model are similar to reported measured values.
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Affiliation(s)
- John T Daugirdas
- Department of Medicine, Division of Nephrology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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3
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Safety and Efficacy of Short Daily Hemodialysis with Physidia S 3 System: Clinical Performance Assessment during the Training Period. J Clin Med 2022; 11:jcm11082123. [PMID: 35456216 PMCID: PMC9031690 DOI: 10.3390/jcm11082123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/04/2023] Open
Abstract
Background: A growing body of scientific evidence indicates that clinical outcomes of hemodialysis patients can be improved with short daily dialysis treatment. Current in-center hemodialysis machines do not fulfill the requirements needed for self-care home hemodialysis (HHD) treatment. In line with the reviviscence of home therapy, several hemodialysis devices have been developed and deployed for treatment. Physidia S3 is one of these new dialysis delivery systems featuring an appealing design and functionalities intended for daily HHD treatment. Methods: In this French multicenter proof-of-concept study enrolling 13 training centers, we report our preliminary experience with a special focus on quantifying clinical performances in short daily HHD treatment performed during the training period of the patients. Results: Among the 80 patients included in this study, a total of 249 sessions could be analyzed. Dialysis dose, estimated from weekly standardized Kt/V, was maintained at 2.22 [1.95–2.61] with a normalized protein catabolic rate of 0.93 [0.73–1.18] g/kg/24 h. Furthermore, anemia and nutritional status were adequately controlled as indicated by 11.6 ± 1.4 g/dL of hemoglobin level and 39.4 ± 5.7 g/L of serum albumin as well as electrolyte disorders. Conclusions: The safety and efficacy of the S3 therapy concept relying on a short daily hemodialysis treatment using a bagged delivery system are in total agreement with daily HHD recommendations. Clinical performances are aligned to the metabolic needs of the vast majority of HHD patients. Currently ongoing studies at home will provide further evidence and value of this therapeutic approach.
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Correa S, Scovner KM, Tumlin JA, Roy-Chaudhury P, Koplan BA, Costea AI, Kher V, Williamson D, Pokhariyal S, McClure CK, Mc Causland FR, Charytan DM. Electrolyte Changes in Contemporary Hemodialysis: A Secondary Analysis of the Monitoring in Dialysis (MiD) Study. KIDNEY360 2021; 2:695-707. [PMID: 34676372 PMCID: PMC8528069 DOI: 10.34067/kid.0007452020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a paucity of contemporary data examining electrolyte changes during and immediately after hemodialysis (HD), and their relationship with dialysate prescriptions. The present study examines these relationships. METHODS We analyzed patient- (n=66) and HD session-level pre- and post-dialysis laboratory data (n=1,713) over a six-month period from the Monitoring in Dialysis Study. We fit mixed effects regression models to analyze electrolyte, blood urea nitrogen, creatinine, and albumin levels immediately post-HD, accounting for pre-HD and dialysate prescriptions. In a subset of US patients (n=40), 15-minute post-HD and 30-minute post-HD values were available at one session. Predictive models were fit to estimate electrolyte levels immediately post-HD, accounting for pre-HD concentrations and dialysate prescriptions. RESULTS Serum bicarbonate, calcium, and albumin increased (mean increase 4.9±0.3 mEq/L, 0.7±0.1 mEq/L, and 0.4±0.03 g/dL, respectively), whereas potassium, magnesium, and phosphorus decreased immediately post-HD (mean -1.2±0.1 mEq/L, -0.3±0.03 mEq/L, and -3.0±0.2 mg/dL, respectively). Hypokalemia and hypophosphatemia were present in 40% of and 67% of immediate post-HD samples, respectively. Dynamic changes were observed in electrolyte concentrations at 15- and 30-minutes post-HD, compared to immediately post-HD. CONCLUSION We describe the magnitude of post-dialytic changes in serum electrolytes with contemporary HD, reporting a high incidence of electrolyte abnormalities post-HD, and present predictive nomograms relating electrolyte changes immediately post-HD to dialysate prescriptions. Our results may be useful for clinical care and provide insights for future research on dialysate prescriptions.
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Affiliation(s)
- Simon Correa
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Katherine Mikovna Scovner
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | | | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, North Carolina,W. G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
| | - Bruce A. Koplan
- Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Vijay Kher
- Medanta Kidney & Urology Institute, Medanta The Medicity, Haryana, India
| | - Don Williamson
- Southeastern Clinical Research Institute, Augusta, Georgia
| | | | | | - Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - David M. Charytan
- New York University School of Medicine and New York University Langone Medical Center, New York, New York
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Zhang W, Du Q, Xiao J, Bi Z, Yu C, Ye Z, Wang M, Chen J. Modification and Validation of the Phosphate Removal Model: A Multicenter Study. Kidney Blood Press Res 2021; 46:53-62. [PMID: 33477164 DOI: 10.1159/000511375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Our research group has previously reported a noninvasive model that estimates phosphate removal within a 4-h hemodialysis (HD) treatment. The aim of this study was to modify the original model and validate the accuracy of the new model of phosphate removal for HD and hemodiafiltration (HDF) treatment. METHODS A total of 109 HD patients from 3 HD centers were enrolled. The actual phosphate removal amount was calculated using the area under the dialysate phosphate concentration time curve. Model modification was executed using second-order multivariable polynomial regression analysis to obtain a new parameter for dialyzer phosphate clearance. Bias, precision, and accuracy were measured in the internal and external validation to determine the performance of the modified model. RESULTS Mean age of the enrolled patients was 63 ± 12 years, and 67 (61.5%) were male. Phosphate removal was 19.06 ± 8.12 mmol and 17.38 ± 6.75 mmol in 4-h HD and HDF treatments, respectively, with no significant difference. The modified phosphate removal model was expressed as Tpo4 = 80.3 × C45 - 0.024 × age + 0.07 × weight + β × clearance - 8.14 (β = 6.231 × 10-3 × clearance - 1.886 × 10-5 × clearance2 - 0.467), where C45 was the phosphate concentration in the spent dialysate measured at the 45th minute of HD and clearance was the phosphate clearance of the dialyzer. Internal validation indicated that the new model was superior to the original model with a significantly smaller bias and higher accuracy. External validation showed that R2, bias, and accuracy were not significantly different than those of internal validation. CONCLUSIONS A new model was generated to quantify phosphate removal by 4-h HD and HDF with a dialyzer surface area of 1.3-1.8 m2. This modified model would contribute to the evaluation of phosphate balance and individualized therapy of hyperphosphatemia.
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Affiliation(s)
- Weichen Zhang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiuna Du
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Jing Xiao
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Zhaori Bi
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Yu
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Zhibin Ye
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Mengjing Wang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China,
| | - Jing Chen
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Rastogi A, Bhatt N, Rossetti S, Beto J. Management of Hyperphosphatemia in End-Stage Renal Disease: A New Paradigm. J Ren Nutr 2020; 31:21-34. [PMID: 32386937 DOI: 10.1053/j.jrn.2020.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 12/12/2022] Open
Abstract
Bone and mineral metabolism becomes dysregulated with progression of chronic kidney disease (CKD), and increasing levels of parathyroid hormone serve as an adaptive response to maintain normal phosphorus and calcium levels. In end-stage renal disease, this response becomes maladaptive and high levels of phosphorus may occur. We summarize strategies to control hyperphosphatemia based on a systematic literature review of clinical trial and real-world observational data on phosphorus control in hemodialysis patients with CKD-mineral bone disorder (CKD-MBD). These studies suggest that current management options (diet and lifestyle changes; regular dialysis treatment; and use of phosphate binders, vitamin D, calcimimetics) have their own benefits and limitations with variable clinical outcomes. A more integrated approach to phosphorus control in dialysis patients may be necessary, incorporating measurement of multiple biomarkers of CKD-MBD pathophysiology (calcium, phosphorus, and parathyroid hormone) and correlation between diet adjustments and CKD-MBD drugs, which may facilitate improved patient management.
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Affiliation(s)
- Anjay Rastogi
- David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Nisha Bhatt
- Division of Nephrology, Department of Medical Affairs, Amgen Inc., Thousand Oaks, California
| | - Sandro Rossetti
- Division of Nephrology, Department of Medical Affairs, Amgen Inc., Thousand Oaks, California
| | - Judith Beto
- Division of Nephrology and Hypertension, Loyola University Chicago, Maywood, Illinois
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7
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Lübbe K, Nüsken E, Rascher K, von Gersdorff G, Cramer H, Samel C, Barth C, Bach D, Weber LT, Dötsch J. Glomerular disease patients have higher odds not to reach quality targets in chronic dialysis compared with CAKUT patients: analyses from a nationwide German paediatric dialysis registry. Pediatr Nephrol 2019; 34:1229-1236. [PMID: 30843113 DOI: 10.1007/s00467-019-04218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 02/08/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Paediatric dialysis patients still suffer from high morbidity rates. To improve this, quality assurance programs like the German QiNKid (Quality in Nephrology for Children)-Registry have been developed. In our study, the significance of underlying renal disease on a range of clinical and laboratory parameters impacting morbidity and mortality was analysed. Our aim was to evaluate whether or not disease-specific dialysis strategies should be considered in planning dialysis for a patient. METHODS Inclusion criteria were defined as follows: (1) CAKUT (congenital anomalies of the kidney and urinary tract) or glomerular disease patient, (2) < 18 years of age, (3) haemodialysis or peritoneal dialysis patient. Only measurements obtained from day 90 to 365 after the date of the first dialysis in the registry were analysed. Laboratory (serum albumin, haemoglobin, ferritin, calcium, phosphate, parathyroid hormone) and clinical parameters (height, blood pressure) were analysed using mixed effects models accounting for the correlation of repeated measures in individual patients. RESULTS The study cohort comprised n = 167 CAKUT and n = 55 glomerular disease patients. Glomerular disease patients had significantly higher odds of hypoalbuminemia (OR 13.90, 95% CI 1.35-159.99; p = 0.0274), anaemia (OR 3.31, 95% CI 1.22-9.13; p = 0.0197), hyperphosphatemia (OR 9.69, 95% CI 2.65-37.26; p = 0.0006) and diastolic hypertension (OR 3.38, 95% CI 1.20-9.79; p = 0.0212). CONCLUSIONS Glomerular disease patients might require more intensive dialysis regimens. The evaluation of hydration status should be given more attention, since conditions differing between the cohorts can be linked to overhydration. The QiNKid-Registry allows monitoring of the quality of paediatric dialysis in a nationwide cohort.
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Affiliation(s)
- Katrin Lübbe
- Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Eva Nüsken
- Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Katherine Rascher
- QiN-Group, Department of Medicine II, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gero von Gersdorff
- QiN-Group, Department of Medicine II, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Heyke Cramer
- QiN-Group, Department of Medicine II, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christina Samel
- Institute of Medical Statistics, Informatics and Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Claudia Barth
- KfH-Curatorium for Dialysis and Kidney Transplantation e.V., Neu-Isenburg, Germany
| | - Dieter Bach
- KfH-Curatorium for Dialysis and Kidney Transplantation e.V., Neu-Isenburg, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Jörg Dötsch
- Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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Abstract
BACKGROUND AND AIMS The efficacy of phosphate binders is difficult to be estimated clinically. This study analyzes the changes in serum phosphate and urinary phosphate excretion after the prescription of phosphate binders (PB) in patients with chronic kidney disease stage 4-5 pre-dialysis, and the usefulness of the ratio between total urinary phosphate and protein catabolic rate (Pu/PCR) for estimating the efficacy of PB. METHODS This retrospective observational cohort study included adult chronic kidney disease patients. Biochemical parameters were determined baseline and after 45-60 days on a low phosphate diet plus PB ("binder" subgroup=260 patients) or only with dietary advice ("control" subgroup=79 patients). RESULTS Phosphate load (total urinary excretion) per unit of renal function (Pu/GFR) was the best parameter correlated with serum phosphate levels (R2=0.61). Mean±SD level of Pu/PCR was 8.2±2.3mg of urinary phosphate per each g of estimated protein intake. After treatment with PB, serum phosphate levels decreased by 11%, urinary phosphate 22%, protein catabolic rate 7%, and Pu/PCR 15%. In the control subgroup, Pu/PCR increased by 20%. Urinary phosphate and urea nitrogen excretion correlated strongly, both baseline and after PB or dietary advice. CONCLUSIONS The proposed parameter Pu/PCR may reflect the rate of intestinal phosphate absorption, and therefore, its variations after PB prescription may be a useful tool for estimating the pharmacological efficacy of these drugs.
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Affiliation(s)
| | | | - Lilia Azevedo
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
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Elias RM, Alvares VRC, Moysés RMA. Phosphate Removal During Conventional Hemodialysis: a Decades-Old Misconception. Kidney Blood Press Res 2018; 43:110-114. [PMID: 29414834 DOI: 10.1159/000487108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/25/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Hyperphosphatemia is associated with high mortality rate in patients on dialysis. Conventional hemodialysis (HD) is a limit technique in removing phosphate (P). There is a widespread belief that P is removed mainly in the first hour of HD. The aim of this study was to certify the percentage of 1-hour removal of P as compared to the entire procedure. METHODS data from the first dialysis of the week of 21 patients (13 men, age 44±15 years), for 3 consecutive dialysis sessions were evaluated. Fresh dialysate samples were collected at 1 hour and at the end of the session from a partial spent dialysate collection method. RESULTS Pre dialysis serum P was 4.7±1.7 mg/dl. Reduction rate of serum P was 47.4 ± 14.3 and 45.1 ± 10.8% in 1- and 4-hour of HD, respectively (p=0.322). P removal was 194 (145, 242) mg in 1-hour (p<0.0001), which represents 25.0 ± 0.2% of the total removed during the entire HD. Patients with pre dialysis P ≥ 5.5mg/dl had higher P removal during HD than those with P < 5.5mg/dl [975 (587, 1354) vs. 776 (580, 784) mg, p=0.025], although the percentage of removal in 1 hour was not different from those with P < 5.5mg/d (24.9 ± 0.3 vs. 25.0 ± 0.1%, p=0.918). P removal during dialysis correlated with pre dialysis serum P (r=0.455, p=0.001), parathormone (r=0.264, p=0.037) and ultrafiltration volume (r=0.343, p=0.019). CONCLUSION despite the P serum concentration normalizing in the first hour of hemodialysis, the removal in the same period reaches only 25% of the entire session.
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Affiliation(s)
- Rosilene M Elias
- Department of Medicine, Renal Division, Universidade de São Paulo, São Paulo, Brazil
| | - Valeria R C Alvares
- Department of Medicine, Renal Division, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa M A Moysés
- Department of Medicine, Renal Division, Universidade de São Paulo, São Paulo, Brazil.,Universidade Nove de Julho, UNINOVE, São Paulo, Brazil
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Leypoldt JK, Agar BU, Akonur A, Gellens ME, Culleton BF. Steady State Phosphorus Mass Balance Model during Hemodialysis Based on a Pseudo One-Compartment Kinetic Model. Int J Artif Organs 2018. [DOI: 10.1177/039139881203501102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John K. Leypoldt
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Baris U. Agar
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Alp Akonur
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Mary E. Gellens
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Bruce F. Culleton
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
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11
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Affiliation(s)
| | - Vincent M. Lynch
- Department of Chemistry, The University of Texas at Austin, Austin TX, USA
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12
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Copland M, Komenda P, Weinhandl ED, McCullough PA, Morfin JA. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. Am J Kidney Dis 2016; 68:S24-S32. [DOI: 10.1053/j.ajkd.2016.05.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 12/17/2022]
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13
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Zheng CM, Zheng JQ, Wu CC, Lu CL, Shyu JF, Yung-Ho H, Wu MY, Chiu IJ, Wang YH, Lin YF, Lu KC. Bone loss in chronic kidney disease: Quantity or quality? Bone 2016; 87:57-70. [PMID: 27049042 DOI: 10.1016/j.bone.2016.03.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/18/2016] [Accepted: 03/28/2016] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) patients experience bone loss and fracture because of a specific CKD-related systemic disorder known as CKD-mineral bone disorder (CKD-MBD). The bone turnover, mineralization, and volume (TMV) system describes the morphological bone lesions in renal osteodystrophy related to CKD-MBD. Bone turnover and bone volume are defined as high, normal, or low, and bone mineralization is classified as normal or abnormal. All types of bone histology related to TMV are responsible for both bone quantity and bone quality losses in CKD patients. This review focuses on current bone quantity and bone quality losses in CKD patients and finally discusses potential therapeutic measures.
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Affiliation(s)
- Cai-Mei Zheng
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Jin-Quan Zheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan; Division of Pulmonary and Critical Care, Department of Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan
| | - Chia-Chao Wu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Lin Lu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Jia-Fwu Shyu
- Department of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan
| | - Hsu Yung-Ho
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - I-Jen Chiu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan
| | - Yuan-Hung Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan; Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yuh-Feng Lin
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Kuo-Cheng Lu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan; Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Cardinal-Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City,Taiwan.
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14
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Chapter 4.1: Treatment of CKD-MBD targeted at lowering high serum phosphorus and maintaining serum calcium. Kidney Int 2016; 76113:S50-99. [PMID: 26746397 DOI: 10.1038/ki.2009.192] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Watanabe Y, Kawanishi H, Suzuki K, Nakai S, Tsuchida K, Tabei K, Akiba T, Masakane I, Takemoto Y, Tomo T, Itami N, Komatsu Y, Hattori M, Mineshima M, Yamashita A, Saito A, Naito H, Hirakata H, Minakuchi J. Japanese society for dialysis therapy clinical guideline for "Maintenance hemodialysis: hemodialysis prescriptions". Ther Apher Dial 2015; 19 Suppl 1:67-92. [PMID: 25817933 DOI: 10.1111/1744-9987.12294] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Preventing/treating Hypophosphatemia by Adding Phosphate to the Dialysate. Int J Artif Organs 2015; 38:671-2. [DOI: 10.5301/ijao.5000453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 11/20/2022]
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Olowu WA. Pre-treatment considerations in childhood hypertension due to chronic kidney disease. World J Nephrol 2015; 4:500-510. [PMID: 26558187 PMCID: PMC4635370 DOI: 10.5527/wjn.v4.i5.500] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/25/2015] [Accepted: 10/08/2015] [Indexed: 02/06/2023] Open
Abstract
Hypertension (HTN) develops very early in childhood chronic kidney disease (CKD). It is linked with rapid progression of kidney disease, increased morbidity and mortality hence the imperative to start anti-hypertensive medication when blood pressure (BP) is persistently > 90th percentile for age, gender, and height in non-dialyzing hypertensive children with CKD. HTN pathomechanism in CKD is multifactorial and complexly interwoven. The patient with CKD-associated HTN needs to be carefully evaluated for co-morbidities that frequently alter the course of the disease as successful treatment of HTN in CKD goes beyond life style modification and anti-hypertensive therapy alone. Chronic anaemia, volume overload, endothelial dysfunction, arterial media calcification, and metabolic derangements like secondary hyperparathyroidism, hyperphosphataemia, and calcitriol deficiency are a few co-morbidities that may cause or worsen HTN in CKD. It is important to know if the HTN is caused or made worse by the toxic effects of medications like erythropoietin, cyclosporine, tacrolimus, corticosteroids and non-steroidal anti-inflammatory drugs. Poor treatment response may be due to any of these co-morbidities and medications. A satisfactory hypertensive CKD outcome, therefore, depends very much on identifying and managing these co-morbid conditions and HTN promoting medications promptly and appropriately. This review attempts to point attention to factors that may affect successful treatment of the hypertensive CKD child and how to attain the desired therapeutic BP target.
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Abstract
The control of serum phosphorus by dialysis is made difficult by the fact that intradialytic blood levels tend to be low, and because phosphorus is removed almost exclusively from the plasma during its passage through the dialyzer. The most practical way to increase phosphorus removal is to extend dialysis time, although attention to dialysis efficiency (surface area, advanced membrane, and higher blood and dialysate flow rates) also plays a role. Benefits of hemodiafiltration in helping control serum phosphorus have been claimed, but not found in all studies. Because serum phosphorus levels tend to plateau during the later parts of a dialysis session, extending weekly dialysis time is of greater benefit for phosphorus removal than for urea removal. Increasing dialysis frequency also probably has a small benefit. It appears that 18-30 hours of dialysis per week are required to obviate the need for phosphorus binders. Several promising models of phosphorus kinetics are under development. These may help predict the change in treatment on serum phosphorus levels, but their ability to do so has not yet been critically assessed.
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Affiliation(s)
- John T Daugirdas
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Sakaguchi Y, Fujii N, Shoji T, Hayashi T, Rakugi H, Iseki K, Tsubakihara Y, Isaka Y. Magnesium modifies the cardiovascular mortality risk associated with hyperphosphatemia in patients undergoing hemodialysis: a cohort study. PLoS One 2014; 9:e116273. [PMID: 25545498 PMCID: PMC4278867 DOI: 10.1371/journal.pone.0116273] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 12/08/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In vitro studies have shown inhibitory effects of magnesium (Mg) on phosphate-induced calcification of vascular smooth muscle cells, raising the possibility that maintaining a high Mg level may be useful for reducing cardiovascular risks of patients with hyperphosphatemia. We examined how serum Mg levels affect the association between serum phosphate levels and the risk of cardiovascular mortality in patients undergoing hemodialysis. METHODS A nationwide register-based cohort study was conducted using database of the Renal Data Registry of the Japanese Society for Dialysis Therapy in 2009. We identified 142,069 patients receiving in-center hemodialysis whose baseline serum Mg and phosphate levels were available. Study outcomes were one-year cardiovascular and all-cause mortality. Serum Mg levels were categorized into three groups (lower, <2.7 mg/dL; intermediate, ≥2.7, <3.1 mg/dL; and higher, ≥3.1 mg/dL). RESULTS During follow-up, 11,401 deaths occurred, out of which 4,751 (41.7%) were ascribed to cardiovascular disease. In multivariable analyses, an increase in serum phosphate levels elevated the risk of cardiovascular mortality in the lower- and intermediate-Mg groups, whereas no significant risk increment was observed in the higher-Mg group. Moreover, among patients with serum phosphate levels of ≥6.0 mg/dL, the cardiovascular mortality risk significantly decreased with increasing serum Mg levels (adjusted odds ratios [95% confidence intervals] of the lower-, intermediate-, and higher-Mg groups were 1.00 (reference), 0.81 [0.66-0.99], and 0.74 [0.56-0.97], respectively.). An interaction between Mg and phosphate on the risk of cardiovascular mortality was statistically significant (P = 0.03). CONCLUSION Serum Mg levels significantly modified the mortality risk associated with hyperphosphatemia in patients undergoing hemodialysis.
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Affiliation(s)
- Yusuke Sakaguchi
- Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Naohiko Fujii
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Tatsuya Shoji
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Hiromi Rakugi
- Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kunitoshi Iseki
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Yoshitaka Isaka
- Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
- * E-mail:
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Leypoldt JK, Agar BU, Culleton BF. Simplified phosphorus kinetic modeling: predicting changes in predialysis serum phosphorus concentration after altering the hemodialysis prescription. Nephrol Dial Transplant 2014; 29:1423-9. [DOI: 10.1093/ndt/gfu032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Ayus JC, Achinger SG, Negri AL. Weekly number of hours of treatment is critical when evaluating mortality in in-center daily dialysis. Kidney Int 2013; 84:409. [DOI: 10.1038/ki.2013.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Schachter ME, Chan CT. Current state of intensive hemodialysis: a comparative review of benefits and barriers. Nephrol Dial Transplant 2013; 27:4307-13. [PMID: 23235954 DOI: 10.1093/ndt/gfs506] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The current interest in intensive hemodialysis (HD) was born out of the impasse in an effort to improve survival and quality of life (QOL) in patients with end-stage renal disease. In this review, we have summarized the emerging data of intensive HD on (i) survival, (ii) cardiovascular outcomes, (iii) phosphate balance and (iv) QOL. Although there is a consistent and compelling signal favoring intensive HD, it is important to balance the enthusiasm with the significant amount of perceived and actual barriers for our patients to overcome to receive or perform intensive HD. For an individual patient, the answer to the question 'What is the best form of intensive hemodialysis?' should be a consideration between the benefits sought and the obstacles in attaining intensive HD. In the future, changes in dialysis technology, healthcare delivery and education strategy are needed to allow the majority of patients to receive optimal renal replacement therapy.
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Affiliation(s)
- Michael E Schachter
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Canada
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Abstract
Conventional, thrice-weekly hemodialysis (CHD) is the most commonly prescribed dialysis regimen. Despite widespread acceptance of CHD, long-term analyses of registry data have revealed an increased risk for mortality during the long 2-day interdialytic interval of thrice-weekly therapies. High mortality rates during this period suggest that there may be a role for more frequent HD in improving patient outcomes and survival through elimination of the long interdialytic period. Several regimens have been investigated including: short, daily HD, frequent nocturnal HD, and alternate-day HD. In this review, we provide an in-depth summary of current data comparing the effects of frequent and CHD modalities on survival, hospitalizations, vascular access complications, burden of therapy, quality of life, residual renal function, cardiovascular parameters, bone mineral metabolism, and anemia. Limitations of the data as well as the role of frequent dialysis in clinical practice are also discussed.
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Wester M, Simonis F, Gerritsen KG, Boer WH, Wodzig WK, Kooman JP, Joles JA. A regenerable potassium and phosphate sorbent system to enhance dialysis efficacy and device portability: an in vitro study. Nephrol Dial Transplant 2013; 28:2364-71. [DOI: 10.1093/ndt/gft205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Leypoldt JK, Akonur A, Agar BU, Culleton BF. Physiologic volume of phosphorus during hemodialysis: Predictions from a pseudo one-compartment model. Hemodial Int 2012; 16 Suppl 1:S15-9. [DOI: 10.1111/j.1542-4758.2012.00742.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- John K. Leypoldt
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
| | - Alp Akonur
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
| | - Baris U. Agar
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
| | - Bruce F. Culleton
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
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Achinger SG, Ikizler TA, Bian A, Shintani A, Ayus JC. Long-term effects of daily hemodialysis on vascular access outcomes: a prospective controlled study. Hemodial Int 2012; 17:208-15. [PMID: 23016876 DOI: 10.1111/j.1542-4758.2012.00756.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Daily hemodialysis has been associated with surrogate markers of improved survival among hemodialysis patients. A potential disadvantage of daily hemodialysis is that frequent vascular access cannulations may affect long-term vascular access patency. The study design was a 4-year, nonrandomized, contemporary control, prospective study of 77 subjects in either 3-h daily hemodialysis (six 3-h dialysis treatments weekly; n = 26) or conventional dialysis (three 4-h dialysis treatments weekly; n = 51). Outcomes of interest were vascular access procedures (fistulagram, thrombectomy and access revision). Total access procedures (fistulagram, thrombectomy and access revision) were 543.2 (95% confidence interval [CI]: 432.9, 673.0) per 1000 person-years in the conventional dialysis group vs. 400.8 (95% CI: 270.2, 572.4) per 1000 person-years in the daily hemodialysis dialysis group (incidence rate ratio = 0.74 with 95% CI: from 0.40 to 1.36, P = 0.33), after adjusting for age, gender, diabetes status, serum phosphorus, hemoglobin level and erythropoietin dose, there was no significant differences in incidence rate of total access procedures (P-value > 0.05). There was no difference in time to first access revision between the daily dialysis and the conventional dialysis groups after adjustment for covariates (hazard ratio = 0.99 95% CI: 0.42, 2.36, P = 0.96). Daily hemodialysis is not associated with increased vascular access complications, or increased vascular access failure rates.
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Wang M, Li H, Liao H, Yu Y, You L, Zhu J, Huang B, Yuan L, Hao C, Chen J. Phosphate removal model: an observational study of low-flux dialyzers in conventional hemodialysis therapy. Hemodial Int 2012; 16:363-76. [PMID: 22360645 DOI: 10.1111/j.1542-4758.2012.00678.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Precise assessing phosphate removal by hemodialysis (HD) is important to improve phosphate control in patients on maintenance HD. We reported a simple noninvasive model to estimate phosphate removal within a 4-hour HD. One hundred sixty-five patients who underwent HD 4 hours per session using low-flux dialyzers made of polysulfone (1.2 m(2)) or triacetate (1.3 m(2)) were enrolled. Blood flows varied from 180 to 300 mL/min. Effluent dialysate samples were collected during the 4-hour HD treatment to measure the total phosphate removal. Predialysis levels of serum phosphate, potassium, hematocrit, intact parathyroid hormone, total carbon dioxide (TCO(2)), alkaline phosphatase, clinical and dialysis characteristics were obtained. One hundred thirty-five observations were randomly selected for model building and the remaining 30 for model validation. Total amount of phosphate removal within the 4-hour HD was mostly 15-30 mmol. A primary model (model 1) predicting total phosphate removal was Tpo(4) = 79.6 × C(45) (mmol/L) - 0.023 × age (years) + 0.065 × weight (kg) - 0.12 × TCO(2) (mmol/L) + 0.05 × clearance (mL/min) - 3.44, where C(45) was phosphate concentration in spent dialysate measured at the 45 minute of HD and clearance was phosphate clearance of dialyzer in vitro conditions offered by manufacturer's data sheet. Since the parameter TCO(2) needed serum sample for measurement, we further derived a noninvasive model (model 2):Tpo(4) = 80.3 × C(45) - 0.024 × age + 0.07 × weight + 0.06 × clearance - 8.14. Coefficient of determination, root mean square error, and residual plots showed the appropriateness of two models. Model validation further suggested good and similar predictive ability of them. This study derived a noninvasive model to predict phosphate removal. It applies to patients treated by 4-hour HD under similar conditions.
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Affiliation(s)
- Mengjing Wang
- Division of Nephrology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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KJELLSTRAND CM, ING TS, KJELLSTRAND PT, ODAR-CEDERLOF I, LAGG CRB. Phosphorus dynamics during hemodialysis. Hemodial Int 2011; 15:226-33. [DOI: 10.1111/j.1542-4758.2011.00538.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hoppe A, von Puttkamer C, Linke U, Kahler C, Booss M, Braunauer-Kolberg R, Hofmann K, Joachimsky P, Hirte I, Schley S, Utsch B, Thumfart J, Briese S, Gellermann J, Zimmering M, Querfeld U, Müller D. A hospital-based intermittent nocturnal hemodialysis program for children and adolescents. J Pediatr 2011; 158:95-9, 99.e1. [PMID: 20691454 DOI: 10.1016/j.jpeds.2010.06.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Revised: 05/20/2010] [Accepted: 06/22/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To establish a hospital-based nocturnal hemodialysis (NHD) program for children and adolescents. STUDY DESIGN Sixteen patients (age, 0.5 to 17 years) were prospectively included. Uremia-associated measures as well as amount and dosage of medication were enumerated. Quality of life also was evaluated. Results were compared with data of the same patients on conventional hemodialysis and with matched control subjects (conventional HD). RESULTS NHD was well tolerated. Median Kt/V values increased. Predialytic mean arterial pressure, urea, phosphate, and parathyroid hormone levels decreased. There was an increase in protein catabolic rate. Dietary and fluid restrictions could be lifted. Amount and dosage of phosphate and potassium binders and antihypertensive medication could be reduced. Quality of life improved and days of absence from school decreased in all patients. CONCLUSIONS In addition to a better control of uremia-associated measures, NHD allows free dietary and fluid intake and improves patient well-being. Given the continuing shortage of donor organs for kidney transplantation and the high morbidity and mortality on conventional HD, intensified dialysis regimens are a much-needed therapeutic option.
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Affiliation(s)
- Anne Hoppe
- Charité, Department of Pediatric Nephrology, Berlin, Germany
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Gutiérrez OM, Wolf M. Dietary phosphorus restriction in advanced chronic kidney disease: merits, challenges, and emerging strategies. Semin Dial 2010; 23:401-6. [PMID: 20557490 DOI: 10.1111/j.1525-139x.2010.00750.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hyperphosphatemia is an independent risk factor for mortality in patients on maintenance dialysis. Since phosphorus clearance by standard three times-weekly dialysis is insufficient to balance ongoing dietary phosphorus intake, strategies to prevent absorption of dietary phosphorus are essential for attenuating increased serum levels. Dietary phosphorus binders are used widely for this purpose but dietary phosphorus restriction is relatively underutilized, most likely because of the logistical complexity of instituting and monitoring a low phosphorus diet, and for fear of worsening protein-energy wasting, which itself is a potent risk factor for mortality. In this review, we propose sustainable strategies for reducing phosphorus intake while avoiding exacerbation of protein-energy wasting. The approach is based on recognition of the dissociation between protein and phosphorus content in phosphorus-rich processed foods and the varying phosphorus bioavailability in different dietary sources. Controlling serum phosphate levels is among the most challenging aspects of day-to-day dialysis care but integration of sensible dietary interventions will likely improve phosphorus control.
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Affiliation(s)
- Orlando M Gutiérrez
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
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Naves-Díaz M, Passlick-Deetjen J, Guinsburg A, Marelli C, Fernández-Martín JL, Rodríguez-Puyol D, Cannata-Andía JB. Calcium, phosphorus, PTH and death rates in a large sample of dialysis patients from Latin America. The CORES Study. Nephrol Dial Transplant 2010; 26:1938-47. [PMID: 20513773 DOI: 10.1093/ndt/gfq304] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Mineral metabolism parameters may play a role in the survival of patients with chronic kidney disease (CKD). METHODS In the CORES Study, we analysed the association between calcium, phosphorus and PTH and mortality (all-cause and cardiovascular) in 16 173 haemodialysis (HD) patients over 18 years from six Latin American countries, who underwent haemodialysis up to 54 months. Unadjusted, case-mix-adjusted and time-dependent multivariable-adjusted hazard ratio (HR) of death were calculated for categories of serum albumin-corrected calcium (Ca(Alb)), phosphorus and PTH using as 'reference values' the range in which the lowest death rate was observed. Age, gender, vitamin D treatment, diabetes, vintage, vascular access, weight, blood pressure and laboratory variables (serum albumin, haemoglobin, creatinine, ferritin and Kt/V) were used as confounding variables. RESULTS Low (<9.5 mg/dL) and high (>10.5 mg/dL) Ca(Alb) increased the HR for all-cause mortality. Low (<9.0 mg/dL) Ca(Alb) increased the HR for cardiovascular mortality. High phosphorus (>5.5 mg/dL) increased the HR for both all-cause and cardiovascular mortality. Low phosphorus (<4.0 and <3.0 mg/dL) increased the HR for both all-cause and cardiovascular mortality. Furthermore, low (<150 pg/mL) and high (>500 and >300 pg/mL) PTH increased the HR for both all-cause and cardiovascular mortality. In addition, only phosphorus >6.0 mg/dL increased the HR for cardiovascular hospitalizations. No effect was observed with Ca(Alb) or PTH. CONCLUSIONS In summary, in 16,173 HD patients, elevated and reduced serum levels of albumin-corrected calcium, phosphorus and PTH levels were associated with increments in all-cause mortality. Similar results were obtained when only cardiovascular mortality was analysed.
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Affiliation(s)
- Manuel Naves-Díaz
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Universidad de Oviedo, Julián Claveria s/n, 33006 Oviedo, Spain
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Abstract
The typical dialysis patient faces both a poor quality of life and a significantly shortened survival. This is often blamed on "uremia." However, defining the clinical entity of uremia is surprisingly difficult. It represents the clinical sequelae of the effects of retention products, other effects of renal disease, and the effects of other comorbid conditions. The list of retention products that could act as uremic toxins is lengthy, but it would appear that urea itself does not contribute significantly to the uremic state. Larger molecular weight substances are likely the major contributors to the uremic milieu. Regardless of the causes, the uremic state persists in many patients who are reaching their dialysis adequacy targets as defined by urea clearance. This raises the possibility that more intensive hemodialysis could improve patient outcomes. Hemodialysis can be intensified by increasing dialysis efficiency without changing duration or frequency. Alternatively, hemodialysis duration, frequency, or both can be increased. All intensification methods increase small solute removal, but the removal of larger molecular weight retention products depends more upon treatment time. Modalities such as short daily hemodialysis, long intermittent hemodialysis, and quotidian nocturnal hemodialysis have been associated with a variety of clinical improvements, as well as improvements in quality of life and a lower standardized mortality ratio. However, the HEMO study approach of intensifying small solute clearance without significant modifications of the dialysis schedule does not appear to be effective. Future research will help to define the optimal treatment duration and frequency in hemodialysis patients.
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Achinger SG, Mizani MR, Ayus JC. Use of 3-hour daily hemodialysis and paricalcitol in patients with severe secondary hyperparathyroidism: A case series. Hemodial Int 2010; 14:193-9. [PMID: 20337743 DOI: 10.1111/j.1542-4758.2009.00424.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with poor metabolic control receiving conventional hemodialysis are at risk for developing severe secondary hyperparathyroidism. We postulated that daily hemodialysis may be effective at controlling parathyroid hormone (PTH) in the setting of severe secondary hyperparathyroidism by improving the control of hyperphosphatemia and allowing increased use of vitamin D analogs. We present 5 patients with severe secondary hyperparathyroidism (median iPTH=1783 pg/mL) who were treated with 3-hour daily hemodialysis (3 hours x 6 times a week). Daily hemodialysis, at 1 year, was associated with a 70.4% reduction in median PTH (1783 pg/mL [interquartile range: 1321-1983]-472 pg/mL [334, 704], P<0.001). Additionally, there was an increase in paricalcitol dose from 0 mcg/d to 10.8 (2.00, 11.7) mcg/d, a 39% reduction in calcium x phosphorus product (80.3 +/- 26.8-48.9 +/- 14.0, P<0.01), a 52% reduction in serum phosphorus (9.90 +/- 2.34-4.75 +/- 0.79 mg/dL, P<0.0001), and a 17.6% increase in serum calcium (8.18 +/- 2.04-9.62 +/- 0.93 mg/dL, P<0.01). Three-hour daily hemodialysis with the use of high-dose paricalcitol is associated with improved control of severe secondary hyperparathyroidism.
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Penne EL, van der Weerd NC, van den Dorpel MA, Grooteman MP, Lévesque R, Nubé MJ, Bots ML, Blankestijn PJ, ter Wee PM. Short-term Effects of Online Hemodiafiltration on Phosphate Control: A Result From the Randomized Controlled Convective Transport Study (CONTRAST). Am J Kidney Dis 2010; 55:77-87. [PMID: 19962805 DOI: 10.1053/j.ajkd.2009.09.023] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 09/24/2009] [Indexed: 12/21/2022]
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Greene T, Daugirdas JT, Depner TA, Gotch F, Kuhlman M. Solute Clearances and Fluid Removal in the Frequent Hemodialysis Network Trials. Am J Kidney Dis 2009; 53:835-44. [DOI: 10.1053/j.ajkd.2008.12.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 12/26/2008] [Indexed: 11/11/2022]
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Bugeja A, Dacouris N, Thomas A, Marticorena R, McFarlane P, Donnelly S, Goldstein M. In-center nocturnal hemodialysis: another option in the management of chronic kidney disease. Clin J Am Soc Nephrol 2009; 4:778-83. [PMID: 19339410 DOI: 10.2215/cjn.05221008] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Some patients are not optimally treated by conventional in-center hemodialysis (HD) and are unable to perform home HD. We examined the effect of in-center thrice-weekly nocturnal HD (INHD) on patient outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients who were not optimally treated on conventional HD were offered INHD. Thirty-nine patients' laboratory data and medication use were analyzed for the 12 mo before and after conversion to INHD until September 1, 2007. Quality of life on conventional HD and INHD was compared. RESULTS After conversion to INHD, median values for phosphorus decreased from 5.9 to 3.7 mg/dl (P < 0.01), alkaline phosphatase level increased from 84 to 161 U/L (P < 0.01), and percentage reduction in urea increased from 74 to 89% (P < 0.01). The mean number of antihypertensive drugs prescribed declined from 2.0 to 1.5 (P < 0.05) during the course of INHD, and the mean daily dosage of phosphate binders declined from 6.2 to 4.9 at study end (P < 0.05). There was a significant reduction in erythropoietin-stimulating agent use of 1992 U/wk (P < 0.01). There was no significant change in median hemoglobin, iron saturation, corrected calcium, or parathyroid hormone levels. Overall, quality of life, sleep, intradialytic cramps, appetite, and energy level all improved significantly on INHD. CONCLUSIONS INHD offers an effective form of HD for long-term dialysis patients who are unable to perform home HD.
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Affiliation(s)
- Ann Bugeja
- Department of Medicine, Ottawa Hospital, Division of Nephrology, Kidney Research Centre, University of Ottawa, Ottawa, Canada.
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Zsom L, Zsom M, Fulop T, Flessner MF. Treatment time, chronic inflammation, and hemodynamic stability: the overlooked parameters in hemodialysis quantification. Semin Dial 2009; 21:395-400. [PMID: 18945325 DOI: 10.1111/j.1525-139x.2008.00488.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Decades after the introduction of chronic maintenance hemodialysis, the optimal means of quantifying dialysis dose remains controversial. Differences of opinion in the international dialysis community lead to substantial diversity in everyday clinical practice. Several studies suggest that the well-recognized international mortality differences in hemodialysis populations may result from these divergent approaches to dialysis care. One of the main areas of divergence is the different degree of reliance on dialysis clearance when prescribing dialysis. The "clearance approach" implies that treatment quality is primarily dependent on efficient removal of uremic toxins as estimated by dialytic urea clearance. Urea can be rapidly removed by high efficiency dialysis in a relatively short time. The main alternative to this strategy is the "time approach" based on the recognition that longer or more frequent dialysis provides benefits beyond increasing urea removal. Some of the putative benefits are more effective volume and blood pressure control, better maintenance of hemodynamic stability because of slower ultrafiltration and removal of uremic toxins that do not behave like urea. Recently, chronic inflammation has been proposed to be an important predictor of outcome in dialysis patients. Inflammatory markers are commonly elevated in chronic renal failure and levels of these seem to correlate with malnutrition, maintenance of residual renal function, and volume control. The relationships between dialysis clearance, treatment time, chronic inflammation, volume control, and hemodynamic stability are explored in this review. We propose that a better understanding of these complex relationships may provide opportunities for improving outcomes of maintenance hemodialysis patients.
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Jaber BL, Finkelstein FO, Glickman JD, Hull AR, Kraus MA, Leypoldt JK, Liu J, Gilbertson D, McCarthy J, Miller BW, Moran J, Collins AJ. Scope and Design of the Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements (FREEDOM) Study. Am J Kidney Dis 2009; 53:310-20. [DOI: 10.1053/j.ajkd.2008.07.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2007] [Accepted: 07/24/2008] [Indexed: 11/11/2022]
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The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessions. ACTA ACUST UNITED AC 2008; 5:34-44. [PMID: 19030001 DOI: 10.1038/ncpneph0979] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 09/12/2008] [Indexed: 01/01/2023]
Abstract
The duration and frequency of hemodialysis was determined empirically when this therapy first came into use, and treatment was commonly three 8 h sessions per week by the end of the 1960s. Subsequently, however, the growing number of patients who required this therapy had to be reconciled with the shortage of equipment; therefore, dialysis time was decreased to three 4 h sessions per week. At the same time, on the basis of data from the first randomized controlled trial of dialysis -- the National Cooperative Dialysis Study -- Kt/V(urea) was devised as the optimum measure of dialysis adequacy. Nowadays, although Kt/V(urea) targets are fulfilled in an increasing number of patients, observational studies show that individuals on hemodialysis continue to experience a high rate of complications, including hypertension, left ventricular hypertrophy, cardiac failure, hyperphosphatemia, malnutrition and death. Although no randomized controlled trial has yet been published, observational data indicate that increasing hemodialysis time and/or frequency improves a number of these complications, especially the death rate. This Review outlines the advantages of longer and/or more frequent dialysis sessions and highlights the barriers to adoption of such regimens, which largely relate to economics, patient willingness, and organization of dialysis units.
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Novak JE, Szczech LA. Phosphate binders in chronic kidney disease and end-stage renal disease: a patient-centered approach. Semin Dial 2008; 22:56-63. [PMID: 19000107 DOI: 10.1111/j.1525-139x.2008.00514.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Disorders of calcium and phosphorus metabolism are associated with significant morbidity and mortality in patients with advanced chronic kidney disease. These patients typically require oral phosphate binders to maintain phosphorus homeostasis, but the choice of which among several agents to use has been actively investigated and debated. Recent debate has been polarized between those who favor calcium-based binders for their proven efficacy and relatively low cost and those who favor sevelamer for its putative beneficial effects on inflammatory biomarkers and vascular calcification. This review summarizes the current state of the art of prescribing phosphate binders, ranging from large-scale clinical trials to focused mechanistic studies, and proposes that the available evidence does not conclusively prove the relative superiority of any one binder.
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Affiliation(s)
- James E Novak
- Division of Nephrology & Hypertension, Henry Ford Health System, Detroit, Michigan 48202, USA.
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Intensified hemodialysis regimens: neglected treatment options for children and adolescents. Pediatr Nephrol 2008; 23:1729-36. [PMID: 18335254 DOI: 10.1007/s00467-008-0783-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 01/07/2008] [Accepted: 01/08/2008] [Indexed: 10/22/2022]
Abstract
During recent years, the importance of intensified dialysis regimens has gathered increasing interest, especially after the Hemodialysis (HEMO) Study Group reported that a higher dose of thrice-weekly hemodialysis failed to improve clinical outcomes. Long nocturnal hemodialysis (three to six times per week) or short daily hemodialysis are the currently used forms of intensified dialysis. There is substantial evidence for cardiovascular and quality-of-life improvements as well as financial benefits with intensified hemodialysis. Preliminary experience with daily hemodialysis and hemodiafiltration in children has been reported. Given the continuing shortage of donor organs for kidney transplantation, the increasing incidence of end-stage renal disease (ESRD) and recognition of the deleterious effects of long-lasting ESRD, growth retardation, and poor social rehabilitation, more intensified dialysis regimens are a much-needed therapeutical option in both adults and children.
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Abstract
Hyperphosphatemia is independently associated with an increased risk of death among dialysis patients. In this study, we have assessed the status of phosphate control and its clinical and laboratory associations in a large international group of patients on chronic peritoneal dialysis (PD) treatment. This cross-sectional multicenter study was carried out in 24 centers in three different countries (Canada, Greece, and Turkey) among 530 PD patients (235 women, 295 men) with a mean+/-s.d. age of 55+/-16 years and mean duration of PD of 33+/-25 months. Serum calcium (Ca(2+)), ionized Ca(2+), phosphate, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D(3), 1,25-dihydroxy vitamin D(3), total alkaline phosphatase, and bone alkaline phosphatase concentrations were investigated, along with adequacy parameters such as Kt/V, weekly creatinine clearance, and daily urine output. Mean Kt/V was 2.3+/-0.65, weekly creatinine clearance 78.5+/-76.6 l, and daily urine output 550+/-603 ml day(-1). Fifty-five percent of patients had a urine volume of <400 ml day(-1). Mean serum phosphorus level was 4.9+/-1.3 mg per 100 ml, serum Ca(2+) 9.4+/-1.07 mg per 100 ml, iPTH 267+/-356 pg ml(-1), ionized Ca(2+) 1.08+/-0.32 mg per 100 ml, calcium phosphorus (Ca x P) product 39+/-19 mg(2)dl(-2), 25(OH)D(3) 8.3+/-9.3 ng ml(-1), 1,25(OH)(2)D(3) 9.7+/-6.7 pg ml(-1), total alkaline phosphatase 170+/-178 U l(-1), and bone alkaline phosphatase 71+/-108 U l(-1). While 14% of patients were hypophosphatemic, with a serum phosphorus level lower than 3.5 mg per 100 ml, most patients (307 patients, 58%) had a serum phosphate level between 3.5 and 5.5 mg per 100 ml. Serum phosphorus level was 5.5 mg per 100 ml or greater in 28% (149) of patients. Serum Ca(2+) level was > or =9.5 mg per 100 ml in 250 patients (49%), between 8.5 and 9.5 mg per 100 ml in 214 patients (40%), and lower than 8.5 mg per 100 ml in 66 patients (12%). Ca x P product was >55 mg(2)dl(-2) in 136 patients (26%) and lower than 55 mg(2)dl(-2) in 394 patients (74%). Serum phosphorus levels were positively correlated with serum albumin (P<0.027) and iPTH (P=0.001), and negatively correlated with age (P<0.033). Serum phosphorus was also statistically different (P = 0.013) in the older age group (>65 years) compared to younger patients; mean levels were 5.1+/-1.4 and 4.5+/-1.1 mg per 100 ml, respectively, in the two groups. In our study, among 530 PD patients, accepted uremic-normal limits of serum phosphorus control was achieved in 58%, Ca x P in 73%, serum Ca(2+) in 53%, and iPTH levels in 24% of subjects. Our results show that chronic PD, when combined with dietary measures and use of phosphate binders, is associated with satisfactory serum phosphorus control in the majority of patients.
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Abstract
Adynamic bone in patients with chronic kidney disease (CKD) is a clinical concern because of its potential increased risk for fracture and cardiovascular disease (CVD). Prevalence rates for adynamic bone are reportedly increased, although the variance for its prevalence and incidence is large. Differences in its prevalence are largely attributed to classification and population differences, the latter of which constitutes divergent groups of elderly patients having diabetes and other comorbidities that are prone to low bone formation. Most patients have vitamin D deficiency and the active form, 1,25-dihydroxyvitamin D, invariably decreases to very low levels during CKD progression. Fortunately, therapy with vitamin D receptor activators (VDRAs) appears to be useful in preventing bone loss, in part, by its effect to stimulate bone formation and in decreasing CVD morbidity, and should be considered as essential therapy regardless of bone turnover status. Future studies will depend on assessing cardiovascular outcomes to determine whether the risk/reward profile for complications related to VDRA and CKD is tolerable.
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Abstract
Hyperphosphatemia is an independent predictor of mortality in end-stage renal disease patients, and 40% – 50% of peritoneal dialysis (PD) patients have suboptimal control of serum phosphate. Systematically addressing this problem requires an understanding of phosphate balance on PD. The present review discusses the determinants of daily phosphate load and focuses on the factors influencing renal and peritoneal clearance of phosphate.
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Affiliation(s)
- Sunil V. Badve
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada
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Nesrallah GE, Suri RS, Carter ST, Moist LM, Garg AX, Awaraji C, Lindsay RM. The International Quotidian Dialysis Registry: annual report 2007. Hemodial Int 2007; 11:271-7. [PMID: 17576289 DOI: 10.1111/j.1542-4758.2007.00179.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In view of the need to study both intermediate and definitive outcomes associated with daily and extended-hours hemodialysis (HD), our group has undertaken the design and implementation of an international registry to collect data describing the treatments and outcomes of patients treated with these regimens. The International Quotidian Dialysis Registry began recruiting patients in June 2004. There are currently 229 patients enrolled in the registry, up from 199 last year. The projected growth is 2000 patients by 2008. This paper constitutes the third annual report of progress of patient and center recruitment, and includes descriptive data drawn from the 3 primary patient groups currently tracked by the registry: home nocturnal, home short-daily, and in-center short-daily HD. As the cohort grows, patients will be compared with control subjects drawn from their respective national registries, and comparative analyses will follow.
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Affiliation(s)
- Gihad E Nesrallah
- Department of Nephrology, Humber River Regional Hospital, Toronto, Canada.
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Achinger SG, Ayus JC. Left ventricular hypertrophy: is hyperphosphatemia among dialysis patients a risk factor? J Am Soc Nephrol 2007; 17:S255-61. [PMID: 17130271 DOI: 10.1681/asn.2006080923] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular disease occurs in ESRD patients at rates that are far higher than is seen in the general population, and cardiovascular deaths account for the majority of deaths among dialysis patients. Abnormal mineral metabolism is a novel cardiovascular risk factor among dialysis patients. Recently published results demonstrated that even with good control of BP and anemia, conventional hemodialysis is associated with significant left ventricular hypertrophy (LVH); however, daily hemodialysis was associated with a significant reduction in LV mass index (LVMI). Furthermore, it was shown that control of serum phosphorus correlates with the reduction in LVMI. These data suggest a novel mechanism for the deleterious effect of elevated serum phosphorus on cardiovascular outcomes among hemodialysis patients: LVH. Other investigators have noted an association of hyperphosphatemia and LVH; however, this study was the first to demonstrate that improvement in serum phosphorus is associated with reduction in LVM. In addition, it is shown that daily hemodialysis is an effective modality in improving serum phosphorus through significantly improved phosphorus removal. Elevated serum phosphorus leads to vascular calcification, which can lead to LVH by decreasing vascular compliance. However, our study showed an improvement in LVMI during a 12-mo period. Because vascular calcification is unlikely to remit over this time period, it is proposed that serum phosphorus has a reversible, cardiotoxic effect that leads to LVH that can be reversed successfully with good control of serum phosphorus.
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Affiliation(s)
- Steven G Achinger
- Dialysis Service, Texas Diabetes Institute, Bextar County Hospital District, San Antonio, TX 78201, USA
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