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Cui L, Zhang L, Li J, Li Y, Hao X, Xu Y, Li C. Correlation between ultrafiltration rate and hemoglobin level and erythropoietin response in hemodialysis patients. Ren Fail 2024; 46:2296609. [PMID: 38178573 PMCID: PMC10773628 DOI: 10.1080/0886022x.2023.2296609] [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: 09/19/2023] [Accepted: 12/13/2023] [Indexed: 01/06/2024] Open
Abstract
This study aimed to investigate the correlation between ultrafiltration rate (UFR) and hemoglobin levels and erythropoietin (EPO) response in patients receiving maintenance hemodialysis (MHD). 225 MHD patients were divided into three groups according to the UFR: < 10 ml/h/kg, 10-13 ml/h/kg, and >13 ml/h/kg. Clinical parameters and prognosis were compared among the groups. Multiple linear correlation and regression analyses were conducted. SPSS 26.0 (IBM, Chicago, IL, USA) was used to analyze all statistics. The UFR < 10 ml/h/kg group was older than the other groups (p < 0.05). The UFR > 13 ml/h/kg group had the highest SpKt/V (p < 0.05), monthly EPO dose/weight (p < 0.001), and EPO resistance index (p < 0.001), as well as the lowest dry weight (p < 0.001), BMI (p < 0.001), hemoglobin (p < 0.001), hematocrit (p < 0.05), and red blood cell count (p < 0.05). Multiple linear regression analysis showed that sex, dry weight, UFR, calcium, phosphorus, albumin, and C-reactive protein levels were associated with hemoglobin levels. Multivariate logistic regression analysis revealed that a higher UFR was associated with lower hemoglobin levels, while male sex and higher levels of calcium and albumin were associated with higher hemoglobin levels. High UFR is associated with more severe anemia and EPO resistance in MHD. This study provides new insights into anemia management in patients undergoing hemodialysis.
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Affiliation(s)
- Li Cui
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lili Zhang
- Department of Nutrition, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Li
- Department of Nutrition, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuan Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaolei Hao
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Xu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chunmei Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Ranchin B, Schmitt CP, Warady BA, Hataya H, Jones J, Lalji R, Licht C, Mosca M, Stronach L, Vidal E, Walle JV, Shroff R. Technical requirements and devices available for long-term hemodialysis in children-mind the gap! Pediatr Nephrol 2024; 39:2579-2591. [PMID: 38141144 DOI: 10.1007/s00467-023-06233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023]
Abstract
Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.
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Affiliation(s)
- Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France.
- Centre de référence des maladies rénales rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron Cedex, France.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
- Department of Pediatrics, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan
| | - Joanne Jones
- Queensland Children's Hospital, University of Queensland, Brisbane, Australia
| | - Rowena Lalji
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Australia
- Metro South and Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Christoph Licht
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Nephrology and Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Melodie Mosca
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Lynsey Stronach
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Enrico Vidal
- Pediatric Nephrology Unit, Department for Woman and Child's Health, University-Hospital of Padua, Padua, Italy
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
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Lane RJ, Keogh SE, Khin NY. An arterial access system for targeted chemotherapy delivery and arterial-arterial extracorporeal recirculation for 'end stage' peripheral vascular disease. J Vasc Access 2024; 25:981-987. [PMID: 37029684 PMCID: PMC11075399 DOI: 10.1177/11297298231165642] [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: 11/15/2022] [Accepted: 03/06/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Vascular access via a single arterial catheter for targeted chemotherapy delivery has difficulties with concentration, dilution, drug retention, plasma binding, and lack of control of the tumour microcirculation. An implantable arterial access system to accommodate multi-catheter access was developed address these problems. The system was also adapted for isolated arterial-to-arterial extracorporeal suprasystolic perfusion for end stage peripheral vascular disease. The arterial-to-arterial logistics were compared with standard venovenous and arteriovenous fistulae access employed in haemodialysis. METHODS Targeted chemotherapy delivery was addressed in a pilot study of vascular liver isolation. Ten patients with secondary colorectal cancer, were treated with multiple infusions employing up to five individually steered catheters. The arterial-to-arterial extracorporeal access system was also used to treat end stage peripheral vascular disease in 20 patients where amputation was the only option. The trial was named Hypertensive Extracorporeal Limb Perfusion (HELP). RESULTS Multiple day only infusions produced a partial response or stable disease in six out of the ten patients in an 'end stage' setting. The mean survival was 11.2 months. Of the twenty patients facing amputation 40% had avoided amputation at follow-up 22 months and 20% had delay of 4 months. CONCLUSION The access system allows repeatable steerable multi-catheter arterial access for chemotherapy delivery to address difficulties of concentration, dilution, plasma binding and microvascular control. The access system supports multiple repeatable suprasystolic extracorporeal arterial to arterial access. It is cardiac independent generating flows of greater than 1 L/min with zero flow in between treatments. The device logistics compares favourably with arteriovenous and venovenous access systems.
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Affiliation(s)
- Rodney J Lane
- Royal North Shore Hospital, St Leonards, NSW, Australia
- North Shore Private Hospital, St Leonards, NSW, Australia
- Macquarie University Hospital, Macquarie Park, NSW, Australia
- AllVascular Pty Ltd, St Leonards, NSW, Australia
| | - Sarah E Keogh
- AllVascular Pty Ltd, St Leonards, NSW, Australia
- School of Biomedical Engineering, University of Sydney, Sydney, NSW, Australia
| | - Nyan Y Khin
- AllVascular Pty Ltd, St Leonards, NSW, Australia
- School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
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Cheetham MS, Ethier I, Krishnasamy R, Cho Y, Palmer SC, Johnson DW, Craig JC, Stroumza P, Frantzen L, Hegbrant J, Strippoli GF. Home versus in-centre haemodialysis for people with kidney failure. Cochrane Database Syst Rev 2024; 4:CD009535. [PMID: 38588450 PMCID: PMC11001293 DOI: 10.1002/14651858.cd009535.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Home haemodialysis (HHD) may be associated with important clinical, social or economic benefits. However, few randomised controlled trials (RCTs) have evaluated HHD versus in-centre HD (ICHD). The relative benefits and harms of these two HD modalities are uncertain. This is an update of a review first published in 2014. This update includes non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of HHD versus ICHD in adults with kidney failure. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2022 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. We searched MEDLINE (OVID) and EMBASE (OVID) for NRSIs. SELECTION CRITERIA RCTs and NRSIs evaluating HHD (including community houses and self-care) compared to ICHD in adults with kidney failure were eligible. The outcomes of interest were cardiovascular death, all-cause death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, vascular access interventions, central venous catheter insertion/exchange, vascular access infection, parathyroidectomy, wait-listing for a kidney transplant, receipt of a kidney transplant, quality of life (QoL), symptoms related to dialysis therapy, fatigue, recovery time, cost-effectiveness, blood pressure, and left ventricular mass. DATA COLLECTION AND ANALYSIS Two authors independently assessed if the studies were eligible and then extracted data. The risk of bias was assessed, and relevant outcomes were extracted. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was performed on outcomes where there was sufficient data. MAIN RESULTS From the 1305 records identified, a single cross-over RCT and 39 NRSIs proved eligible for inclusion. These studies were of varying design (prospective cohort, retrospective cohort, cross-sectional) and involved a widely variable number of participants (small single-centre studies to international registry analyses). Studies also varied in the treatment prescription and delivery (e.g. treatment duration, frequency, dialysis machine parameters) and participant characteristics (e.g. time on dialysis). Studies often did not describe these parameters in detail. Although the risk of bias, as assessed by the Newcastle-Ottawa Scale, was generally low for most studies, within the constraints of observational study design, studies were at risk of selection bias and residual confounding. Many study outcomes were reported in ways that did not allow direct comparison or meta-analysis. It is uncertain whether HHD, compared to ICHD, may be associated with a decrease in cardiovascular death (RR 0.92, 95% CI 0.80 to 1.07; 2 NRSIs, 30,900 participants; very low certainty evidence) or all-cause death (RR 0.80, 95% CI 0.67 to 0.95; 9 NRSIs, 58,984 patients; very low certainty evidence). It is also uncertain whether HHD may be associated with a decrease in hospitalisation rate (MD -0.50 admissions per patient-year, 95% CI -0.98 to -0.02; 2 NRSIs, 834 participants; very low certainty evidence), compared with ICHD. Compared with ICHD, it is uncertain whether HHD may be associated with receipt of kidney transplantation (RR 1.28, 95% CI 1.01 to 1.63; 6 NRSIs, 10,910 participants; very low certainty evidence) and a shorter recovery time post-dialysis (MD -2.0 hours, 95% CI -2.73 to -1.28; 2 NRSIs, 348 participants; very low certainty evidence). It remains uncertain if HHD may be associated with decreased systolic blood pressure (SBP) (MD -11.71 mm Hg, 95% CI -21.11 to -2.46; 4 NRSIs, 491 participants; very low certainty evidence) and decreased left ventricular mass index (LVMI) (MD -17.74 g/m2, 95% CI -29.60 to -5.89; 2 NRSIs, 130 participants; low certainty evidence). There was insufficient data to evaluate the relative association of HHD and ICHD with fatigue or vascular access outcomes. Patient-reported outcome measures were reported using 18 different measures across 11 studies (QoL: 6 measures; mental health: 3 measures; symptoms: 1 measure; impact and view of health: 6 measures; functional ability: 2 measures). Few studies reported the same measures, which limited the ability to perform meta-analysis or compare outcomes. It is uncertain whether HHD is more cost-effective than ICHD, both in the first (SMD -1.25, 95% CI -2.13 to -0.37; 4 NRSIs, 13,809 participants; very low certainty evidence) and second year of dialysis (SMD -1.47, 95% CI -2.72 to -0.21; 4 NRSIs, 13,809 participants; very low certainty evidence). AUTHORS' CONCLUSIONS Based on low to very low certainty evidence, HHD, compared with ICHD, has uncertain associations or may be associated with decreased cardiovascular and all-cause death, hospitalisation rate, slower post-dialysis recovery time, and decreased SBP and LVMI. HHD has uncertain cost-effectiveness compared with ICHD in the first and second years of treatment. The majority of studies included in this review were observational and subject to potential selection bias and confounding, especially as patients treated with HHD tended to be younger with fewer comorbidities. Variation from study to study in the choice of outcomes and the way in which they were reported limited the ability to perform meta-analyses. Future research should align outcome measures and metrics with other research in the field in order to allow comparison between studies, establish outcome effects with greater certainty, and avoid research waste.
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Affiliation(s)
- Melissa S Cheetham
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Isabelle Ethier
- Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Health Innovation and Evaluation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Rathika Krishnasamy
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Australasian Kidney Trials Network, Translational Research Institute, Woolloongabba, Australia
| | - Yeoungjee Cho
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Paul Stroumza
- Medical Office, Diaverum Marseille, Marseille, France
| | - Luc Frantzen
- Medical Office, Diaverum Marseille, Marseille, France
| | - Jorgen Hegbrant
- Division of Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Komaru Y, Bai YZ, Kreisel D, Herrlich A. Interorgan communication networks in the kidney-lung axis. Nat Rev Nephrol 2024; 20:120-136. [PMID: 37667081 DOI: 10.1038/s41581-023-00760-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/06/2023]
Abstract
The homeostasis and health of an organism depend on the coordinated interaction of specialized organs, which is regulated by interorgan communication networks of circulating soluble molecules and neuronal connections. Many diseases that seemingly affect one primary organ are really multiorgan diseases, with substantial secondary remote organ complications that underlie a large part of their morbidity and mortality. Acute kidney injury (AKI) frequently occurs in critically ill patients with multiorgan failure and is associated with high mortality, particularly when it occurs together with respiratory failure. Inflammatory lung lesions in patients with kidney failure that could be distinguished from pulmonary oedema due to volume overload were first reported in the 1930s, but have been largely overlooked in clinical settings. A series of studies over the past two decades have elucidated acute and chronic kidney-lung and lung-kidney interorgan communication networks involving various circulating inflammatory cytokines and chemokines, metabolites, uraemic toxins, immune cells and neuro-immune pathways. Further investigations are warranted to understand these clinical entities of high morbidity and mortality, and to develop effective treatments.
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Affiliation(s)
- Yohei Komaru
- Department of Medicine, Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Yun Zhu Bai
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Department of Pathology & Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Andreas Herrlich
- Department of Medicine, Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
- VA Saint Louis Health Care System, John Cochran Division, St. Louis, MO, USA.
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Curtis KA, Waikar SS, Mc Causland FR. Higher NT-proBNP levels and the risk of intradialytic hypotension at hemodialysis initiation. Hemodial Int 2024; 28:77-84. [PMID: 37875429 DOI: 10.1111/hdi.13125] [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: 01/17/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) is a potent predictor of adverse outcomes in hemodialysis initiation. These patients often experience intradialytic hypotension, which may partially reflect cardiac dysfunction, but the association of NT-proBNP with intradialytic hypotension is not clear. METHODS We performed a post hoc analysis of a randomized trial that tested mannitol versus placebo in 52 patients initiating hemodialysis (NCT01520207). NT-proBNP was measured prior to the first and third sessions (n = 87). Mixed-effects models (adjusting for randomized treatment, sex, race, age, diabetes, heart failure, catheter use, pre-dialysis systolic blood pressure, pre-dialysis weight, ultrafiltration volume, serum sodium, bicarbonate, urea nitrogen, phosphate, albumin, hemoglobin, and session length) were fit to examine the association of NT-proBNP with systolic blood pressure decline (pre-dialysis minus nadir systolic blood pressure). Additionally, mixed-effects Poisson models were fit to examine the association with intradialytic hypotension (≥20 mmHg decline in systolic blood pressure). FINDINGS Mean age was 55 ± 16 years; 33% had baseline heart failure. The median NT-proBNP was 5498 [25th-75th percentile 2011, 14,790] pg/mL; 26 sessions (30%) were complicated by intradialytic hypotension. In adjusted models, each unit higher log-NT-proBNP was associated with 6.0 mmHg less decline in systolic blood pressure (95%CI -9.2 to -2.8). Higher pre-dialysis NT-proBNP, per log-unit, was associated with a 52% lower risk of intradialytic hypotension (IRR 0.48, 95%CI 0.23-0.97), without evidence for effect modification by randomized treatment (P-interaction = 0.17). DISCUSSION In patients initiating hemodialysis, higher NT-proBNP is associated with less decline in intradialytic systolic blood pressure and lower risk of intradialytic hypotension. Future studies should investigate if higher pre-dialysis NT-proBNP levels may identify patients who might tolerate more aggressive ultrafiltration.
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Affiliation(s)
- Katherine A Curtis
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Milken Institute School of Public Health, The George Washington University, Washington DC, USA
| | - Sushrut S Waikar
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Al Nusair H, Hamdan W, Garma J, Eid A, Alnjadat R, Al-Nsair N, Fonbuena M, Davao C. The Implementation of a Modified Fluid Assessment Tool to Improve the Clinical Assessment, Detection, and Management of Blood Pressure Control and Fluid Alterations Among Hemodialysis Patients. Int J Nephrol Renovasc Dis 2023; 16:261-268. [PMID: 38107557 PMCID: PMC10723595 DOI: 10.2147/ijnrd.s440990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023] Open
Abstract
Background Fluid overload is a common complication of the care of End-stage Renal Disease patients that may lead to prolonged hospitalization and mortality. This warrants an effective and systemic approach to early recognition and management to improve patient outcomes. Aim This study aims to evaluate the effect of a modified fluid assessment tool to improve accurate clinical assessments, detection, and management of blood pressure control and fluid alteration among hemodialysis patients. Methods In this retrospective study, data were collected from forty-three dialysis patients who were seen and followed up from a dialysis unit of an acute care hospital during 8 weeks of standard care. A modified assessment tool was used to systematically highlight the appropriateness of the patient set dry weight using intradialytic weight gain (IWDG) and patient blood pressure. Paired sample t-test and repeated measure ANOVA within-group analysis were applied to compare the mean difference score for IDWG and the mean arterial pressure within the study group, respectively. Result A total of 43 patients were enrolled (mean age, 59.07) (ranges 27-88 years) (SD - 14.30); 51.16% female; 79% Emirati Nationals, with Chronic Kidney Disease. A repeated measure ANOVA analysis showed a significant difference in the mean arterial pressure within the study group based on time, over six measurements (p = 0.001). However, the difference between the pre- and post-intra-dialytic weight gain mean scores yields insignificant results (p = 0.346). Conclusion The implementation of a modified assessment tool improved blood pressure control, increased staff and physician involvement in assessing patient dry weight facilitated through fluid status evaluation, methodical assessment of dry weight, and precise fluid removal calculation, enhancing overall blood pressure and fluid management in HD patients.
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Affiliation(s)
- Hussam Al Nusair
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Wael Hamdan
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Joy Garma
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Ahmed Eid
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Rafi Alnjadat
- Applied Health Sciences, Al-Balqa Applied University, Irbid, Jordan
| | - Nezam Al-Nsair
- College of Nursing, Xavier University, Cincinnati, OH, USA
| | - Mariezl Fonbuena
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Christin Davao
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
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8
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Purcell LK, Schnitker JW, Moore TM, Peña AM, Love MF, Ford AI, Vassar BM. Health inequities in dialysis care: A scoping review. Semin Dial 2023; 36:430-447. [PMID: 37734842 DOI: 10.1111/sdi.13176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023]
Abstract
MAIN PROBLEM We aim to look at potential gaps in current dialysis literature on inequities and explore future research that could contribute to more equitable care. METHODS Following guidelines from the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review of health inequities in dialysis. PubMed and Ovid Embase were searched in July 2022 for articles published between 2016 and 2022 that examined at least one of the following NIH defined health inequities: race/ethnicity, sex/gender, LGBTQ+ identity, underserved rural populations, education level, income, and occupation status. Frequencies of each health inequity as well as trends over time of the four most examined inequities were analyzed. RESULTS In our sample of 69 included studies, gaps were identified in LGBTQ+ identity and patient education. Inequities pertaining to race/ethnicity, sex/gender, underserved rural populations, and income were sufficiently reported. No trends between inequities investigated over time were identified. CONCLUSIONS Our scoping review examined current literature on health inequities pertaining to dialysis and found gaps concerning LGBTQ+ and patients with lower levels of education. To help fill these gaps, and possibly alleviate additional burden to these patients, we recommend cultural competency training for providers and dialysis center staff as well as community-based educational programs to improve dialysis patients' health literacy.
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Affiliation(s)
- Lindsey Kay Purcell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Joseph William Schnitker
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Ty Michael Moore
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Andriana Mercedes Peña
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Mitchell Faris Love
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Alicia Ito Ford
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Benjamin Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
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9
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Anaya AB, Lee MM, Neu AM, Swartz SM, Geer JJ, Warady BA. Standardizing Blood Pressure Measurements in Pediatric Hemodialysis: a Collaborative Journey. Curr Hypertens Rep 2023; 25:329-334. [PMID: 37505377 DOI: 10.1007/s11906-023-01255-3] [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] [Accepted: 06/30/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE OF REVIEW This manuscript details the development and execution of a quality improvement (QI) initiative aimed at standardizing blood pressure (BP) measurement practices in pediatric hemodialysis (HD) units across a national dialysis collaborative. RECENT FINDINGS Although there are recommendations for the detection and treatment of hypertension in the pediatric population, currently there is no data or recommendations specific to the methodology of measuring blood pressure in a pediatric hemodialysis setting. In 2016, the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) Collaborative assembled a dedicated working group to thoroughly examine BP measurement practices across participating pediatric HD centers and, drawing from current research, to establish a standardized best practice for BP measurement in pediatric HD patients both in-center and at home. Employing QI methodology, the working group devised a standardized "BP Bundle" and implemented it throughout the SCOPE Collaborative. This work led to successful practice improvement by establishing a consistent approach to BP measurement in pediatric HD patients cared for in SCOPE centers. With a standard best practice now in place and over 85% compliance with the BP Bundle across the SCOPE Collaborative, researchers and healthcare professionals can more accurately study and ultimately enhance the cardiovascular health of pediatric HD patients.
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Affiliation(s)
- Audrey B Anaya
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Marsha M Lee
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
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10
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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11
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Rocco MV, Rigaud M, Ertel C, Russell G, Zemdegs J, Vecchio M. Fluid Intake Management in Maintenance Hemodialysis Using a Smartphone-Based Application: A Pilot Study. Kidney Med 2023; 5:100703. [PMID: 37663954 PMCID: PMC10470202 DOI: 10.1016/j.xkme.2023.100703] [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: 09/05/2023] Open
Abstract
Rationale & Objective Increased interdialytic weight gain (IDWG) has been associated with increased morbidity and mortality. We evaluated the usefulness and safety of a mobile application (app) that allows patients receiving maintenance hemodialysis to self-monitor their daily fluid intake. Study Design Within group comparison before or during intervention. Setting & Participants Patients receiving maintenance hemodialysis with mean IDWG of <4%. Exposure Participants were trained to use a smartphone-based app, FiApp that allowed them to record fluid intake and compare with individual targeted daily fluid intake determined by the nephrologist. Outcomes The primary study outcome was the association between IDWG and fluid intake recorded in the FiApp. Secondary outcomes included FiApp safety and usage. Patient interviews were performed at weeks 1 and 4 to collect information regarding FiApp usability and recommendations for app improvements. Analytical Approach Mean, median, and standard deviation. Results Eighteen of 25 patients completed the full 4-week study, provided all app data, and completed 2 patient interviews. The mean 4-week IDWG during app use was similar to the baseline mean 4-week IDWG before app use; however, 61% of the participants had a decrease in IDWG when using the app compared with IDWG at baseline. Of the 18 participants who completed the study, only 1 had a mean 4-week IDWG that was 20% higher than that at baseline. The app was used on ≥80% of the days by 13 (72%) of 18 participants, and was used every day in 7 (39%) of 18 participants. The mean relationship between fluid reported in the app and fluid consumed was 40%. Limitations This safety study recruited patients who had IDWG of <4%. Conclusions A smartphone-based app can be safely used to help patients receiving maintenance hemodialysis track and control fluid intake. Motivated patients were able to decrease IDWG despite baseline IDWG being <4% of the body weight. Trial Registration NCT03759847. Plain-Language Summary Patients receiving maintenance hemodialysis struggle to limit fluid intake. Excess fluid intake can lead to adverse cardiovascular events. We developed a smartphone app to help patients receiving dialysis self-monitor their fluid intake. In this safety study in patients receiving dialysis with an interdialytic weight gain of <4% of the body weight, more than half of the patients were able to decrease their interdialytic fluid intake while using the app, and only 1 patient had an increase in interdialytic weight gain of >20% while using the app. Information gleaned from structured patient interviews will be used to refine this app.
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Affiliation(s)
- Michael V. Rocco
- Wake Forest University School of Medicine, Section on Nephrology, Winston-Salem, NC
| | | | | | - Greg Russell
- Wake Forest University School of Medicine, Department of Biostatistics and Data Science, Winston-Salem, NC
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Hamrahian SM, Vilayet S, Herberth J, Fülöp T. Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects. Int J Nephrol Renovasc Dis 2023; 16:173-181. [PMID: 37547077 PMCID: PMC10404053 DOI: 10.2147/ijnrd.s245621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023] Open
Abstract
Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient's symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients' risk factors can mitigate negative outcomes.
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Affiliation(s)
| | - Salem Vilayet
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Johann Herberth
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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13
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Mishra RK, Najafi B, Hamad A, Bara R, Lee M, Ibrahim R, Mathew M, Talal T, Al-Ali F. Intradialytic plantar electrical nerve stimulation to improve mobility and plantar sensation among adults with diabetes undergoing hemodialysis: a randomized double-blind trial. J Nephrol 2023:10.1007/s40620-023-01625-9. [PMID: 37326952 DOI: 10.1007/s40620-023-01625-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/08/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Impaired mobility is a debilitating consequence of hemodialysis. We examined the efficacy of intradialytic-plantar-electrical-nerve-stimulation (iPENS) to promote mobility among diabetes patients undergoing hemodialysis.. METHODS Adults with diabetes undergoing hemodialysis received either 1-h active iPENS, (Intervention-Group) or non-functional iPENS (Control-Group) during routine hemodialysis for 12 weeks (3 sessions/week). Participants and care-providers were blinded. Mobility (assessed using a validated pendant-sensor) and neuropathy (quantified by vibration-perception-threshold test) outcomes were assessed at baseline and 12 weeks. RESULTS Among 77 enrolled subjects (56.2 ± 2.6 years old), 39 were randomly assigned to the intervention group, while 38 were assigned to the control group. No study-related adverse events and dropouts were reported in the intervention group. Compared to the control group, significant improvements with medium to large effect sizes were observed in the intervention group at 12 weeks for mobility-performance metrics, including active-behavior, sedentary-behavior, daily step counts, and sit-to-stand duration variability (p < 0.05), Cohen's d effect size (d = 0.63-0.84). The magnitude of improvement in active-behavior was correlated with improvement in the vibration-perception-threshold test in the intervention group (r = - 0.33, p = 0.048). A subgroup with severe-neuropathy (vibration-perception-threshold > 25 V) showed a significant reduction in plantar numbness at 12 weeks compared to baseline (p = 0.03, d = 1.1). CONCLUSIONS This study supports feasibility, acceptability, and effectiveness of iPENS to improve mobility and potentially reduce plantar numbness in people with diabetes undergoing hemodialysis. Considering that exercise programs are not widely used in hemodialysis clinical practice, iPENS may serve as a practical, alternative solution to reduce hemodialysis-acquired weakness and promote mobility.
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Affiliation(s)
- Ram Kinker Mishra
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX, 77030, USA
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX, 77030, USA.
| | - Abdullah Hamad
- Department of Nephrology, Hamad General Hospital, Doha, Qatar
| | - Rasha Bara
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX, 77030, USA
| | - Myeounggon Lee
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX, 77030, USA
| | - Rania Ibrahim
- Department of Nephrology, Hamad General Hospital, Doha, Qatar
| | - Mincy Mathew
- Department of Nephrology, Hamad General Hospital, Doha, Qatar
| | - Talal Talal
- Diabetic Foot and Wound Clinic, Hamad Medical Co, Doha, Qatar
| | - Fadwa Al-Ali
- Department of Nephrology, Hamad General Hospital, Doha, Qatar
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14
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Mermelstein A, Raimann JG, Wang Y, Kotanko P, Daugirdas JT. Ultrafiltration Rate Levels in Hemodialysis Patients Associated with Weight-Specific Mortality Risks. Clin J Am Soc Nephrol 2023; 18:767-776. [PMID: 36913263 PMCID: PMC10278805 DOI: 10.2215/cjn.0000000000000144] [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: 10/07/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND We hypothesized that the association of ultrafiltration rate with mortality in hemodialysis patients was differentially affected by weight and sex and sought to derive a sex- and weight-indexed ultrafiltration rate measure that captures the differential effects of these parameters on the association of ultrafiltration rate with mortality. METHODS Data were analyzed from the US Fresenius Kidney Care (FKC) database for 1 year after patient entry into a FKC dialysis unit (baseline) and over 2 years of follow-up for patients receiving thrice-weekly in-center hemodialysis. To investigate the joint effect of baseline-year ultrafiltration rate and postdialysis weight on survival, we fit Cox proportional hazards models using bivariate tensor product spline functions and constructed contour plots of weight-specific mortality hazard ratios over the entire range of ultrafiltration rate values and postdialysis weights (W). RESULTS In the studied 396,358 patients, the average ultrafiltration rate in ml/h was related to postdialysis weight (W) in kg: 3W+330. Ultrafiltration rates associated with 20% or 40% higher weight-specific mortality risk were 3W+500 and 3W+630 ml/h, respectively, and were 70 ml/h higher in men than in women. Nineteen percent or 7.5% of patients exceeded ultrafiltration rates associated with a 20% or 40% higher mortality risk, respectively. Low ultrafiltration rates were associated with subsequent weight loss. Ultrafiltration rates associated with a given mortality risk were lower in high-body weight older patients and higher in patients on dialysis for more than 3 years. CONCLUSIONS Ultrafiltration rates associated with various levels of higher mortality risk depend on body weight, but not in a 1:1 ratio, and are different in men versus women, in high-body weight older patients, and in high-vintage patients.
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Affiliation(s)
- Ariella Mermelstein
- Renal Research Institute, New York, New York
- Katz School of Science and Health at Yeshiva University, New York, New York
| | - Jochen G. Raimann
- Renal Research Institute, New York, New York
- Katz School of Science and Health at Yeshiva University, New York, New York
| | - Yuedong Wang
- University of California—Santa Barbara, Santa Barbara, California
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
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15
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Yang LJ, Chao YL, Kuo IC, Niu SW, Hung CC, Chiu YW, Chang JM. High Ultrafiltration Rate Is Associated with Increased All-Cause Mortality in Incident Hemodialysis Patients with a High Cardiothoracic Ratio. J Pers Med 2022; 12:jpm12122059. [PMID: 36556279 PMCID: PMC9786000 DOI: 10.3390/jpm12122059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
A high ultrafiltration rate (UFR) is associated with increased mortality in hemodialysis patients. However, whether a high UFR itself or heart failure with fluid overload followed by a high UFR causes mortality remains unknown. In this study, 2615 incident hemodialysis patients were categorized according to their initial cardiothoracic ratios (CTRs) to assess whether UFR was associated with mortality in patients with high or low CTRs. In total, 1317 patients (50.4%) were women and 1261 (48.2%) were diabetic. During 2246 (1087−3596) days of follow-up, 1247 (47.7%) cases of all-cause mortality were noted. UFR quintiles 4 and 5 were associated with higher risks of all-cause mortality than UFR quintile 2 in fully adjusted Cox regression analysis. As the UFR increased by 1 mL/kg/h, the risk of all-cause mortality increased 1.6%. Subgroup analysis revealed that in UFR quintile 5, hazard ratios (HRs) for all-cause mortality were 1.91, 1.48, 1.22, and 1.10 for CTRs of >55%, 50−55%, 45−50%, and <45%, respectively. HRs for all-cause mortality were higher in women and patients with high body weight. Thus, high UFRs may be associated with increased all-cause mortality in incident hemodialysis patients with a high CTR, but not in those with a low CTR.
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Affiliation(s)
- Lii-Jia Yang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal CiJin Hospital, Kaohsiung 80544, Taiwan
| | - Yu-Lin Chao
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - I-Ching Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung 80145, Taiwan
| | - Sheng-Wen Niu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung 80145, Taiwan
| | - Chi-Chih Hung
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Correspondence:
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Jer-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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16
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Flythe JE, Assimon MM, Tugman MJ, Narendra JH, Singh SK, Jin W, Li Q, Bansal N, Hostetter TH, Dember LM. Efficacy, Safety, and Tolerability of Oral Furosemide Among Patients Receiving Hemodialysis: A Pilot Study. Kidney Int Rep 2022; 7:2186-2195. [PMID: 36217511 PMCID: PMC9546731 DOI: 10.1016/j.ekir.2022.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Diuretic use may reduce volume-related complications in hemodialysis. We evaluated the efficacy, safety, and tolerability of furosemide in patients with hemodialysis-dependent kidney failure. Methods We conducted an open label, single-arm, 18-week, dose titration pilot study of oral furosemide (maximum dose 320 mg/day) among patients receiving maintenance hemodialysis who reported at least 1 cup of urine output per day. The primary efficacy outcome was an increase from baseline to a specified threshold of 24-hour urine volume, with the threshold based on baseline urine volume (<200 ml/day vs. ≥200 ml/day). Safety outcomes included hypokalemia and hypomagnesemia, and tolerability was assessed by prespecified patient-reported symptoms. Results Of the 39 participants, 28 (72%) received the expected furosemide dose, 3 (8%) underwent dose reduction, 5 (12%) discontinued furosemide without dose reduction, and 3 (8%) underwent dose reduction and subsequently discontinued furosemide. The median (quartile 1, quartile 3) baseline 24-hour urine volume was 290 ml (110, 740), and the maximum, average daily study furosemide dose ranged from 69 mg/day to 320 mg/d. The urine output efficacy outcome was met by 12 (33%), 11 (33%), and 7 (22%) participants at weeks 5, 12, and 18, respectively, in the intention-to-treat analysis, and by 12 (39%), 9 (35%), and 7 (28%) participants at weeks 5, 12, and 18, respectively, in the on-treatment analysis. There were no electrolyte, furosemide level, or patient-reported hearing change safety events. Conclusion Furosemide was generally safe and well tolerated, but only one-third of participants met the efficacy definition at week 5. The clinical importance of the efficacy findings is uncertain.
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Affiliation(s)
- Jennifer E. Flythe
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Magdalene M. Assimon
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew J. Tugman
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Julia H. Narendra
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Simran K. Singh
- College of Arts and Sciences, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Wanting Jin
- Department of Biostatistics, Gillings School of Global Public Health, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Quefeng Li
- Department of Biostatistics, Gillings School of Global Public Health, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Thomas H. Hostetter
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura M. Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ravi KS. High Ultrafiltration Rates and Mortality in Hemodialysis Patients: Current Evidence and Future Steps. KIDNEY360 2022; 3:1293-1295. [PMID: 36176654 PMCID: PMC9416820 DOI: 10.34067/kid.0003402022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
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18
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Roblero MFS, Rubio MAB, González-Moya M, Varela JC, Alba AP, Gumpert JV, Cigarrán S, Vidau P, Marcos SG, Luquin PA, Piera EC, Mariño AG, Espigares MJ, Molina MD, Molina P. Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. Nefrologia 2022; 42:460-470. [PMID: 36400687 DOI: 10.1016/j.nefroe.2022.11.004] [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: 12/31/2020] [Accepted: 07/12/2021] [Indexed: 06/16/2023] Open
Abstract
Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Pedro Vidau
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | | | | | - Mariola D Molina
- Departamento de Matemáticas, Universidad de Alicante, San Vicente del Raspeig, Alicante, Spain
| | - Pablo Molina
- Hospital Universitari Dr Peset, FISABIO, Departamento de Medicina, Universitat de València, Valencia, Spain
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19
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Navarrete JE, Rajabalan A, Cobb J, Lea JP. Proportion of Hemodialysis Treatments with High Ultrafiltration Rate and the Association with Mortality. KIDNEY360 2022; 3:1359-1366. [PMID: 36176655 PMCID: PMC9416834 DOI: 10.34067/kid.0001322022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/02/2022] [Indexed: 01/11/2023]
Abstract
Background Rapid fluid removal during hemodialysis has been associated with increased mortality. The limit of ultrafiltration rate (UFR) monitored by the Centers for Medicare & Medicaid Services is 13 ml/kg per hour. It is not clear if the proportion of treatments with high UFR is associated with higher mortality. We examined the association of proportion of dialysis treatments with high UFR and mortality in end stage kidney failure patients receiving hemodialysis. Methods This was a retrospective study of incident patients initiating hemodialysis between January 1, 2010, and December 31, 2019, at Emory dialysis centers. The proportion of treatments with high UFR (>13 ml/kg per hour) per patient was calculated using data from the initial 3 months of dialysis therapy. Patients were categorized on the basis of quartiles of proportion of dialysis sessions with high UFR. Risk of death and survival probabilities were calculated and compared for all quartiles. Results Of 1050 patients eligible, the median age was 59 years, 56% were men, and 91% were Black. The median UFR was 6.5 ml/kg per hour, and the proportion of sessions with high UFR was 5%. Thirty-one percent of patients never experienced high UFR. Being a man, younger age, shorter duration of hemodialysis sessions, lower weight, diabetic status, higher albumin, and history of heart failure were associated with a higher proportion of sessions with high UFR. Patients in the higher quartile (26% dialysis with high UFR, average UFR 9.8 ml/kg per hour, median survival of 5.6 years) had a higher risk of death (adjusted hazard ratio 1.54; 95% CI, 1.13 to 2.10) compared with those in the lower quartile (0% dialysis with high UFR, average UFR 4.7 ml/kg per hour, median survival 8.8 years). Conclusions Patients on hemodialysis who did not experience frequent episodes of elevated UFR during the first 3 months of their dialysis tenure had a significantly lower risk of death compared with patients with frequent episodes of high UFR.
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Affiliation(s)
- José E. Navarrete
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| | - Ajai Rajabalan
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| | - Jason Cobb
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| | - Janice P. Lea
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
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20
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Raimann JG, Wang Y, Mermelstein A, Kotanko P, Daugirdas JT. Ultrafiltration rate thresholds associated with increased mortality risk in hemodialysis, unscaled or scaled to body size. Kidney Int Rep 2022; 7:1585-1593. [PMID: 35812299 PMCID: PMC9263411 DOI: 10.1016/j.ekir.2022.04.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction One proposed threshold ultrafiltration rate (UFR) of concern in hemodialysis patients is 13 ml/h per kg. We evaluated associations among UFR, postdialysis weight, and mortality to determine whether exceeding such a threshold would result in similar levels of risk for patients of different body weights. Methods Data were analyzed in this retrospective cohort study for 1 year following dialysis initiation (baseline) and over 2 years of follow-up in incident patients receiving thrice-weekly in-center hemodialysis. Patient-level UFR was averaged over the baseline period. To investigate the joint effect of UFR and postdialysis weight on survival, we fit Cox proportional hazards models using bivariate tensor product spline functions, adjusting for sex, race, age, diabetes, and predialysis serum albumin, phosphorus, and systolic blood pressure (BP). We constructed contour plots of mortality hazard ratios (MHRs) over the entire range of UFR values and postdialysis weights. Results In the studied 2542 patients, UFR not scaled to body weight was strongly associated with MHR, whereas postdialysis weight was inversely associated with MHR. MHR crossed 1.5 when unscaled UFR exceeded 1000 ml/h, and this relationship was largely independent of postdialysis weight in the range of 80 to 140 kg. A UFR warning level associated with a lower MHR of 1.3 would be 900 ml/h, whereas the UFR associated with an MHR of 1.0 was patient-size dependent. The MHR when exceeding a UFR threshold of 13 ml/h per kg was dependent on patient weight (MHR = 1.20, 1.45, and >2.0 for a 60, 80, and 100 kg patient, respectively). Conclusion UFR thresholds based on unscaled UFR give more uniform risk levels for patients of different sizes than thresholds based on UFR/kg.
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21
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Fujioka H, Imamura T, Koike T, Kinugawa K. Initial Experience to Follow Lung Fluid Levels during Hemodialysis: A Possibility of Remote Dielectric Sensing-Guided Hemodialysis. J Cardiovasc Dev Dis 2022; 9:jcdd9020057. [PMID: 35200710 PMCID: PMC8879829 DOI: 10.3390/jcdd9020057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/16/2022] Open
Abstract
Remote dielectric sensing (ReDSTM) is a novel technology that noninvasively quantifies lung fluid levels. Trends in ReDS values following hemodialysis remain uninvestigated. In a 64-year-old man with clinically stable hemodynamics, 2.7 L of fluid was drained during hemodialysis whereas the ReDS value remained almost unchanged (from 32 to 30%). In a 60-year-old woman with unstable hemodynamics, only 1.8 L of fluid was drained during hemodialysis, whereas ReDS value decreased considerably from 37 to 27%. Given our initial experience measuring ReDS values during hemodialysis, the ratio of fluid removal by hemodialysis between systemic plasma and lung fluid might vary in each patient. ReDS value might be a promising marker to determine the degree of fluid removal in addition to the conventional multidisciplinary index, particularly for those with unstable hemodynamics. The implications of ReDS-guided hemodialysis remain a future concern.
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22
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Daugirdas JT. A Body Size-Adjusted Maximum Ultrafiltration Rate Warning Level Is Not Equitable for Larger Patients. Clin J Am Soc Nephrol 2021; 16:1901-1902. [PMID: 34764201 PMCID: PMC8729496 DOI: 10.2215/cjn.04850421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- John T. Daugirdas
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
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23
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Canaud B, Stephens MP, Nikam M, Etter M, Collins A. Multitargeted interventions to reduce dialysis-induced systemic stress. Clin Kidney J 2021; 14:i72-i84. [PMID: 34987787 PMCID: PMC8711765 DOI: 10.1093/ckj/sfab192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Hemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure simultaneously induces persistent physiological changes that adversely affect several organs. Dialysis patients experience this systemic stress condition usually thrice weekly and sometimes more frequently depending on the treatment schedule. Dialysis-induced systemic stress results from multifactorial components that include treatment schedule (i.e. modality, treatment time), hemodynamic management (i.e. ultrafiltration, weight loss), intensity of solute fluxes, osmotic and electrolytic shifts and interaction of blood with components of the extracorporeal circuit. Intradialytic morbidity (i.e. hypovolemia, intradialytic hypotension, hypoxia) is the clinical expression of this systemic stress that may act as a disease modifier, resulting in multiorgan injury and long-term morbidity. Thus, while lifesaving, HD exposes the patient to several systemic stressors, both hemodynamic and non-hemodynamic in origin. In addition, a combination of cardiocirculatory stress, greatly conditioned by the switch from hypervolemia to hypovolemia, hypoxemia and electrolyte changes may create pro-arrhythmogenic conditions. Moreover, contact of blood with components of the extracorporeal circuit directly activate circulating cells (i.e. macrophages-monocytes or platelets) and protein systems (i.e. coagulation, complement, contact phase kallikrein-kinin system), leading to induction of pro-inflammatory cytokines and resulting in chronic low-grade inflammation, further contributing to poor outcomes. The multifactorial, repetitive HD-induced stress that globally reduces tissue perfusion and oxygenation could have deleterious long-term consequences on the functionality of vital organs such as heart, brain, liver and kidney. In this article, we summarize the multisystemic pathophysiological consequences of the main circulatory stress factors. Strategies to mitigate their effects to provide more cardioprotective and personalized dialytic therapies are proposed to reduce the systemic burden of HD.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Melanie P Stephens
- MSL & Medical Strategies for Innovative Therapies, Fresenius Medical Care, Waltham, MA, USA
| | - Milind Nikam
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Michael Etter
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
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24
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Flythe JE, Liu S, Montez-Rath ME, Winkelmayer WC, Chang TI. Ultrafiltration rate and incident atrial fibrillation among older individuals initiating hemodialysis. Nephrol Dial Transplant 2021; 36:2084-2093. [PMID: 33561218 PMCID: PMC8826739 DOI: 10.1093/ndt/gfaa332] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Higher ultrafiltration (UF) rates are associated with numerous adverse cardiovascular outcomes among individuals receiving maintenance hemodialysis. We undertook this study to investigate the association of UF rate and incident atrial fibrillation in a large, nationally representative US cohort of incident, older hemodialysis patients. METHODS We used the US Renal Data System linked to the records of a large dialysis provider to identify individuals ≥67 years of age initiating hemodialysis between January 2006 and December 2011. We applied an extended Cox model as a function of a time-varying exposure to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of delivered UF rate and incident atrial fibrillation. RESULTS Among the 15 414 individuals included in the study, 3177 developed atrial fibrillation. In fully adjusted models, a UF rate >13 mL/h/kg (versus ≤13 mL/h/kg) was associated with a higher hazard of incident atrial fibrillation [adjusted HR 1.19 (95% CI 1.07-1.30)]. Analyses using lower UF rate thresholds (≤10 versus >10 mL/h/kg and ≤8 versus >8 mL/h/kg, separately) yielded similar results. Analyses specifying the UF rate as a cubic spline (per 1 mL/h/kg) confirmed an approximately linear dose-response relationship between the UF rate and the risk of incident atrial fibrillation: risk began at UF rates of ~6 mL/h/kg and the magnitude of this risk flattened, but remained elevated, at rates ≥9 mL/h/kg. CONCLUSION In this observational study of older individuals initiating hemodialysis, higher UF rates were associated with higher incidences of atrial fibrillation.
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute of Kidney Health, Baylor College of Medicine, Houston, TX, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
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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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26
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Zschätzsch S, Stauss-Grabo M, Gauly A, Braun J. Integrating Monitoring of Volume Status and Blood Volume-Controlled Ultrafiltration into Extracorporeal Kidney Replacement Therapy. Int J Nephrol Renovasc Dis 2021; 14:349-358. [PMID: 34511978 PMCID: PMC8416185 DOI: 10.2147/ijnrd.s319911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/13/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Volume management in hemodialysis (HD) requires the ability to assess volume status objectively and determine treatment strategies that achieve euvolemia without compromising hemodynamic stability. The aim of this study was to compare dialysis with and without blood volume-controlled ultrafiltration (UF) in combination with body composition monitoring, and to evaluate indicators for adequate dialysis (Kt/V), ultrafiltration volume, fluid status, and the occurrence of intradialytic morbid events (IME). Patients and Methods Patients undergoing hemodialysis or on-line hemodiafiltration with support of a blood volume monitor (BVM) - a feedback control device integrated into the 5008 and 6008 HD systems - were enrolled. Patients received treatment for four weeks using the 6008 CAREsystem and the BVM (6008+). Data on dialysis dose (Kt/V), UF volume and predialysis fluid status were documented. This data was also documented retrospectively for four weeks with (5008+) and without (5008-) the use of the BVM with the 5008 system. Comparisons were analyzed using linear mixed models. Results Twenty-four patients were enrolled. Kt/V was unaffected by blood volume-controlled UF (5008- vs 5008+: p=0.230) and was equally achieved with both HD systems (5008+ vs 6008+: p=0.922). The UF volume and fluid status achieved were comparable, independent of the use of UF control with BVM (5008- vs 5008+; UF volume: p=0.166; fluid overload: p=0.390) or the HD system (5008+ vs 6008+: UF volume: p=0.003; fluid overload: p=0.838), except for UF volume being higher in the 6008+ phase. IMEs occurred in less than 3% of treatments, with no difference between study phases. Conclusion This study demonstrates that a clinical approach to kidney replacement therapy that tracks volume status and manages intradialytic fluid removal by blood volume-controlled UF delivers adequate dialysis without compromising fluid removal. It maintains volume status and ensures low incidence of IMEs.
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Affiliation(s)
- Sebastian Zschätzsch
- Center for Kidney and Blood Pressure Diseases, Georg-Haas-Dialysis Center, Giessen, Germany
| | | | - Adelheid Gauly
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Jennifer Braun
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
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27
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Slon Roblero MF, Bajo Rubio MA, González-Moya M, Calviño Varela J, Pérez Alba A, Villaro Gumpert J, Cigarrán S, Vidau P, García Marcos S, Abáigar Luquin P, Coll Piera E, Gascón Mariño A, Espigares MJ, Molina MD, Molina P. Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. Nefrologia 2021; 42:S0211-6995(21)00144-2. [PMID: 34393002 DOI: 10.1016/j.nefro.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 11/25/2022] Open
Abstract
Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Pedro Vidau
- Hospital Universitario Central de Asturias, Oviedo, España
| | | | | | | | | | | | - Mariola D Molina
- Departamento de Matemáticas, Universidad de Alicante, San Vicente del Raspeig, Alicante, España
| | - Pablo Molina
- Hospital Universitari Dr Peset, FISABIO, Departamento de Medicina, Universitat de València, Valencia, España
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28
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Fernandez-Prado R, Peña-Esparragoza JK, Santos-Sánchez-Rey B, Pereira M, Avello A, Gomá-Garcés E, González-Rivera M, González-Martin G, Gracia-Iguacel C, Mahillo I, Ortiz A, González-Parra E. Ultrafiltration rate adjusted to body weight and mortality in hemodialysis patients. Nefrologia 2021; 41:426-435. [PMID: 36165111 DOI: 10.1016/j.nefroe.2021.10.005] [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: 06/15/2020] [Accepted: 10/17/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND AIMS Mortality among hemodialysis patients remains high. An elevated ultrafiltration rate adjusted by weight (UFR/W) has been associated with hypotension and higher risk of death and/or cardiovascular events. METHODS We evaluated the association between UFR/W and mortality in 215 hemodialysis patients. The mean follow-up was 28 ± 6.12 months. We collected patients' baseline characteristics and mean UFR/W throughout the follow-up. RESULTS Mean UFR/W was 9.0 ± 2,4 and tertiles 7.1 y 10.1 mL/kg/h. We divided our population according to the percentage of sessions with UFR/W above the limits described in the literature associated with increased mortality (10.0 ml/kg/h and 13.0 mL/kg/h). Patients with higher UFR/W were younger, with higher interdialytic weight gain and weight reduction percentage but lower dry, pre and post dialysis weight. Throughout the follow-up, 46 (21.4%) patients died, the majority over 70 years old, diabetic or with cardiovascular disease. There were neither differences regarding mortality between groups nor differences in UFR/W among patients who died and those who did not. Contrary to previous studies, we did not find an association between UFR/W and mortality, maybe due to a higher prevalence in the use of cardiovascular protection drugs and lower UFR/W. CONCLUSIONS The highest UFR/W were observed in younger patients with lower weight and were not associated with an increased mortality.
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29
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Ertuglu LA, Demiray A, Basile C, Afsar B, Covic A, Kanbay M. Sodium and ultrafiltration profiling in hemodialysis: A long-forgotten issue revisited. Hemodial Int 2021; 25:433-446. [PMID: 34133065 DOI: 10.1111/hdi.12952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/21/2021] [Accepted: 05/16/2021] [Indexed: 12/16/2022]
Abstract
Sodium and ultrafiltration profiling are method of dialysis in which dialysate sodium concentration and ultrafiltration rate are altered during the course of the dialysis session. Sodium and ultrafiltration profiling have been used, commonly simultaneously, to improve hemodynamic stability during hemodialysis. Sodium profiling is particularly effective in decreasing the incidence of intradialytic hypotension, while ultrafiltration profiling is suggested to decrease subclinical repeated end organ ischemia during dialysis. However, complications such as increased interdialytic weight gain and thirst due to sodium excess have prevented widespread use of sodium profiling. Evidence suggest that different sodium profiling techniques may lead to different clinical results, and preferring sodium balance neutral sodium profiling may mitigate adverse effects related to sodium overload. However, evidence is lacking on the long-term clinical outcomes of different sodium profiling methods. Optimal method of sodium profiling as well as the utility of sodium/ultrafiltration profiling in routine practice await further clinical investigation.
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Affiliation(s)
- Lale A Ertuglu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Atalay Demiray
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Baris Afsar
- Division of Nephrology, Department of Internal Medicine, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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30
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Bellin EY, Hellebrand AM, Kaplan SM, Ledvina JG, Markis WT, Levin NW, Kaufman AM. Epidemiology of nursing home dialysis patients-A hidden population. Hemodial Int 2021; 25:548-559. [PMID: 34132036 PMCID: PMC8596662 DOI: 10.1111/hdi.12943] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/11/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
Introduction Dialysis patients are often discharged from hospitals to skilled nursing facilities (SNFs), but little has been published about their natural history. Methods Using electronic medical record data, we conducted a retrospective cohort study of nursing home patients treated with in‐SNF hemodialysis from January 1, 2018 through June 20, 2020 within a dialysis organization across eight states. A dialytic episode began with the first in‐SNF dialysis and was ended by hospitalization, death, transfer, or cessation of treatment. The clinical characteristics and natural history of these patients and their dialytic episodes are described. Findings Four thousand five hundred and ten patients experienced 9274 dialytic episodes. Dialytic episodes had a median duration of 18 days (IQR: 8–38) and were terminated by a hospitalization n = 5747 (62%), transfer n = 2638 (28%), death n = 568 (6%), dialysis withdrawal n = 129 (1.4%), recovered function n = 2 (0.02%), or other cause n = 6 (0.06%). Increased patient mortality was associated with advancing age, low serum creatinine, albumin, or sodium, and low pre‐dialytic systolic blood pressure (sBP). U‐shaped relationships to mortality were observed for intradialytic hypotension frequency and for post‐ > pre‐hemodialysis sBP frequency. Prescription of dialysis five times weekly in the first 2 weeks was associated with better survival in the first 90 days (HR 0.77, CI 0.62–0.96; p < 0.02). Discussion Provision of in‐SNF dialysis by an external dialysis organization enables discharge from the acute care setting for appropriate treatment with increased nursing contact time in an otherwise under‐resourced environment. SNF ESRD patient clinical characteristics and outcomes are extensively characterized for the first time.
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Affiliation(s)
- Eran Y Bellin
- Departments of Epidemiology & Population Health and Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | | | | | - Nathan W Levin
- Internal Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
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31
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Covic A, Siriopol D. Assessment and Management of Volume Overload Among Patients on Chronic Dialysis. Curr Vasc Pharmacol 2021; 19:34-40. [PMID: 32096744 DOI: 10.2174/1570161118666200225093827] [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: 11/27/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/11/2022]
Abstract
Volume overload is the most common complication in end-stage renal disease (ESRD) patients, being directly related to numerous complications including resistant hypertension, cardiac hypertrophy, congestive heart failure or arterial stiffness, among others. Therefore, volume overload is now considered an important risk factor for hard outcomes, like all-cause or cardiovascular mortality. Relying solely on clinical examination for assessing volume overload in ESRD patients lacks sensitivity and specificity. Numerous efforts have been made to identify new methods that could objectively assess volume status; however, each of them has important limitations. This review aims to discuss the most frequently used methods (biomarkers, inferior vena cava assessment, lung ultrasonography, bioimpedance analysis and blood volume monitoring) and to compare the advantage of each method vs. the overall/ clinical strategy.
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Affiliation(s)
- Adrian Covic
- Nephrology Department, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Iasi 700115, Romania
| | - Dimitrie Siriopol
- Nephrology Department, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Iasi 700115, Romania
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32
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Ranchin B, Maucort-Boulch D, Bacchetta J. Big data and outcomes in paediatric haemodialysis: how can nephrologists use these new tools in daily practice? Nephrol Dial Transplant 2021; 36:387-391. [PMID: 33257930 DOI: 10.1093/ndt/gfaa225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bruno Ranchin
- Centre de Référence des Maladies Rénales Rares, Service de Néphrologie Rhumatologie Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron Cedex, France
| | - Delphine Maucort-Boulch
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Service de Néphrologie Rhumatologie Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron Cedex, France.,Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France.,INSERM 1033, LYOS, Prévention des Maladies Osseuses, Lyon, France
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33
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Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Tang X, Chen L, Chen W, Li P, Zhang L, Fu P. Effects of diuretics on intradialytic hypotension in maintenance dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol 2021; 53:1911-1921. [PMID: 33675484 DOI: 10.1007/s11255-021-02805-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/08/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Intradialytic hypotension (IDH) is a serious complication in dialysis patients. Diuretics might reduce the incidence of IDH by decreasing ultrafiltration. However, the effect of diuretics on IDH in maintenance dialysis patients is still unclear. METHODS We searched Medline, Embase, the Cochrane Library, China National Knowledge Infrastructure and clinical trials registries from 1945 to May 2019. Randomized controlled trials (RCTs) or observational studies about IDH in maintenance dialysis with diuretics were included. RESULTS Seven studies including 28,226 patients were included, of which 4 were RCTs involving mineralocorticoid receptor antagonists (MRAs) and 3 were observational studies involving loop diuretics. There was a trend that a lower incidence rate of IDH in maintenance dialysis patients who used loop diuretics than control, although the result was not statistically significant (OR 0.65, 95% CI 0.34-1.22, P = 0.18). Similarly, lower incidence rate of all-cause mortality (OR 0.92, 95% CI 0.87-0.99; P = 0.02) and cardiovascular (CV) mortality (OR 0.86, 95% CI 0.75-0.99, P = 0.03) in dialysis patients who used loop diuretics than control. On the contrary, there were no significant difference in the incidence of IDH (OR 1.35, 95% CI 0.78-2.34, P = 0.29) and all-cause mortality (OR 0.73, 95% CI 0.26-2.01; P = 0.54) and CV mortality (OR 0.57, 95% CI 0.14-2.25; P = 0.42) in maintenance dialysis patients who used MRAs compared with control. CONCLUSION Loop diuretics, but not MRAs, might have a potential benefit to reduce the incidence rate of IDH, all-cause mortality and CV mortality. More high-quality studies are needed to strengthen the arguments.
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Affiliation(s)
- Xin Tang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Lixin Chen
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Wenwen Chen
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Peiyun Li
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China.
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
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Fernandez-Prado R, Peña-Esparragoza JK, Santos-Sánchez-Rey B, Pereira M, Avello A, Gomá-Garcés E, González-Rivera M, González-Martin G, Gracia-Iguacel C, Mahillo I, Ortiz A, González-Parra E. Ultrafiltration rate adjusted to body weight and mortality in hemodialysis patients. Nefrologia 2021. [PMID: 33663812 DOI: 10.1016/j.nefro.2020.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND AIMS Mortality among hemodialysis patients remains high. An elevated ultrafiltration rate adjusted by weight (UFR/W) has been associated with hypotension and higher risk of death and/or cardiovascular events. METHODS We evaluated the association between UFR/W and mortality in 215 hemodialysis patients. The mean follow-up was 28 ± 6.12 months. We collected patientś baseline characteristics and mean UFR/W throughout the follow-up. RESULTS Mean UFR/W was 9.0 ± 2,4 and tertiles 7.1 y 10.1 mL/kg/h. We divided our population according to the percentage of sessions with UFR/W above the limits described in the literature associated with increased mortality (10.0 mL/kg/h and 13.0 mL/kg/h). Patients with higher UFR/W were younger, with higher interdialytic weight gain and weight reduction percentage but lower dry, pre and post dialysis weight. Throughout the follow-up, 46 (21.4%) patients died, the majority over 70 years old, diabetic or with cardiovascular disease. There were neither differences regarding mortality between groups nor differences in UFR/W among patients who died and those who did not. Contrary to previous studies, we did not find an association between UFR/W and mortality, maybe due to a higher prevalence in the use of cardiovascular protection drugs and lower UFR/W. CONCLUSIONS The highest UFR/W were observed in younger patients with lower weight and were not associated with an increased mortality.
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Liu N, Kauffman RJ. Enhancing healthcare professional and caregiving staff informedness with data analytics for chronic disease management. INFORMATION & MANAGEMENT 2021. [DOI: 10.1016/j.im.2020.103315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Uduagbamen PK, Kadiri S. Intradialysis hypotension and hypertension in patients with end stage kidney disease in Nigeria: risk factors and clinical correlates. Ghana Med J 2021; 55:34-42. [PMID: 38322382 PMCID: PMC10665260 DOI: 10.4314/gmj.v55i1.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background Many shortcomings associated with haemodialysis for instance, intradialysis blood pressure changes, often lead to inadequate dialysis dose. Measures are needed to improve on this. Objectives To determine the risk factors and clinical correlates of intradialysis blood pressure variations. Methods Maintenance haemodialysis sessions for 232 consented patients with end stage kidney disease who had 1248 sessions were studied. Data collected was from history, examination findings, serum electrolytes and hematocrit. Blood pressure reading was taken manually at rest. Statistical analysis was with SPSS 22. Chi square and t-test were used to compare proportions and means respectively while regression analysis was used to determine predictors of blood pressure changes. Results The mean age of participants was 49.9 ± 4.6. More participants (38.8%) had hypertension associated CKD, than chronic glomerulonephritis, (37.9%). Majority (60.7%) had internal jugular catheter. Intradialysis hypertension was commoner than intradialysis hypotension (24.4% versus 19.4%). Intradialysis hypotension was commoner in females, diabetics and with less frequent dialysis while intradialysis hypertension was commoner in males, frequent erythropoietin use. The mean dialysis dose (Kt/V) was 1.02 ± 0.4, with 0.68 ± 0.1 for intradialysis hypotension and 0.84 ± 0.2 for intradialysis hypertension. Conclusion Risk factors for intradialysis hypertension were males, frequent erythropoietin use while for intradialysis hypotension, were female gender and less frequent dialysis. Effective intra and inter-dialytic blood pressure control with adequate pre dialysis work up should be carried out to lessen the degree, burden and outcome of these variations. Funding None declared.
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Affiliation(s)
- Peter K Uduagbamen
- Division of Nephrology and Hypertension, Department of Internal Medicine, Babcock University Teaching Hospital, Ilishan-Remo, Nigeria
- Nephrology Unit, Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Solomon Kadiri
- Nephrology Unit, Department of Internal Medicine, University College Hospital, Ibadan, Nigeria
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Yoowannakul S, Vongsanim S, Tangvoraphonkchai K, Mohamed A, Davenport A. Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00321-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Quality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms.
Methods
We reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW).
Results
We studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times.
We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times.
Conclusion
We found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.
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Olaniran KO, Eneanya ND, Zhao SH, Ofsthun NJ, Maddux FW, Thadhani RI, Dalrymple LS, Nigwekar SU. Mortality and Hospitalizations among Sickle Cell Disease Patients with End-Stage Kidney Disease Initiating Dialysis. Am J Nephrol 2021; 51:995-1003. [PMID: 33486484 DOI: 10.1159/000513012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is the most common inherited hematological disorder and a well-described risk factor for end-stage kidney disease (ESKD). Mortality and hospitalizations among patients with SCD who develop ESKD remain understudied. Furthermore, prior studies focused only on SCD patients where ESKD was caused by SCD. We aimed to describe mortality and hospitalization risk in all SCD patients initiating dialysis and explore risk factors for mortality and hospitalization. METHODS We performed a national observational cohort study of African American ESKD patients initiating dialysis (2000-2014) in facilities affiliated with a large dialysis provider. SCD was identified by diagnosis codes and matched to a reference population (non-SCD) by age, sex, dialysis initiation year, and geographic region of care. Sensitivity analyses were conducted by restricting to patients where SCD was recorded as the cause of ESKD. RESULTS We identified 504 SCD patients (mean age: 47 ± 14 years; 48% females) and 1,425 reference patients (mean age: 46 ± 14 years; 49% females). The median follow-up was 2.4 (IQR 1.0-4.5) years. Compared to the reference, SCD was associated with higher mortality risk (hazard ratio 1.66; 95% confidence interval [CI]: 1.36-2.03) and higher hospitalization rates (incidence rate ratio 2.12; 95% CI: 1.88-2.38) in multivariable analyses. Exploratory multivariable mortality risk models showed the largest mortality risk attenuation with the addition of time-varying hemoglobin and high-dose erythropoietin, but the association of SCD with mortality remained significant. Sensitivity analyses (restricted to ESKD caused by SCD) also showed significant associations between SCD and mortality and hospitalizations, but with larger effect estimates. High-dose erythropoietin was associated with the highest risk for mortality and hospitalization in SCD. CONCLUSIONS Among ESKD patients, SCD is associated with a higher risk for mortality and hospitalization, particularly in patients where SCD is identified as the cause of ESKD.
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Affiliation(s)
- Kabir O Olaniran
- Division of Nephrology, Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA,
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sophia H Zhao
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Norma J Ofsthun
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
- Fresenius Medical Care AG & Co, KGaA, Bad Homburg, Germany
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Mass General Brigham, Boston, Massachusetts, USA
| | | | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Evans M, Xu H, Rydell H, Prütz KG, Lindholm B, Stendahl M, Segelmark M, Carrero JJ. Association Between Implementation Of Novel Therapies And Improved Survival In Patients Starting Hemodialysis: The Swedish Renal Registry 2006-2015. Nephrol Dial Transplant 2020; 36:gfaa357. [PMID: 33326038 PMCID: PMC8237989 DOI: 10.1093/ndt/gfaa357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/22/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The recent years have witnessed significant therapeutic advances for patients on hemodialysis. We evaluated temporal changes in treatments practices and survival rates among incident hemodialysis patients. METHODS Observational study of patients initiating hemodialysis in Sweden 2006-2015. Trends of hemodialysis-related practices, medications, and routine laboratory biomarkers were evaluated. The incidence of death and major cardiovascular events (MACE) across calendar years were compared against the age-sex-matched general population. Via Cox regression, we explored whether adjustment for implementation of therapeutic advances modified observed survival and MACE risks. RESULTS Among 6,612 patients, age and sex were similar, but the burden of co-morbidities increased over time. The proportion of patients receiving treatment by hemodiafiltration, >3 sessions/week, lower ultrafiltration rate, and working fistulas increased progressively, as did use of non-calcium phosphate binders, cinacalcet, and vitamin D3. The standardized 1-year mortality decreased from 13.2% in 2006/07 to 11.1% in 2014/15. The risk of death decreased by 6% (HR 0.94, 95% CI 0.90-0.99) every two years, and the risk of MACE by 4% (HR 0.96; 0.92-1.00). Adjustment for changes in treatment characteristics abrogated these associations (HR 1.00; 0.92-1.09 for death and 1.00; 0.94-1.06 for MACE). Compared with the general population, the risk of death declined from 6 times higher 2006/2007 [standardized incidence rate ratio, sIRR 6.0 (5.3-6.9)], to 5.6 higher 2014/15 [sIRR 5.57 (4.8-6.4)]. CONCLUSIONS Gradual implementation of therapeutic advances over the last decade was associated with a parallel reduction in short-term risk of death and MACE among hemodialysis patients.
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Affiliation(s)
- Marie Evans
- Division of Renal Medicine, Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Helena Rydell
- Division of Renal Medicine, Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Karl-Göran Prütz
- Swedish Renal Registry, Department of Internal Medicine, Ryhov Regional Hospital, Jönköping, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine, Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Maria Stendahl
- Swedish Renal Registry, Department of Internal Medicine, Ryhov Regional Hospital, Jönköping, Sweden
| | - Mårten Segelmark
- Department of Clinical Sciences, Division of Nephrology, Lund University and Skane University Hospital, Lund, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Cedeño S, Desco M, Aleman Y, Macías N, Fernández-Pena A, Vega A, Abad S, López-Gómez JM. Intradialytic hypotension and relationship with cognitive function and brain morphometry. Clin Kidney J 2020; 14:1156-1164. [PMID: 33841861 PMCID: PMC8023187 DOI: 10.1093/ckj/sfaa070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/31/2020] [Indexed: 12/15/2022] Open
Abstract
Background The haemodynamic stress brought about by dialysis could justify the loss of structural and functional integrity of the central nervous system (CNS). The main objective of this study was to analyse the relationship between intradialytic hypotension (IDH) and cognitive function and brain morphometry. Methods The cross-sectional KIDBRAIN study (Cohort Study of Morphological Changes of the Brain by MRI in Chronic Kidney Disease Patients) included 68 prevalent patients with no history of neurological disorders (cerebrovascular disease and cognitive impairment) undergoing haemodialysis (HD). We analysed 18 non-consecutive dialysis sessions (first three of each month over a 6-month period) and various definitions of IDH were recorded. Global cognitive function (GCF) was assessed using the Mini-Mental State Examination (MMSE) and parameters of structural integrity of the CNS were obtained using volume morphometry magnetic resonance imaging analysis [grey matter (GM), white matter (WM) and hippocampus). Results A greater number of sessions with IDH were associated with less volume of WM (r = −0.359,P = 0.003) and hippocampus (r = −0.395, P = 0.001) independent of cardiovascular risk factors according to multivariable linear regression models (β = −0.198, P = 0.046 for WM; β = −0.253, P = 0.017 for hippocampus). The GCF by the MMSE was 27.3 ± 7.3.1 and was associated with WM volume (β = 0.403, P = 0.001) independent of GM and hippocampus volume. Symptomatic IDH was associated with GCF (r = −0.420, P < 0.001) in adjusted analysis (β = −0.339, P = 0.008). Conclusions Even when asymptomatic, IDH is associated with a lower WM and hippocampus volume and reduced GCF in patients undergoing HD, thus suggesting greater vulnerability of the brain to the haemodynamic stress that may be generated by a dialysis session.
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Affiliation(s)
- Santiago Cedeño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Yasser Aleman
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - 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
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Fissell RB, Cavanaugh KL. Barriers to home dialysis: Unraveling the tapestry of policy. Semin Dial 2020; 33:499-504. [PMID: 33210358 DOI: 10.1111/sdi.12939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 12/22/2022]
Abstract
Home dialysis use as a treatment for end-stage kidney disease varies locally, nationally, and internationally. There is a call to action in the United States to significantly increase access and uptake of home dialysis as the preferred dialysis treatment option. Although most do not object to patient choice in modality selection, the reality is that there are multilevel barriers both obvious and subtle that interfere with expanding home dialysis access. Financial barriers and how payment is structured continue to be key drivers, although new models of care are emerging that include for the first time incentives rather than penalties regarding home dialysis. Resources to support implementation include expert personnel requiring educational training. Policies requiring training curriculum content that is not only specified within nephrology but also for these multidisciplinary providers requisite for successful home dialysis to ensure professional expertise is ready and available, and also to cultivate champions of home modality within the broader nephrology community. Perhaps most importantly, innovation through expanded investment in research is necessary to advance practices, elevate quality, and improve outcomes. Policy in a variety of sectors at local, regional, national, and international levels has the potential to drastically drive expansion and increasing success of home dialysis.
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Affiliation(s)
- Rachel B Fissell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, TN, USA
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Pinter J, Chazot C, Stuard S, Moissl U, Canaud B. Sodium, volume and pressure control in haemodialysis patients for improved cardiovascular outcomes. Nephrol Dial Transplant 2020; 35:ii23-ii30. [PMID: 32162668 PMCID: PMC7066545 DOI: 10.1093/ndt/gfaa017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Indexed: 12/12/2022] Open
Abstract
Chronic volume overload is pervasive in patients on chronic haemodialysis and substantially increases the risk of cardiovascular death. The rediscovery of the three-compartment model in sodium metabolism revolutionizes our understanding of sodium (patho-)physiology and is an effect modifier that still needs to be understood in the context of hypertension and end-stage kidney disease. Assessment of fluid overload in haemodialysis patients is central yet difficult to achieve, because traditional clinical signs of volume overload lack sensitivity and specificity. The highest all-cause mortality risk may be found in haemodialysis patients presenting with high fluid overload but low blood pressure before haemodialysis treatment. The second highest risk may be found in patients with both high blood pressure and fluid overload, while high blood pressure but normal fluid overload may only relate to moderate risk. Optimization of fluid overload in haemodialysis patients should be guided by combining the traditional clinical evaluation with objective measurements such as bioimpedance spectroscopy in assessing the risk of fluid overload. To overcome the tide of extracellular fluid, the concept of time-averaged fluid overload during the interdialytic period has been established and requires possible readjustment of a negative target post-dialysis weight. 23Na-magnetic resonance imaging studies will help to quantitate sodium accumulation and keep prescribed haemodialytic sodium mass balance on the radar. Cluster-randomization trials (e.g. on sodium removal) are underway to improve our therapeutic approach to cardioprotective haemodialysis management.
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Affiliation(s)
- Jule Pinter
- Renal Division, University Hospital of Würzburg, Würzburg, Germany
| | | | - Stefano Stuard
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Ulrich Moissl
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
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Flythe JE, Tugman MJ, Narendra JH, Assimon MM, Li Q, Wang Y, Brunelli SM, Hinderliter AL. Effect of ultrafiltration profiling on outcomes among maintenance hemodialysis patients: a pilot randomized crossover trial. J Nephrol 2020; 34:113-123. [PMID: 32975783 DOI: 10.1007/s40620-020-00862-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND More rapid fluid removal during hemodialysis is associated with adverse cardiovascular outcomes and longer dialysis recovery times. The effect of ultrafiltration (UF) profiling, independent of concomitant sodium profiling, on markers of intradialytic hemodynamics and other outcomes has been inadequately studied. METHODS Four-phase, blinded crossover trial. Participants (UF rates > 10 mL/h/kg) were assigned in random order to receive hemodialysis with UF profiling (constantly declining UF rate, intervention) vs. hemodialysis with conventional UF (control). Each 3-week 9-treatment period was followed by a 1-week 3-treatment washout period. Participants crossed into each study arm twice (2 phases/arm); 18 treatments per treatment type. The primary outcomes were intradialytic hypotension, pre- to post-dialysis troponin T change, and change from baseline in left ventricular global longitudinal strain. Other outcomes included intradialytic symptoms and blood volume measured-plasma refill (post-dialysis volume status measure), among others. Each participant served as their own control. RESULTS On average, the 34 randomized patients (mean age 56 years, 24% female, mean dialysis vintage 6.3 years) had UF rates > 10 mL/h/kg in 56% of treatments during the screening period. All but 2 patients completed the 15-week study (prolonged hospitalization, kidney transplant). There was no significant difference in intradialytic hypotension, troponin T change, or left ventricular strain between hemodialysis with UF profiling and conventional UF. With UF profiling, participants had significantly lower odds of light-headedness and plasma refill compared to hemodialysis with conventional UF. CONCLUSIONS Ultrafiltration (UF) profiling did not reduce the odds of treatment-related cardiac stress but did reduce the odds of light-headedness and post-dialysis hypervolemia. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03301740 (registered October 4, 2017).
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA. .,Cecil G. Sheps Center for Health Services Research, UNC, Chapel Hill, NC, USA.
| | - Matthew J Tugman
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA
| | - Julia H Narendra
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA
| | - Magdalene M Assimon
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, 7024 Burnett-Womack CB #7155, Chapel Hill, NC, 27599-7155, USA
| | - Quefeng Li
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Yueting Wang
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - Alan L Hinderliter
- Division of Cardiology, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
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Lim Y, Yang G, Cho S, Kim SR, Lee YJ. Association between Ultrafiltration Rate and Clinical Outcome Is Modified by Muscle Mass in Hemodialysis Patients. Nephron Clin Pract 2020; 144:447-452. [PMID: 32721970 DOI: 10.1159/000509350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The association between ultrafiltration rate (UFR) and mortality may be affected by the muscle mass or volume status in hemodialysis (HD) patients. However, there is an absence of data regarding this association. METHODS We performed an observational study on patients (≥18 years old) who had been on HD for at least 3 months. A body composition monitor (BCM) was used for baseline bioimpedance analysis measurement. The primary composite outcome was defined as the time to death or the first cardiovascular event. RESULTS The median (interquartile range) UFR, volume excess measured by the BCM, and lean tissue index (LTI) (calculated as lean tissue mass/height2) were 11.4 (8.0-15.0) mL/h/kg, 2.4 (1.4-4.1) L, and 12.5 (10.4-14.4) kg/m2, respectively. During 284 person-years of follow-up, the primary outcome occurred in 44 of the 167 patients (26%). Higher UFR was associated with an increased outcome of death or cardiovascular event; the adjusted hazard ratio (HR) was 1.044 (95% confidence interval [CI]: 1.006-1.083). This association remained consistent even after adjusting for volume excess. However, the association between UFR and the primary outcome was modified by LTI (pinteraction = 0.027); the association was significant in patients with LTI < 12.5 kg/m2, and the HR (95% CI) was 1.050 (1.001-1.102). CONCLUSION Higher UFR was associated with an increased risk of a composite outcome of death or cardiovascular event regardless of volume status in HD patients. However, muscle mass may modify the association between higher UFR and increased risk of a composite outcome.
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Affiliation(s)
- Yuntac Lim
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Gyeonghun Yang
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Seong Cho
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Sung Rok Kim
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Yu-Ji Lee
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea,
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Franz DD, Hussein WF, Abra G, Diskin CD, Duggal V, Teuteberg JJ, Chang TI, Schiller B. Outcomes Among Patients With Left Ventricular Assist Devices Receiving Maintenance Outpatient Hemodialysis: A Case Series. Am J Kidney Dis 2020; 77:226-234. [PMID: 32711070 DOI: 10.1053/j.ajkd.2020.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/16/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The incidence of left ventricular assist device (LVAD) implantation as destination therapy for heart failure is increasing and kidney failure requiring maintenance hemodialysis is a common complication. Because little is known about the safety or efficacy of outpatient hemodialysis among patients with LVADs, this study sought to describe their clinical course. STUDY DESIGN Case series of patients with an LVAD undergoing maintenance outpatient hemodialysis whose clinical data were obtained from an electronic medical record. SETTING & PARTICIPANTS Adults who received an LVAD, survived to hospital discharge, and were subsequently treated with maintenance hemodialysis by a not-for-profit dialysis provider between 2011 and 2019. RESULTS 11 patients were included. 6 had a known history of chronic kidney disease. Patients underwent outpatient hemodialysis for a mean duration of 165.2 (range, 31-542) days, during which they were treated with 544 total dialysis sessions. 6 of these sessions were stopped early due to dialysis-related adverse events (1.1%). More than 80% of follow-up time was spent out of the hospital; however, 55% of patients were rehospitalized within 1 month of starting outpatient hemodialysis. The most common reason for hospitalization was infection (32%), followed by hypervolemia (14%), and cerebrovascular accident or transient ischemic attack (11%). 4 patients recovered kidney function, 1 underwent combined heart and kidney transplantation, 2 continued treatment, 2 died, and 2 were lost to follow-up. LIMITATIONS Retrospective design, small number of cases, and lack of complete follow-up data. CONCLUSIONS Approximately half the patients with complete follow-up either recovered kidney function or underwent combined heart and kidney transplantation. This case series demonstrates that outpatient hemodialysis centers, in partnership with LVAD treatment teams, can successfully provide hemodialysis to patients on LVAD support.
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Affiliation(s)
- Douglas D Franz
- Department of Medicine, Stanford University, Palo Alto, CA; Veteran Affairs Palo Alto Health Care System, Palo Alto, CA.
| | - Wael F Hussein
- Department of Medicine, Stanford University, Palo Alto, CA; Satellite Healthcare, San Jose, CA
| | - Graham Abra
- Department of Medicine, Stanford University, Palo Alto, CA; Satellite Healthcare, San Jose, CA
| | - Charles D Diskin
- Department of Medicine, Stanford University, Palo Alto, CA; Satellite Healthcare, San Jose, CA
| | - Vishal Duggal
- Department of Medicine, Stanford University, Palo Alto, CA; Satellite Healthcare, San Jose, CA
| | | | - Tara I Chang
- Department of Medicine, Stanford University, Palo Alto, CA
| | - Brigitte Schiller
- Department of Medicine, Stanford University, Palo Alto, CA; Satellite Healthcare, San Jose, CA
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Zsom L, Zsom M, Abdul Salim S, Fülöp T. Subjective global assessment of nutrition, dialysis quality, and the theory of the scientific method in Nephrology practice. Artif Organs 2020; 44:1021-1030. [PMID: 33617092 DOI: 10.1111/aor.13762] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022]
Abstract
In an era of evidence-based medicine and dialysis performance measures, there is strong motivation to find specific, objective, quantifiable, and reproducible parameters to characterize the clinical condition of chronic kidney disease patients and to present population-wide statistics that may describe quality of care in dialysis centers. Yet, in the last three decades, several studies demonstrated that while parameters including Kt/V urea, serum phosphorus, parathyroid hormone, serum cholesterol fulfill all these criteria, efforts to optimize these lab parameters failed to improve survival on dialysis. However, subjective assessments of nutrition including subjective global assessment and malnutrition-inflammation score, while not ideally suited for statistical analysis and not optimal from the point of view of scientific methodology due to their general, semi-quantifiable, subjective nature have, nevertheless, proved themselves as some of the strongest predictors of clinical outcomes in the dialysis population. Where does this paradox leave us? We propose that a deeper understanding of relevance of these variables in the dialysis population may improve appreciation of the clinical situation of individual patients and may result in a paradigm shift from dialysis adequacy to quality dialysis.
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Affiliation(s)
- Lajos Zsom
- Cegléd Dialysis Unit, Fresenius Medical Care, Cegléd, Hungary
| | - Marianna Zsom
- Department of Medicine, Szent Rókus Hospital, Baja, Hungary
| | - Sohail Abdul Salim
- Department of Medicine, Nephrology Division, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.,Department of Medicine, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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Definiciones de hipotensión intradiálisis con poder predictivo de mortalidad en una cohorte de hemodiálisis. Nefrologia 2020; 40:403-413. [DOI: 10.1016/j.nefro.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 10/03/2019] [Accepted: 01/19/2020] [Indexed: 11/22/2022] Open
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Pereira-García M, Fernández-Prado R, Avelló-Escribano A, González-Parra E. Análisis de la ultrafiltración media por sesión de los pacientes en una unidad de hemodiálisis. ENFERMERÍA NEFROLÓGICA 2020. [DOI: 10.37551/s2254-28842020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción: En los pacientes en hemodiálisis (HD), el ajuste erróneo del peso ideal puede llevarlos a la sobrecarga de líquido que puede desembocar en episodios de insuficiencia cardiaca o a la inversa, a una situación de bajo peso generando hipotensiones que pueden originar cardiopatía isquémica. Se estima como adecuada una ultrafiltración (UF) máxima de 10 ml/kg/h, valor por encima del cual está demostrado el aumento de la mortalidad. Objetivos: Analizar que tasa de ultrafiltración media usamos en nuestra unidad, y conocer qué porcentaje de pacientes sobrepasaban la ultrafiltración máxima recomendada. Material y Método: Realizamos un estudio observacional, prospectivo, en 58 pacientes en hemodiálisis, analizando la tasa de ultrafiltración expresada en ml/kg/h por sesión durante 6 meses. Se definió una tasa de UF>10 ml/kg/h como punto de corte para, según los criterios actuales de tasa adecuada, determinar que pacientes presentaban una UF superior a 10 ml/Kg/h en más de un 25% de las sesiones. Resultados: Durante el periodo de estudio la tasa media de UF de todos los pacientes fue de 8,78±2,76 ml/kg/h, aunque el porcentaje de sesiones por paciente con tasa de UF superior a 10 ml/kg/h fue de un 35,9±29,74%. Conclusión: Un porcentaje alto de pacientes presentan tasas de UF por encima de los valores recomendados. Se han de buscar estrategias para minimizar esta situación, donde la educación sanitaria sobre alimentación y el ajuste individualizado de las sesiones de diálisis son aspectos fundamentales.
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Affiliation(s)
- Mónica Pereira-García
- Fundación Renal Iñigo Álvarez de Toledo-Hospital Universitario Fundación Jiménez Díaz. Madrid. España
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Flythe JE, Chang TI, Gallagher MP, Lindley E, Madero M, Sarafidis PA, Unruh ML, Wang AYM, Weiner DE, Cheung M, Jadoul M, Winkelmayer WC, Polkinghorne KR. Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 97:861-876. [PMID: 32278617 PMCID: PMC7215236 DOI: 10.1016/j.kint.2020.01.046] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/05/2019] [Accepted: 01/08/2020] [Indexed: 02/07/2023]
Abstract
Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.
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Affiliation(s)
- Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Martin P Gallagher
- George Institute for Global Health, Renal and Metabolic Division, Camperdown, Australia; Concord Repatriation General Hospital, Department of Renal Medicine, Sydney, Australia
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Magdalena Madero
- Department of Medicine, Division of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Michel Jadoul
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Melbourne, Australia; Department of Medicine, Monash University, Clayton, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahan, Melbourne, Australia.
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