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Honore PM, Blackman S, Perriens E, Bousbiat I, Wang MM. Is prolonged intermittent renal replacement therapy actually safe for hemodynamically unstable patients. Crit Care 2023; 27:159. [PMID: 37085939 PMCID: PMC10122323 DOI: 10.1186/s13054-023-04438-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023] Open
Affiliation(s)
- Patrick M Honore
- UCLouvain Medical School, CHU UCL Godinne Namur, Avenue G Thérasse 1, 5530, Yvoir, Belgium.
| | - Sydney Blackman
- Brugmann University Hospital, ULB University, Brussels, Belgium
| | - Emily Perriens
- Brugmann University Hospital, ULB University, Brussels, Belgium
| | | | - Min-Min Wang
- Acute Therapies Greater China, Baxter International Inc., Shanghai, China.
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Figuer A, Alique M, Valera G, Serroukh N, Ceprían N, de Sequera P, Morales E, Carracedo J, Ramírez R, Bodega G. New mechanisms involved in the development of cardiovascular disease in chronic kidney disease. Nefrologia 2023; 43:63-80. [PMID: 37268501 DOI: 10.1016/j.nefroe.2023.05.014] [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: 11/15/2021] [Accepted: 03/02/2022] [Indexed: 06/04/2023] Open
Abstract
Chronic kidney disease (CKD) is a pathology with a high worldwide incidence and an upward trend affecting the elderly. When CKD is very advanced, the use of renal replacement therapies is required to prolong its life (dialysis or kidney transplantation). Although dialysis improves many complications of CKD, the disease does not reverse completely. These patients present an increase in oxidative stress, chronic inflammation and the release of extracellular vesicles (EVs), which cause endothelial damage and the development of different cardiovascular diseases (CVD). CKD patients develop premature diseases associated with advanced age, such as CVD. EVs play an essential role in developing CVD in patients with CKD since their number increases in plasma and their content is modified. The EVs of patients with CKD cause endothelial dysfunction, senescence and vascular calcification. In addition, miRNAs free or transported in EVs together with other components carried in these EVs promote endothelial dysfunction, thrombotic and vascular calcification in CKD, among other effects. This review describes the classic factors and focuses on the role of new mechanisms involved in the development of CVD associated with CKD, emphasizing the role of EVs in the development of cardiovascular pathologies in the context of CKD. Moreover, the review summarized the EVs' role as diagnostic and therapeutic tools, acting on EV release or content to avoid the development of CVD in CKD patients.
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Affiliation(s)
- Andrea Figuer
- Departamento de Biología de Sistemas, Universidad de Alcalá (IRYCIS), Alcalá de Henares (Madrid), Spain
| | - Matilde Alique
- Departamento de Biología de Sistemas, Universidad de Alcalá (IRYCIS), Alcalá de Henares (Madrid), Spain.
| | - Gemma Valera
- Departamento de Biología de Sistemas, Universidad de Alcalá (IRYCIS), Alcalá de Henares (Madrid), Spain
| | - Nadia Serroukh
- Departamento de Genética, Fisiología y Microbiología, Facultad de Ciencias Biológicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - Noemí Ceprían
- Departamento de Genética, Fisiología y Microbiología, Facultad de Ciencias Biológicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - Patricia de Sequera
- Sección de Nefrología, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
| | - Enrique Morales
- Sección de Nefrología, Hospital 12 de Octubre, Madrid, Spain
| | - Julia Carracedo
- Departamento de Genética, Fisiología y Microbiología, Facultad de Ciencias Biológicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - Rafael Ramírez
- Departamento de Biología de Sistemas, Universidad de Alcalá (IRYCIS), Alcalá de Henares (Madrid), Spain
| | - Guillermo Bodega
- Departamento de Biomedicina y Biotecnología, Universidad de Alcalá, Alcalá de Henares (Madrid), Spain
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de Sequera P, Pérez-García R, Molina M, Álvarez-Fernández G, Muñoz-González RI, Mérida E, Camba MJ, Blázquez LA, Alcaide MP, Echarri R. Advantages of the use of citrate over acetate as a stabilizer in hemodialysis fluid: A randomized ABC-treat study. Nefrologia 2022; 42:327-337. [PMID: 36210622 DOI: 10.1016/j.nefroe.2021.12.003] [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: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 06/16/2023] Open
Abstract
Hemodialysis (HD) with bicarbonate dialysis fluid (DF) requires the presence of an acid to prevent the precipitation of calcium and magnesium carbonate. The most used acid is acetic acid, with it several complications have been described. In a previous work we described the acute changes during an HD session with a DF with citrate instead of acetate. Now we report the results in the medium term, 16 weeks. It is a prospective, multicenter, crossover and randomized study, where 56 HD patients with bicarbonate three times a week were dialysed for 16 weeks with 3 mmol/L acetate and 16 weeks with 1 mmol/L citrate. Patients older than 18 years with a previous stay on HD of more than 3 months and with a normal functioning arteriovenous fistula were included. Epidemiological data, dialysis, bioimpedance, biochemistry before and after HD, as well as hypotensive episodes, were collected monthly. After 16 weeks of citrate treatment, preHD ionic calcium and magnesium were significantly lower and PTH higher than in the acetate period. No differences were observed in the effectiveness of dialysis. Hypotensive episodes were significantly more frequent with acetate than with citrate: 311 (14.1%) vs 238 (10.8%) sessions. The lean mass index increased by 0.96 ± 2.33 kg/m2 when patients switched from LD with acetate to citrate. HD with citrate modifies several parameters of bone mineral metabolism, not only acutely as previously described, but also in the long term. The substitution of acetate for citrate improves hemodynamic stability, producing less hypotension and can improve nutritional status.
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Affiliation(s)
- Patricia de Sequera
- Departamento de Medicina, Universidad Complutense, Madrid, Spain; Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain.
| | - Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Manuel Molina
- Servicio de Nefrología, Hospital Universitario General de Santa Lucía, Cartagena, Spain
| | | | | | - Evangelina Mérida
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Jesús Camba
- Servicio de Nefrología, Complejo Hospitalario Universitario de Ourense, Orense, Spain
| | - Luis Alberto Blázquez
- Servicio de Nefrología, Hospital General Universitario de Guadalajara, Guadalajara, Spain
| | - Maria Paz Alcaide
- Servicio de Nefrología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rocío Echarri
- Servicio de Nefrología, Hospital Universitario Infanta Sofia, Madrid, Spain
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4
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Figuer A, Alique M, Valera G, Serroukh N, Ceprían N, de Sequera P, Morales E, Carracedo J, Ramírez R, Bodega G. Nuevos mecanismos implicados en el desarrollo de la enfermedad cardiovascular en la enfermedad renal crónica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Hanoy M, Le Roy F. Prescription en hémodiafiltration : quel abord vasculaire, quel débit de pompe à sang, quel concentré acide, quel débit de substitution, quelle modalité ? Nephrol Ther 2022. [DOI: 10.1016/s1769-7255(22)00034-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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de Sequera P, Pérez-García R, Molina M, Álvarez-Fernández G, Muñoz-González RI, Mérida E, Camba MJ, Blázquez LA, Alcaide MP, Echarri R. Advantages of the use of citrate over acetate as a stabilizer in hemodialysis fluid: A randomized ABC-treat study. Nefrologia 2021; 42:S0211-6995(21)00137-5. [PMID: 34391608 DOI: 10.1016/j.nefro.2021.06.006] [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: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022] Open
Abstract
Hemodialysis (HD) with bicarbonate dialysis fluid (DF) requires the presence of an acid to prevent the precipitation of calcium and magnesium carbonate. The most used acid is acetic acid, with it several complications have been described. In a previous work, we described the acute changes during an HD session with a DF with citrate instead of acetate. Now, we report the results in the medium term, 16 weeks. It is a prospective, multicenter, crossover and randomized study, where 56 HD patients with bicarbonate three times a week were dialysed for 16 weeks with 3mmol/L acetate and 16 weeks with 1mmol/L citrate. Patients older than 18 years with a previous stay on HD of more than 3 months and with a normal functioning arteriovenous fistula were included. Epidemiological data, dialysis, bioimpedance, biochemistry before and after HD, as well as hypotensive episodes, were collected monthly. After 16 weeks of citrate treatment, pre-HD ionic calcium and magnesium were significantly lower and paratiroid hormone (PTH) higher than in the acetate period. No differences were observed in the effectiveness of dialysis. Hypotensive episodes were significantly more frequent with acetate than with citrate: 311 (14.1%) vs 238 (10.8%) sessions. The lean mass index increased by 0.96±2.33kg/m2 when patients switched from DF with acetate to citrate. HD with citrate modifies several parameters of bone mineral metabolism, not only acutely as previously described, but also in the long-term. The substitution of acetate for citrate improves hemodynamic stability, producing less hypotension and can improve nutritional status.
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Affiliation(s)
- Patricia de Sequera
- Departamento de Medicina, Universidad Complutense, Madrid, España; Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España.
| | - Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Manuel Molina
- Servicio de Nefrología, Hospital Universitario General de Santa Lucía, Cartagena, España
| | | | | | - Evangelina Mérida
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Maria Jesús Camba
- Servicio de Nefrología, Complejo Hospitalario Universitario de Ourense, Orense, España
| | - Luis Alberto Blázquez
- Servicio de Nefrología, Hospital General Universitario de Guadalajara, Guadalajara, España
| | - María Paz Alcaide
- Servicio de Nefrología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Rocío Echarri
- Servicio de Nefrología, Hospital Universitario Infanta Sofia, Madrid, España
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Vida C, Carracedo J, de Sequera P, Bodega G, Pérez R, Alique M, Ramírez R. A high magnesium concentration in citrate dialysate prevents oxidative stress and damage in human monocytes in vitro. Clin Kidney J 2021; 14:1403-1411. [PMID: 33959268 PMCID: PMC8087128 DOI: 10.1093/ckj/sfaa131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of dialysis fluids (DFs) during haemodialysis has been associated with increased oxidative stress and reduced serum magnesium (Mg) levels, contributing to chronic inflammation. Since the role of Mg in modulating immune function and reducing oxidative stress has been demonstrated, the aim of this study was to characterize in vitro whether increasing the Mg concentration in DFs could protect immune cells from oxidative stress and damage. METHODS The effect of citrate [citrate dialysis fluid (CDF), 1 mM] or acetate [acetate dialysis fluid (ADF), 3 mM] dialysates with low (0.5 mM; routinely used) or high (1 mM, 1.25 mM and 2 mM) Mg concentrations was assessed in THP-1 human monocytes. The levels of reactive oxygen species (ROS), malondialdehyde (MDA) and oxidized/reduced (GSSG/GSH) glutathione were quantified under basal and inflammatory conditions (stimulation with lipopolysaccharide, LPS). RESULTS The increase of Mg in CDF resulted in a significant reduction of ROS production under basal and inflammatory conditions (extremely marked in 2 mM Mg; P < 0.001). These effects were not observed in ADF. Interestingly, in a dose-dependent manner, high Mg doses in CDF reduced oxidative stress in monocytes under both basal and inflammatory conditions. In fact, 2 mM Mg significantly decreased the levels of GSH, GSSG and MDA and the GSSG/GSH ratio in relation to 0.5 mM Mg. CONCLUSIONS CDF produces lower oxidative stress than ADF. The increase of Mg content in DFs, especially in CDF, could have a positive and protective effect in reducing oxidative stress and damage in immune cells, especially under inflammatory conditions.
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Affiliation(s)
- Carmen Vida
- Dpto de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Julia Carracedo
- Dpto Genética, Fisiología y Microbiología (Sección Fisiología), Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Patricia de Sequera
- Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
- Dpto de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Guillermo Bodega
- Dpto de Biomedicina y Biotecnología, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Rafael Pérez
- Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Matilde Alique
- Dpto de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria, (IRYCIS), Madrid, Spain
| | - Rafael Ramírez
- Dpto de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria, (IRYCIS), Madrid, Spain
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8
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Marcelli D, Basile C. Has time come to replace the residual acetate with citrate in the dialysis fluid? J Nephrol 2021; 35:87-90. [PMID: 33661506 DOI: 10.1007/s40620-021-00991-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Affiliation(s)
| | - Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy. .,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
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Pizzarelli F, Cantaluppi V, Panichi V, Toccafondi A, Ferro G, Farruggio S, Grossini E, Dattolo PC, Miniello V, Migliori M, Grimaldi C, Casani A, Borzumati M, Cusinato S, Capitanini A, Quercia A, Filiberti O, Dani L. Citrate high volume on-line hemodiafiltration modulates serum Interleukin-6 and Klotho levels: the multicenter randomized controlled study "Hephaestus". J Nephrol 2021; 34:1701-1710. [PMID: 33559851 DOI: 10.1007/s40620-020-00943-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies addressing the anti-inflammatory properties of citrate dialysate enrolled patients in both hemodialysis (HD) and hemodiafiltration (HDF), the latter not adjusted for adequate convective exchange. This is a potential source of confounding in that HDF itself has anti-inflammatory effects regardless of the buffer, and optimal clinical outcomes are related to the amount of convection. METHODS To distinguish the merits of the buffer from those of convection, we performed a 6-month, prospective, randomized, crossover AB-BA study. Comparisons were made during the 3-month study period of on-line HDF with standard dialysate containing three mmol of acetic acid (OL-HDFst) and the 3-month of OL-HDF with dialysate containing one mmol of citric acid (OL-HDFcit). Primary outcome measure of the study was interleukin-6 (IL-6). Klotho, high sensitivity C-reactive protein (hsCRP), fetuin and routine biochemical parameters were also analyzed. RESULTS We analyzed 47 patients (mean age 64 years, range 27-84 years) enrolled in 10 participating Nephrology Units. Convective volumes were around 25 L/session with 90 percent of sessions > 20 L and ß2-microglobulin reduction rate 76% in both HDFs. Baseline median IL-6 values in OL-HDFst were 5.6 pg/ml (25:75 interquartile range IQR 2.9:10.6) and in OL-HDFcit 6.6 pg/ml (IQR 3.4:11.4 pg/ml). The difference was not statistically significant (p 0.88). IL-6 values were lower during OL-HDFcit than during OL-HDFst, both when analyzed as the median difference of overall IL-6 values (p 0.02) and as the median of pairwise differences between the baseline and the 3-month time points (p 0.03). The overall hsCRP values too, were lower during OL-HDFcit than during OL-HDFst (p 0.01). Klotho levels showed a time effect (p 0.02) and the increase was significant only during OL-HDFcit (p 0.01). CONCLUSIONS Citrate buffer modulated IL-6, hsCRP and Klotho levels during high volume OL-HDF. These results are not attributable to differences in the dialysis technology that was applied and may suggest a potential biological effect of citrate on CKD-associated inflammatory state. ClinicalTrials.gov identifier NCT02863016.
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Affiliation(s)
- Francesco Pizzarelli
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy.
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
| | - Vincenzo Panichi
- Nephrology and Dialysis Unit, Versilia Hospital, ASL Nord-Ovest, Lido Di Camaiore, Italy
| | - Alessandro Toccafondi
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy
| | - Giuseppe Ferro
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy
| | - Serena Farruggio
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
| | - Elena Grossini
- Lab Physiology, Department Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
| | - Pietro Claudio Dattolo
- Nephrology and Dialysis Unit, SM Annunziata Hospital, ASL Toscana Centro, via dell'Antella, 50012, Firenze, Italy
| | | | - Massimiliano Migliori
- Nephrology and Dialysis Unit, Versilia Hospital, ASL Nord-Ovest, Lido Di Camaiore, Italy
| | - Cristina Grimaldi
- Nephrology and Dialysis Unit, NSGD Hospital, ASL Toscana Centro, Firenze, Italy
| | - Aldo Casani
- Nephrology and Dialysis Unit, ASL Nord-Ovest, Massa Carrara, Italy
| | - Maurizio Borzumati
- Nephrology and Dialysis Unit, ASL VCO, Verbania, Verbano Cusio Ossola, Italy
| | - Stefano Cusinato
- Nephrology and Dialysis Unit, Borgomanero Hospital, ASL NO Novara, Borgomanero, Italy
| | | | | | | | - Lucia Dani
- Nephrology and Dialysis Unit, ASL Toscana Centro, Empoli, Italy
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Pizzarelli F, Basile C. The Gordian knot of the long-term safety of dialysate citrate: is there really a concern about patient hard outcomes? Nephrol Dial Transplant 2020; 35:1090-1094. [DOI: 10.1093/ndt/gfaa033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/27/2020] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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Increasing the Magnesium Concentration in Various Dialysate Solutions Differentially Modulates Oxidative Stress in a Human Monocyte Cell Line. Antioxidants (Basel) 2020; 9:antiox9040319. [PMID: 32326605 PMCID: PMC7222382 DOI: 10.3390/antiox9040319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/01/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022] Open
Abstract
Oxidative stress is exacerbated in hemodialysis patients by several factors, including the uremic environment and the use of dialysis fluids (DFs). Since magnesium (Mg) plays a key role in modulating immune function and in reducing oxidative stress, we aimed to evaluate whether increasing the Mg concentration in different DFs could protect against oxidative stress in immunocompetent cells in vitro. Effect of ADF (acetate 3 mM), CDF (citrate 1 mM), and ACDF (citrate 0.8 mM + acetate 0.3 mM) dialysates with Mg at standard (0.5 mM) or higher (1, 1.25, and 2 mM) concentrations were assessed in THP-1 monocyte cultures. Reactive oxygen species (ROS) and malondialdehyde (MDA) levels were quantified under basal and uremic conditions (indoxyl sulfate (IS) treatment). Under uremic conditions, the three DFs with 0.5 mM Mg promoted higher ROS production and lipid damage than the control solution. However, CDF and ACDF induced lower levels of ROS and MDA, compared to that induced by ADF. High Mg concentration (1.25 and/or 2 mM) in CDF and ACDF protected against oxidative stress, indicated by reduced ROS and MDA levels compared to respective DFs with standard concentration of Mg. Increasing Mg concentrations in ADF promoted high ROS production and MDA content. Thus, an increase in Mg content in DFs has differential effects on the oxidative stress in IS-treated THP-1 cells depending on the dialysate used.
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Potier J, Dolley-Hitze T, Hamel D, Landru I, Cardineau E, Queffeulou G, Zagdoun E, Renaudineau E, Molinari N, Gamon L, Morena M, Cristol JP, Canaud B. Long-term effects of citric acid-based bicarbonate haemodialysis on patient outcomes: a survival propensity score–matched study in western France. Nephrol Dial Transplant 2020; 35:1228-1236. [DOI: 10.1093/ndt/gfz274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/22/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Citric acid–based bicarbonate haemodialysis (CIT-HD) has gained more clinical acceptance over the last few years in France and is a substitute for other acidifiers [e.g. acetic acid (CH3COOH) and hydrochloric acid (HCl)]. This trend was justified by several clinical benefits compared with CH3COOH as well as the desire to avoid the consequences of the corrosive action of HCl, but a nationwide clinical report raised concerns about the long-term safety of CIT-HD. The aim of this study was to assess the long-term effects of CIT-HD exposure on patient outcomes in western France.
Methods
This is a population-based retrospective multicentre observational study performed in 1132 incident end-stage kidney disease patients in five sanitary territories in western France who started their renal replacement therapy after 1 January 2008 and followed up through 15 October 2018. Relevant data, collected prospectively with the same medical software, were anonymously aggregated for the purposes of the study. The primary goal of this study was to investigate the effects of citrate exposure on all-cause mortality. To provide a control group to CIT-HD one, propensity score matching (PSM) at 2:1 was performed in two steps: the first analysis was intended to be exploratory, comparing patients who received citrate ≤80% of the time (CIT-HD ≤80) versus those who received citrate >80% of the time (CIT-HD >80), while the second analysis was intended to be explanatory in comparing patients with 0% (CIT-HD0) versus 100% citrate time exposure (CIT-HD100).
Results
After PSM, in the exploratory part of the analysis, 432 CIT-HD ≤80 patients were compared with 216 CIT-HD >80 patients and no difference was found for all-cause mortality using the Kaplan–Meier model (log-rank 0.97), univariate Cox regression analysis {hazard ratio [HR] 1.01 [95% confidence interval (CI) 0.71–1.40]} and multivariate Cox regression analysis [HR 1.11 (95% CI 0.76–1.61)] when adjusted for nine variables with clinical pertinence and high statistical relevance in the univariate analysis. In the explanatory part of the analysis, 316 CIT-HD0 patients were then compared with 158 CIT-HD100 patients and no difference was found using the Kaplan–Meier model (log-rank 0.06), univariate Cox regression analysis [HR 0.69 (95% CI 0.47–1.03)] and multivariate Cox regression analysis [HR 0.87 (95% CI 0.57–1.33)] when adjusted for seven variables with clinical pertinence and high statistical relevance in the univariate analysis.
Conclusions
Findings of this study support the notion that CIT-HD exposure ≤6 years has no significant effect on all-cause mortality in HD patients. This finding remains true for patients receiving high-volume online haemodiafiltration, a modality most frequently prescribed in this cohort.
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Affiliation(s)
- Jacky Potier
- Department of Nephrology and Hemodialysis, Centre Hospitalier Public du Cotentin, Cherbourg, France
| | | | | | - Isabelle Landru
- Department of Nephrology and Hemodialysis, Centre Hospitalier Robert Bisson, Lisieux, France
| | - Erick Cardineau
- Department of Nephrology and Hemodialysis, Centre Hospitalier Intercommunal Alencon-Mamers, Alençon, France
| | - Guillaume Queffeulou
- Department of Nephrology and Hemodialysis, Centre Hospitalier Public du Cotentin, Cherbourg, France
| | - Elie Zagdoun
- Department of Nephrology and Hemodialysis, Centre Hospitalier Mémorial France Etats-Unis, Saint-Lô, France
| | - Eric Renaudineau
- Department of Nephrology and Hemodialysis, Centre Hospitalier Broussais, Saint-Malo, France
| | - Nicolas Molinari
- IMAG, CNRS, Centre Hospitalier Universitaire de Montpellier, University of Montpellier, Montpellier, France
| | - Lucie Gamon
- Clinical Research and Epidemiology Unit, Centre Hospitalier Universitaire de Montpellier, University of Montpellier, Montpellier, France
| | - Marion Morena
- PhyMedExp. INSERM, CNRS, Université de Montpellier, Montpellier, France
| | - Jean-Paul Cristol
- PhyMedExp. INSERM, CNRS, Université de Montpellier, Montpellier, France
- Département de Biochimie et Hormonologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Bernard Canaud
- School of Medicine, Montpellier University, Montpellier, France
- FMC, Global Medical Office, Bad Homburg, Germany
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Citrate anion improves chronic dialysis efficacy, reduces systemic inflammation and prevents Chemerin-mediated microvascular injury. Sci Rep 2019; 9:10622. [PMID: 31337804 PMCID: PMC6650610 DOI: 10.1038/s41598-019-47040-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/25/2019] [Indexed: 12/04/2022] Open
Abstract
Systemic inflammation and uremic toxins (UT) determine the increased cardiovascular mortality observed in chronic hemodialysis (HD) patients. Among UT, the adipokine Chemerin induces vascular dysfunction by targeting both endothelial and vascular smooth muscular cells (EC and VSMC). As Citrate anion modulates oxidative metabolism, systemic inflammation and vascular function, we evaluated whether citrate-buffered dialysis improves HD efficiency, inflammatory parameters and chemerin-mediated microvascular injury. 45 patients were treated in sequence with acetate, citrate and, again, acetate-buffered dialysis solution (3 months per interval). At study admission and after each treatment switch, we evaluated dialysis efficacy and circulating levels of chemerin and different inflammatory biomarkers. In vitro, we stimulated EC and VSMC with patients’ plasma and we investigated the role of chemerin as UT. Citrate dialysis increased HD efficacy and reduced plasma levels of CRP, fibrinogen, IL6 and chemerin. In vitro, patients’ plasma induced EC and VSMC dysfunction. These effects were reduced by citrate-buffered solutions and paralleled by the decrease of chemerin levels. Consistently, chemerin receptor knockdown reduced EC and VSMC dysfunction. In conclusion, Switching from acetate to citrate improved dialysis efficacy and inflammatory parameters; in vitro, chemerin-induced EC and VSMC injury were decreased by using citrate as dialysis buffer.
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Dao M, Touam M, Joly D, Mercadal L. Nouveaux dialysats : quel acide dans le bain de dialyse ? Nephrol Ther 2019; 15 Suppl 1:S91-S97. [DOI: 10.1016/j.nephro.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
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de Sequera Ortiz P, Pérez García R, Molina Nuñez M, Muñoz González RI, Álvarez Fernández G, Mérida Herrero E, Camba Caride MJ, Blázquez Collado LA, Alcaide Lara MP, Echarri Carrillo R. Prospective randomised multicentre study to demonstrate the benefits of haemodialysis without acetate (with citrate): ABC-treat Study. Acute effect of citrate. Nefrologia 2019; 39:424-433. [PMID: 30686542 DOI: 10.1016/j.nefro.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/11/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Dialysis fluid (DF), an essential element in hemodialysis (HD), is manufactured in situ by mixing three components: treated water, bicarbonate concentrate and acid concentrate. To avoid the precipitation of calcium and magnesium carbonate that is produced in DF by the addition of bicarbonate, it is necessary to add an acid. There are 2 acid concentrates that contain acetate (ADF) or citrate (CDF) as a stabilizer. OBJECTIVE To compare the acute effect of HD with CDF vs. ADF on the metabolism of calcium, phosphorus and magnesium, acid base balance, coagulation, inflammation and hemodynamic stability. METHODS Prospective, multicenter, randomized and crossed study, of 32 weeks duration, in patients in three-week HD, AK-200-Ultra-S or Artis monitor, 16 weeks with ADF SoftPac®, prepared with 3mmol/L of acetate, and 16 weeks with CDF SelectBag Citrate®, with 1mmol/L of citrate. Patients older than 18 years were included in HD for a minimum of 3 months by arteriovenous fistula. Epidemiological, dialysis, pre and postdialysis biochemistry, episodes of arterial hypotension, and coagulation scores were collected monthly during the 8 months of the study. Pre and post-dialysis analysis were extracted: venous blood gas, calcium (Ca), ionic calcium (Cai), phosphorus (P), magnesium (Mg) and parathyroid hormone (PTH) among others. ClinicalTrials.gov NCT03319680. RESULTS We included 56 patients, 47 (84%) men and 9 (16%) women, mean age: 65.3 (16.4) years, technique HD/HDF: 20 (35.7%)/36 (64.3%). We found differences (p<0.05) when using the DF with citrate (C) versus acetate (A) in the postdialysis values of bicarbonate [C: 26.9 (1.9) vs. A: 28.5 (3) mmol/L], Cai [C: 1.1 (0.05) vs. A: 1.2 (0.08) mmol/L], Mg [C: 1.8 (0.1) vs A: 1, 9 (0.2) mg/dL] and PTH [C: 255 (172) vs. 148 (149) pg/mL]. We did not find any differences in any of the parameters measured before dialysis. Of the 4,416 sessions performed, 2,208 in each group, 311 sessions (14.1%) with ADF and 238 (10.8%) with CDF (p<0.01), were complicated by arterial hypotension. The decrease in maximum blood volume measured by Hemoscan® biosensor was also lower [-3.4 (7.7) vs -5.1 (8.2)] although without statistical significance. CONCLUSION Dialysis with citrate acutely produces less postdialysis alkalemia and significantly modifies Ca, Mg and PTH. CDF has a positive impact on hemodynamic tolerance.
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Affiliation(s)
| | - Rafael Pérez García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
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Lugon J, Pereira G, Strogoff-de-Matos J, Peixoto A. Kinetics of acid-base parameters in conventional hemodialysis. Braz J Med Biol Res 2018; 52:e7974. [PMID: 30539970 PMCID: PMC6301264 DOI: 10.1590/1414-431x20187974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/22/2018] [Indexed: 11/22/2022] Open
Abstract
Details about the acid-base changes in hemodialysis are scarce in the literature but are potentially relevant to adequate management of patients. We addressed the acid-base kinetics during hemodialysis and throughout the interdialytic period in a cross-sectional study of adults undergoing conventional hemodialysis. Samples for blood gas analysis were obtained from the arterial limb of the arteriovenous fistula before the first session of the week (HD1), immediately at the end of HD1, and on sequential collections at 15, 30, 45, 60, and 120 min post-HD1. Additional blood samples were collected after ∼20 h following the end of the first dialysis and immediately prior to the initiation of the second dialysis of the week. Thirty adult patients were analyzed (55±15 years, 50% men, 23% diabetic; dialysis vintage 69±53 months). Mean serum bicarbonate levels increased at the end of HD1 (22.3±2.7 mEq/L vs 17.5±2.3 mEq/L, P<0.001) and remained stable until 20 h after the end of the session. The mean values of pCO2 before HD1 were below reference and at 60 and 120 min post-HD1 were significantly lower than at the start (31.3±2.7 mmHg and 30.9±3.7 mmHg vs 34.3±4.1 mmHg, P=0.041 and P=0.010, respectively). The only point of collection in which mean values of pCO2 were above 35 mmHg was 20 h post-dialysis. Serum bicarbonate levels remained stable for at least 20 h after the dialysis sessions, a finding that may have therapeutic implications. During dialysis, the respiratory response for correction of metabolic acidosis (i.e., pCO2 elevation) was impaired.
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Affiliation(s)
- J.R. Lugon
- Divisão de Nefrologia, Departamento de Medicina, Faculdade de Medicina, Universidade Federal Fluminense, Niteroi, RJ, Brasil
| | - G.R.M. Pereira
- Curso de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal Fluminense, Niteroi, RJ, Brasil
| | - J.P. Strogoff-de-Matos
- Divisão de Nefrologia, Departamento de Medicina, Faculdade de Medicina, Universidade Federal Fluminense, Niteroi, RJ, Brasil
| | - A.J. Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA
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Pérez-García R, Ramírez Chamond R, de Sequera Ortiz P, Albalate M, Puerta Carretero M, Ortega M, Ruiz Caro MC, Alcazar Arroyo R. Citrate dialysate does not induce oxidative stress or inflammation in vitro as compared to acetate dialysate. Nefrologia 2018; 37:630-637. [PMID: 29122211 DOI: 10.1016/j.nefro.2017.03.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/20/2017] [Accepted: 03/16/2017] [Indexed: 11/17/2022] Open
Abstract
Increased acetataemia during haemodialysis sessions has been associated with a number of abnormalities, including increased oxidative stress, pro-inflammatory cytokines and nitric oxide synthesis. However, citric acid may play an alternative role to acetate as a dialysate stabiliser given that the effect of citrate on complement and leukocyte activation is different to that of acetate. The purpose of this study was to compare the inflammatory effect in immunocompetent blood cells of acetate dialysate and citrate dialysate. MATERIAL AND METHODS The effect of acetate and/or citrate was investigated in the whole blood of uraemic patients and in healthy in vitro samples. Four types of dialysate were tested: dialysate 1, acetate-free with 1mmol/L of citrate; dialysate 2, with 0.8mmol/L of citrate and 0.3mmol/L of acetate; dialysate 3, citrate-free with 3mmol/L of acetate; and dialysate 4, citrate-free with 4mmol/L of acetate. The cell types used were: human monocyte culture (THP-1); and peripheral blood mononuclear cells (PBMCs) from healthy subjects and uraemic patients on haemodialysis. ICAM-1 was determined and levels of reactive oxygen species and total microvesicles were quantified. RESULTS Unlike the citrate dialysates, the dialysates with acetate (dialysate 3 and dialysate 4) induced increased ICAM-1 expression density in THP-1 cells; an increase in ICAM-1 expression was observed in the immunocompetent cells of healthy subjects with acetate dialysate (dialysate 3 and dialysate 4) but not with citrate dialysate (dialysate 1 and dialysate 2). No significant ICAM-1 differences were found between the different dialysates in the cells of haemodialysed patients. Reactive oxygen species expression and the number of microvesicles increased significantly with acetate dialysate but not with citrate dialysate in the cells of both healthy subjects and haemodialysed patients. CONCLUSIONS At the concentrations in which it is generally used in clinical practice, acetate-based dialysate increases oxidative stress and the total number of microvesicles and may induce other pro-inflammatory stimuli typical of uraemic patients on haemodialysis. Citrate dialysates do not induce this activation, which could make them a suitable alternative in clinical practice.
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Affiliation(s)
- Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España.
| | - Rafael Ramírez Chamond
- Departamento de Biología de Sistemas, Facultad de Medicina y Ciencias de la Salud Universidad de Alcalá, Alcalá de Henares (Madrid), España
| | | | - Marta Albalate
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | | | - Mayra Ortega
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - M Caridad Ruiz Caro
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
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Marshall MR. Measuring the patient response to dialysis therapy: hemodiafiltration and clinical trials. Kidney Int 2018; 91:1279-1282. [PMID: 28501302 DOI: 10.1016/j.kint.2017.02.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 10/19/2022]
Abstract
There is a strong biological plausibility for benefit from removal of larger uremic toxins and increasing positive clinical experience with hemodiafiltration. However, evidence supporting hemodiafiltration is not definitive with studies that are often limited by serious methodological shortcomings. Morena et al. show that hemodiafiltration may prevent intradialytic hypotension, albeit in a study that also has some shortcomings. Ongoing research for hemodiafiltration is still needed through high-quality clinical trials that adhere to standards for clinical trial conduct and reporting.
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Affiliation(s)
- Mark R Marshall
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Renal Medicine, Counties Manukau District Health Board, Auckland, New Zealand; Therapeutic Area, Baxter Healthcare (Asia) Pty. Ltd., Singapore.
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Comparison of the hemodynamic tolerance and the biological parameters of four acetate-free hemodialysis methods. Nephrol Ther 2017; 13:532-536. [DOI: 10.1016/j.nephro.2017.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 02/28/2017] [Accepted: 03/16/2017] [Indexed: 11/20/2022]
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Smith WB, Gibson S, Newman GE, Hendon KS, Askelson M, Zhao J, Hantash J, Flanagan B, Larkin JW, Usvyat LA, Thadhani RI, Maddux FW. The dynamics of the metabolism of acetate and bicarbonate associated with use of hemodialysates in the ABChD trial: a phase IV, prospective, single center, single blind, randomized, cross-over, two week investigation. BMC Nephrol 2017; 18:273. [PMID: 28851317 PMCID: PMC5576126 DOI: 10.1186/s12882-017-0683-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 08/04/2017] [Indexed: 11/17/2022] Open
Abstract
Background In the United States, hemodialysis (HD) is generally performed via a bicarbonate dialysate. It is not known if small amounts of acid used in dialysate to buffer the bicarbonate can meaningfully contribute to overall buffering administered during HD. We aimed to investigate the metabolism of acetate with use of two different acid buffer concentrates and determine if it effects blood bicarbonate concentrations in HD patients. Methods The Acid-Base Composition with use of hemoDialysates (ABChD) trial was a Phase IV, prospective, single blind, randomized, cross-over, 2 week investigation of peridialytic dynamics of acetate and bicarbonate associated with use of acid buffer concentrates. Eleven prevalent HD patients participated from November 2014 to February 2015. Patients received two HD treatments, with NaturaLyte® and GranuFlo® acid concentrates containing 4 and 8 mEq/L of acetate, respectively. Dialysate order was chosen in a random fashion. The endpoint was to characterize the dynamics of acetate received and metabolized during hemodialysis, and how it effects overall bicarbonate concentrations in the blood and dialysate. Acetate and bicarbonate concentrations were assessed before, at 8 time points during, and 6 time points after the completion of HD. Results Data from 20 HD treatments for 11 patients (10 NaturaLyte® and 10 GranuFlo®) was analyzed. Cumulative trajectories of arterialized acetate were unique between NaturaLyte® and GranuFlo® (p = 0.003), yet individual time points demonstrated overlap without remarkable differences. Arterialized and venous blood bicarbonate concentrations were similar at HD initiation, but by 240 min into dialysis, mean arterialized bicarbonate concentrations were 30.2 (SD ± 4.16) mEq/L in GranuFlo® and 28.8 (SD ± 4.26) mEq/L in NaturaLyte®. Regardless of acid buffer concentrate, arterial blood bicarbonate was primarily dictated by the prescribed bicarbonate level. Subjects tolerated HD with both acid buffer concentrates without experiencing any related adverse events. Conclusions A small fraction of acetate was delivered to HD patients with use of NaturaLyte® and GranuFlo® acid buffers; the majority of acetate received was observed to be rapidly metabolized and cleared from the circulation. Blood bicarbonate concentrations appear to be determined mainly by the prescribed concentration of bicarbonate. Trial registration This trial was registered on ClinicalTrials.gov on 11 Dec 2014 (NCT02334267). Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0683-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William B Smith
- Volunteer Research Group and New Orleans Center for Clinical Research at the University of Tennessee Medical Center, 1928 Alcoa Highway, Suite 107, Knoxville, TN, 37920, USA.
| | - Sandy Gibson
- Volunteer Research Group and New Orleans Center for Clinical Research at the University of Tennessee Medical Center, 1928 Alcoa Highway, Suite 107, Knoxville, TN, 37920, USA
| | - George E Newman
- Knoxville Kidney Center, PLLC, 320 Park 40 N Blvd, Knoxville, TN, 37923, USA
| | - Kendra S Hendon
- Knoxville Kidney Center, PLLC, 320 Park 40 N Blvd, Knoxville, TN, 37923, USA
| | | | - James Zhao
- EDETEK, 500 College Road East, Suite 200, Princeton, NJ, 08540, USA
| | - Jamil Hantash
- Tandem Labs, 115 Silvia Street, West Trenton, NJ, 08628, USA
| | - Brigid Flanagan
- Frenova Renal Research, 920 Winter Street, Waltham, MA, 02451, USA
| | - John W Larkin
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| | - Len A Usvyat
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| | - Ravi I Thadhani
- Massachusetts General Hospital Division of Nephrology, 55 Fruit Street #1008, Boston, MA, 02114, USA
| | - Franklin W Maddux
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
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Tangvoraphonkchai K, Davenport A. Increasing Haemodialytic Clearances as Residual Renal Function Declines: An Incremental Approach. Blood Purif 2017; 44:217-226. [DOI: 10.1159/000475458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/02/2017] [Indexed: 11/19/2022]
Abstract
Many patients with chronic kidney disease start undergoing thrice-weekly haemodialysis (HD), aiming for an HD sessional dialyzer urea clearance target, irrespective of whether they have residual renal function (RRF). While increasing sessional dialyzer urea clearance above a target of 1.2 has not been shown to improve patient survival, it has been shown that the preservation of RRF improves patient self-reported outcomes and survival. Observational studies have suggested that initiating twice-weekly HD schedules leads to greater preservation of RRF. This has led to the concept of following an incremental approach to initiating HD, steadily increasing the amount of weekly dialyzer clearance as RRF decreases. Incremental dialysis practice requires the regular assessment of RRF to prevent inadequate delivery of dialysis treatment. Once RRF is lost, then the dialysis schedule and modality need to be adjusted to try to increase the middle-sized solute clearance and protein-bound toxins.
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Kato A, Takita T, Furuhashi M. Hypersensitivity reactions to acetate in the bicarbonate dialysate in a patient undergoing pre-dilution online hemodiafiltration. CEN Case Rep 2017; 5:31-33. [PMID: 28509160 DOI: 10.1007/s13730-015-0185-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/24/2015] [Indexed: 10/23/2022] Open
Abstract
A 63-year-old male patient first experienced recurrent hypotensive episode during the dialysis session just after switching the mode from hemodialysis to online hemodiafiltration (OL-HDF) with infusion in pre-dilution of the bicarbonate dialysate containing 9.2 mEq/L of acetate. Peripheral eosinophil count and serum IgE were both elevated to 16,440/μL and 2000 IU/L. The reactions promptly dissolved with substitution of acetate-free solution. This case illustrated that pre-dilution OL-HDF can induce an occult hypersensitivity to acetate in the standard bicarbonate dialysate.
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Affiliation(s)
- Akihiko Kato
- Blood Purification Unit, Hamamatsu University Hospital, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Takako Takita
- Division of Nephrology, Maruyama Hospital, Hamamatsu, Japan
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Molina Nuñez M, de Alarcón R, Roca S, Álvarez G, Ros MS, Jimeno C, Bucalo L, Villegas I, García MÁ. Citrate versus acetate-based dialysate in on-line haemodiafiltration. A prospective cross-over study. Blood Purif 2016; 39:181-187. [PMID: 25791278 DOI: 10.1159/000371569] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/14/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS A bicarbonate dialysate acidified with citrate (CD) has been reported to have local anticoagulant effect and improves biocompatibility. This study examines the effect of CD on dialysis efficiency, coagulation, acid-base status, electrolytes, and inflammation in patients in on-line hemodiafiltration (OL-HDF). METHODS 35 patients in OL-HDF were enrolled in a prospective, cross-over study for a 24-week period and two phases alternating CD and acetate dialysate fluid (AD). Parameters on study were predialysis levels of bicarbonate and ionic calcium, reactive C Protein (CRP), and beta-2 microglobulin (B2MG) and postdialysis levels of activated tromboplastine time, bicarbonate, and ionized calcium. RESULTS No significant differences in coagulation parameters, pH, and predialysis bicarbonate were found. The postdialysis bicarbonate and postdialysis calcium were lower with CD. Dialysis efficiency was greater with CD. Regarding inflammatory parameters, both CRP and B2MG were lower using CD. CONCLUSION The use of CD is safe and effective in OL-HDF, and it improves dialysis efficacy, postdialysis alkalosis, and inflammation.
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Ortiz PDS, Ramón MA, Pérez-García R, Prats EC, Cobo PA, Arroyo RA, Díaz MO, Carretero MP. Acute effect of citrate bath on postdialysis alkalaemia. Nefrologia 2015; 35:164-71. [PMID: 26300510 DOI: 10.1016/j.nefro.2014.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/21/2014] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The correction of metabolic acidosis caused by renal failure is achieved by adding bicarbonate during dialysis. In order to avoid the precipitation of calcium carbonate and magnesium carbonate that takes place in the dialysis fluid (DF) when adding bicarbonate, it is necessary to add an acid, usually acetate, which is not free of side effects. Thus, citrate appears as an advantageous alternative to acetate, despite the fact that its acute effects are not accurately known. OBJECTIVE To assess the acute effect of a dialysis fluid containing citrate instead of acetate on acid-base balance and calcium-phosphorus metabolism parameters. MATERIAL AND METHODS A prospective crossover study was conducted with twenty-four patients (15 male subjects and 9 female subjects). All patients underwent dialysis with AK-200-Ultra-S monitor with SoftPac® dialysis fluid, made with 3 mmol/L of acetate and SelectBag Citrate®, with 1 mmol/L of citrate and free of acetate. The following were measured before and after dialysis: venous blood gas monitoring, calcium (Ca), ionic calcium (Cai), phosphorus (P) and parathyroid hormone (PTH). RESULTS Differences (p<0.05) were found when using the citrate bath (C) compared to acetate (A) in the postdialysis values of: pH, C: 7.43 (0.04) vs. A: 7.47 (0.05); bicarbonate, C: 24.7 (2.7) vs. A: 27.3 (2.1) mmol/L; base excess (BEecf), C: 0.4 (3.1) vs. A: 3.7 (2.4) mmol/L; corrected calcium (Cac), C: 9.8 (0.8) vs. A: 10.1 (0.7) mg/dL; and Cai, C: 1.16 (0.05) vs. A: 1.27 (0.06) mmol/L. No differences were found in either of the parameters measured before dialysis. CONCLUSION Dialysis with citrate provides better control of postdialysis acid-base balance, decreases/avoids postdialysis alkalaemia, and lowers the increase in Cac and Cai. This finding is of special interest in patients with predisposing factors for arrhythmia and patients with respiratory failure, carbon dioxide retention, calcifications and advanced liver disease.
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Affiliation(s)
| | | | - Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid (España)
| | | | | | | | - Maira Ortega Díaz
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid (España)
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Mercadal L, Franck JE, Metzger M, Yuan W, Kolko A, Monnet E, Hannedouche T, Jacquelinet C, Stengel B. Improved survival associated with acetate-free haemodialysis in elderly: a registry-based study. Nephrol Dial Transplant 2015; 30:1560-8. [DOI: 10.1093/ndt/gfv248] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 05/12/2015] [Indexed: 11/13/2022] Open
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Nistor I, Palmer SC, Craig JC, Saglimbene V, Vecchio M, Covic A, Strippoli GFM. Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2015; 2015:CD006258. [PMID: 25993563 PMCID: PMC10766139 DOI: 10.1002/14651858.cd006258.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Convective dialysis modalities (haemofiltration (HF), haemodiafiltration (HDF), and acetate-free biofiltration (AFB)) removed excess body fluid across the dialysis membrane with positive pressure and accumulated middle- and larger-size accumulated solutes more efficiently than haemodialysis (HD). This increased larger solute removal combined with use of ultra-pure dialysis fluid in convective dialysis is hypothesised to reduce the frequency and severity of symptoms during dialysis as well as improve clinical outcomes. Convective dialysis therapies (HDF and HF) are associated with lower mortality compared to diffusive therapy (HD) in observational studies. This is an update of a review first published in 2006. OBJECTIVES To compare convective (HF, HDF, or AFB) with diffusive (HD) dialysis modalities on clinical outcomes (mortality, major cardiovascular events, hospitalisation and treatment-related adverse events) in men and women with end-stage kidney disease (ESKD). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register (to 18 February 2015) through contact with a Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials comparing convective therapy (HF, HDF, AFB) with another convective therapy or diffusive therapy (HD) for treatment of ESKD. DATA COLLECTION AND ANALYSIS Two independent authors identified studies, extracted data and assessed study risk of bias. We summarised treatment effects using the random effects model. We reported results as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous data together with 95% confidence intervals (CI). We assessed for heterogeneity using the Chi(2) test and explored the amount of variation in treatment estimates beyond that expected by chance using the I(2) statistic. MAIN RESULTS Twenty studies comprising 667 participants were included in the 2006 review. In that review, there was insufficient evidence of treatment effects on major clinical outcomes to draw clinically meaningful conclusions. Searching to February 2015 identified 40 eligible studies comprising 3483 participants overall. In total, 35 studies (4039 participants) compared HF, HDF or AFB with HD, three studies (54 participants) compared AFB with HDF, and three studies (129 participants) compared HDF with HF.Risks of bias in all studies were generally high resulting in low confidence in estimated treatment effects. Convective dialysis had no significant effect on all-cause mortality (11 studies, 3396 participants: RR 0.87, 95% CI 0.72 to 1.05; I(2) = 34%), but significantly reduced cardiovascular mortality (6 studies, 2889 participants: RR 0.75, 95% CI 0.61 to 0.92; I(2) = 0%). One study reported no significant effect on rates of nonfatal cardiovascular events (714 participants: RR 1.14, 95% CI 0.86 to 1.50) and two studies showed no significant difference in hospitalisation (2 studies, 1688 participants: RR 1.23, 95% CI 0.93 to 1.63; I(2) = 0%). One study reported rates of hypotension during dialysis were significantly reduced with convective therapy (906 participants: RR 0.72, 95% CI 0.66 to 0.80). Adverse events were not systematically evaluated in most studies and data for health-related quality of life were sparse. Convective therapies significantly reduced predialysis levels of B2 microglobulin (12 studies, 1813 participants: MD -5.55 mg/dL, 95% CI -9.11 to -1.98; I(2) = 94%) and increased dialysis dose (Kt/V urea) (14 studies, 2022 participants: MD 0.07, 95% CI -0.00 to 0.14; I(2) = 90%) compared to diffusive therapy, but results across studies were very heterogeneous. Sensitivity analyses limited to studies comparing HDF with HD showed very similar results. Directly comparative data for differing types of convective dialysis were insufficient to draw conclusions.Studies had important risks of bias leading to low confidence in the summary estimates and were generally limited to patients who had adequate dialysis vascular access. AUTHORS' CONCLUSIONS Convective dialysis may reduce cardiovascular but not all-cause mortality and effects on nonfatal cardiovascular events and hospitalisation are inconclusive. However, any treatment benefits of convective dialysis on all patient outcomes including cardiovascular death are unreliable due to limitations in study methods and reporting. Future studies which assess treatment effects of convection dose on patient outcomes including mortality and cardiovascular events would be informative.
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Affiliation(s)
- Ionut Nistor
- "Gr. T. Popa" University of Medicine and PharmacyNephrology DepartmentBdul Carol I, No 50IasiIasiRomania700503
- Ghent University HospitalEuropean Renal Best Practice Methods Support TeamGhentBelgium
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Valeria Saglimbene
- Mario Negri Sud ConsortiumClinical Pharmacology and EpidemiologyVia Nazionale 8/ASanta Maria ImbaroChietiItaly66030
| | - Mariacristina Vecchio
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologyVia Nazionale 8/ASanta Maria ImbaroChietiItaly66030
| | - Adrian Covic
- "Gr. T. Popa" University of Medicine and PharmacyNephrology DepartmentBdul Carol I, No 50IasiIasiRomania700503
| | - Giovanni FM Strippoli
- The Children’s Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum Medical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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Santoro A, Mancini E. Is hemodiafiltration the technical solution to chronic inflammation affecting hemodialysis patients? Kidney Int 2015; 86:235-7. [PMID: 25079020 DOI: 10.1038/ki.2014.81] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic inflammation is a complication of conventional hemodialysis that induces progressive cardiovascular damage. An apparently straightforward manipulation to treat this-removal of a large amount of uremic toxins by convection-has proven that the relationships between inflammation and convective techniques such as hemodiafiltration are more complicated than we currently understand. This Commentary addresses all the doubts and questions that lie behind the assertion that convection is the solution to the problem of inflammation in dialysis.
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Affiliation(s)
- Antonio Santoro
- Nephrology, Dialysis and Hypertension Unit, Azienda Ospedaliero-Universitaria di Bologna, Teaching Hospital Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Elena Mancini
- Nephrology, Dialysis and Hypertension Unit, Azienda Ospedaliero-Universitaria di Bologna, Teaching Hospital Policlinico S.Orsola-Malpighi, Bologna, Italy
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Šafránek R, Moučka P, Vávrová J, Palička V, Pavlíková L, Sulková SD. Changes of serum calcium, magnesium and parathyroid hormone induced by hemodialysis with citrate-enriched dialysis solution. Kidney Blood Press Res 2015; 40:13-21. [PMID: 25661822 DOI: 10.1159/000368478] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS In recent years, one of technical attempts to improve biocompatibility and tolerability of the hemodialysis procedure is the substitution of acetate in dialysis solution with citrate. The aim of our study was to compare two dialysis solutions: traditional bicarbonate dialysis solution containing acetate (3 mmol/L) (solution A); and (solution C) commercially produced citrate-enriched bicarbonate dialysis solution (0.8 mmol/L citrate). METHODS Patients from a single hemodialysis center (N=126) were included in the study. Both conventional low-flux hemodialysis and on-line hemodiafiltration procedures were studied. Both dialysis solutions contained identical calcium (1.5 mmol/L) and magnesium (0.5 mmol/L) concentrations. RESULTS Parathyroid hormone (iPTH) concentration decreased during procedures with solution A by 64%. On the contrary, when solution C was used, iPTH concentration increased insignificantly by 4%. For solution A, serum calcium and magnesium increased during procedures in patients with predialysis concentrations lower than 2.33 and 0.76 mmol/L, respectively. In procedures with dialysis solution C these concentrations were significantly lower: 2.19 mmol/L for Ca and 0.68 mmol/L for Mg. CONCLUSION Our study clearly shows that the substitution of part of acetate with citrate in dialysis solution significantly influences changes of serum calcium, magnesium and parathyroid hormone concentrations during hemodialysis and hemodiafiltration procedures.
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Affiliation(s)
- Roman Šafránek
- Hemodialysis Center, University Hospital, Hradec Kralove, Czech Republic
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Tiranathanagul K, Tangvoraphonkchai K, Srisawat N, Susantitaphong P, Tungsanga K, Praditpornsilpa K, Eiam-Ong S. Acute intradialytic cardiac function and inflammatory cytokine changes during high-efficiency online hemodiafiltration with acetate-free and standard dialysis solutions. Ther Apher Dial 2014; 19:250-8. [PMID: 25545821 DOI: 10.1111/1744-9987.12271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/01/2014] [Indexed: 11/28/2022]
Abstract
Acetate in standard acetate-containing bicarbonate (AC) dialysis fluid could induce peripheral vasodilatation, suppression of myocardial function, and inflammatory cytokine production, resulting in intradialytic hypotension in conventional hemodialysis (HD) patients. Online hemodiafiltration (HDF) provides superior hemodynamic stability over HD. The potentially additive hemodynamic benefits of the novel acetate-free bicarbonate (AF) dialysis fluid in online HDF have never been explored before. The present randomized, double-blind, crossover study was conducted in 22 online HDF patients to investigate the impact of AF dialysis fluid on hemodynamic and cytokine changes compared with AC dialysis fluid in online HDF. The results demonstrated the comparable changes of arterial pressure between AF and AC online HDF. During the study periods, the incidences of composite intradialytic hypotension and other adverse events were not different. The baseline and hourly changes of cardiac index, cardiac output, and peripheral vascular resistance during dialysis were comparable (P=0.534, 0.199, and 0.641, respectively). The percent reductions of NT-proBNP and cTnT were not significantly different (72.6 ± 12.3 vs. 72.6 ± 12.8%, P=0.99 and 35.2 ± 12.8 vs. 36.7 ± 12.0%, P=0.51). The changes of all pro-inflammatory cytokines (IL-2β, IL-6, IL-8, and TNF-α) and anti-inflammatory cytokine (IL-10) during dialysis were comparable between both groups. In conclusion, AF dialysis solution does not offer additional hemodynamic benefit for stable online HDF patients. The hemodynamic stability provided by online HDF might protect the adverse effects of acetate.
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Affiliation(s)
- Khajohn Tiranathanagul
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kamonwan Tangvoraphonkchai
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Medicine, Faculty of Medicine, Mahasarakham University, Maha Sarakham, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Unarokov ZM, Mukhoedova TV, Shuvaeva OV. Comparison of sustained low-efficiency dialysis with acetate-free and acetate-containing bicarbonate dialysate in unstable patients. Artif Organs 2014; 38:883-8. [PMID: 24393008 DOI: 10.1111/aor.12251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This work is focused on the problem of maintenance of intradialytic hemodynamic safety in unstable patients with acute kidney injury (AKI). A hypothesis that "small" quantities of acetate in standard bicarbonate dialysate can cause pronounced acetatemia and exacerbate cardiovascular instability was tested. In this prospective randomized study, a group of patients with AKI after cardiac surgery was treated with sustained low-efficiency dialysis with either acetate-containing bicarbonate dialysate or acetate-free dialysate, where acetate is replaced by hydrochloric acid. It was demonstrated that application of acetate-containing bicarbonate dialysate results in blood acetate levels up to 12 times the normal level. Additionally, it is associated with a 3.8-fold-increased risk of hemodynamic complications in comparison with acetate-free dialysate. The choice of acetate-free or acetate-containing bicarbonate dialysate does not influence adequacy of correction of the acid-base and electrolyte content of blood.
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Affiliation(s)
- Zaur M Unarokov
- Department of Anesthesiology and Critical Care, Academician E.N. Meshalkin Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia
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Post-dilution on line haemodiafiltration with citrate dialysate: first clinical experience in chronic dialysis patients. ScientificWorldJournal 2013; 2013:703612. [PMID: 24367243 PMCID: PMC3866782 DOI: 10.1155/2013/703612] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/28/2013] [Indexed: 11/18/2022] Open
Abstract
Background. Citrate has anticoagulative properties and favorable effects on inflammation, but it has the potential hazards of inducing hypocalcemia. Bicarbonate dialysate (BHD) replacing citrate for acetate is now used in chronic haemodialysis but has never been tested in postdilution online haemodiafiltration (OL-HDF). Methods. Thirteen chronic stable dialysis patients were enrolled in a pilot, short-term study. Patients underwent one week (3 dialysis sessions) of BHD with 0.8 mmol/L citrate dialysate, followed by one week of postdilution high volume OL-HDF with standard bicarbonate dialysate, and one week of high volume OL-HDF with 0.8 mmol/L citrate dialysate. Results. In citrate OL-HDF pretreatment plasma levels of C-reactive protein and β2-microglobulin were significantly reduced; intra-treatment plasma acetate levels increased in the former technique and decreased in the latter. During both citrate techniques (OL-HDF and HD) ionized calcium levels remained stable within the normal range. Conclusions. Should our promising results be confirmed in a long-term study on a wider population, then OL-HDF with citrate dialysate may represent a further step in improving dialysis biocompatibility.
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Grundström G, Christensson A, Alquist M, Nilsson LG, Segelmark M. Replacement of acetate with citrate in dialysis fluid: a randomized clinical trial of short term safety and fluid biocompatibility. BMC Nephrol 2013; 14:216. [PMID: 24103587 PMCID: PMC4124727 DOI: 10.1186/1471-2369-14-216] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 10/01/2013] [Indexed: 11/16/2022] Open
Abstract
Background The majority of bicarbonate based dialysis fluids are acidified with acetate. Citrate, a well known anticoagulant and antioxidant, has been suggested as a biocompatible alternative. The objective of this study was to evaluate short term safety and biocompatibility of a citrate containing acetate-free dialysis fluid. Methods Twenty four (24) patients on maintenance dialysis three times per week, 13 on on-line hemodiafiltration (HDF) and 11 on hemodialysis (HD), were randomly assigned to start with either citrate dialysis fluid (1 mM citrate, 1.5 mM calcium) or control fluid (3 mM acetate, 1.5 mM calcium) in an open-labeled cross-over trial (6 + 6 weeks with 8 treatments wash-out in between). Twenty (20) patients, 11 on HDF and 9 on HD were included in the analyses. Main objective was short term safety assessed by acid–base status, plasma ionized calcium and parathyroid hormone (PTH). In addition, biocompatibility was assessed by markers of inflammation (pentraxin 3 (PTX-3), CRP, IL-6, TNF-α and IL-1β) and thrombogenicity (activated partial thromboplastin time (APTT) and visual clotting scores). Results No differences dependent on randomization order or treatment mode (HD vs. HDF) were detected. Citrate in the dialysis fluid reduced the intra-dialytic shift in pH (+0.04 week 6 vs. +0.06 week 0, p = 0.046) and base excess (+3.9 mM week 6 vs. +5.6 mM week 0, p = 0.006) over the study period. Using the same calcium concentration (1.5 mM), citrate dialysis fluid resulted in lower post-dialysis plasma ionized calcium level (1.10 mM vs. 1.27 mM for control, p < 0.0001) and higher post-dialysis PTH level (28.8 pM vs. 14.7 pM for control, p < 0.0001) while pre-dialysis levels were unaffected. Citrate reduced intra-dialytic induction of PTX-3 (+1.1 ng/ml vs. +1.4 ng/ml for control, p = 0.04) but had no effect on other markers of inflammation or oxidative stress. Citrate reduced visual clotting in the arterial air chamber during HDF (1.0 vs. 1.8 for control, p = 0.03) and caused an intra-dialytic increase in APTT (+6.8 s, p = 0.003) without affecting post-dialysis values compared to control. Conclusions During this small short term study citrate dialysis fluid was apparently safe to use in HD and on-line HDF treatments. Indications of reduced treatment-induced inflammation and thrombogenicity suggest citrate as a biocompatible alternative to acetate in dialysis fluid. However, the results need to be confirmed in long term studies. Trial registration ISRCTN: ISRCTN28536511
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Tomo T. Optimal composition of dialysis fluid for on-line hemodiafiltration in central dialysis fluid delivery system. Blood Purif 2013; 35 Suppl 1:69-73. [PMID: 23466383 DOI: 10.1159/000346360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In this paper, we propose 'the preferred composition of dialysis fluid for on-line hemodiafiltration (HDF) in central dialysis fluid delivery system, (CDDS)': sodium concentration 138-140 mEq/l; potassium concentration 2.0 mEq/l; calcium concentration 2.5-3.5 mEq/l; glucose concentration 1.0-1.5 g/l; buffer: bicarbonate (acetate free is preferred). Concentrations of electrolytes in dialysis fluid (= substitution fluid) are applied to the compositions of launched dialysis fluid in Japan. From the viewpoint of biocompatibility and correction of metabolic acidosis, acetate-free bicarbonate buffer is thought to be important. This proposal of the preferred composition of dialysis fluid for on-line HDF in CDDS is based on a few reports. Further investigations and research to reveal the optimal composition of dialysis fluid for on-line HDF are expected in the future.
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Affiliation(s)
- Tadashi Tomo
- Department of Nephrology, Oita University Hospital, Oita, Japan.
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Petitclerc T, Diab R, Le Roy F, Mercadal L, Hmida J. [Acetate-free hemodialysis: what does it mean?]. Nephrol Ther 2010; 7:92-8. [PMID: 21130720 DOI: 10.1016/j.nephro.2010.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 10/20/2010] [Accepted: 10/21/2010] [Indexed: 11/18/2022]
Abstract
Substituting bicarbonate by acetate in dialysis fluids has been proposed for avoiding precipitation of calcium and magnesium carbonates. However, acetate hemodialysis has been abandoned because of deleterious effects of acetate. Conventional bicarbonate hemodialysis is not totally acetate-free, because 3 to 7 mEq/l of acetic acid are added to the dialysate. Acetate-free hemodialysis is possible with another acid (chlorhydric acid or citric acid) or without acid by using some techniques of low-efficiency hemodiafiltration, as acetate-free biofiltration, which avoids the deleterious effect of blood acidification into the dialyzer. In this paper, advantages and disadvantages of different techniques of acetate-free hemodialysis are discussed.
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Affiliation(s)
- Thierry Petitclerc
- Département de biophysique, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, 75013 Paris, France.
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Bolasco P, Ghezzi PM, Serra A, Corazza L, Fundoni GF, Pistis R, Gazzanelli L, Piras A, Accalai G, Calvisi L, Carpentieri E, Contu R, Grussu S, Mattana G, Pinna M, Scalas MR, Sulis E. Effects of acetate-free haemodiafiltration (HDF) with endogenous reinfusion (HFR) on cardiac troponin levels. Nephrol Dial Transplant 2010; 26:258-63. [PMID: 20601367 DOI: 10.1093/ndt/gfq359] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Haemofiltrate reinfusion (HFR) is a form of haemodiafiltration (HDF) in which replacement fluid is constituted by ultrafiltrate from the patient 'regenerated' through a cartridge containing hydrophobic styrene resin. Bicarbonate-based dialysis solutions (DS) used in routine haemodialysis and HDF contain small quantities of acetate (3-5 mMol/L) as stabilizing agent, one of the major causes of intradialytic hypotension. Acetate-free (AF) DS have recently been made available, substituting acetate with hydrochloric acid. Cardiac troponin (cTnT) constitutes an appreciable marker of myocardial damage and cardiac hypertrophy, and correlates with left ventricular mass. METHODS The aim of this study was to assess the impact of the presence or lack of acetate in DS on cTnT levels in patients treated with HFR and to evaluate outcome of intra-session cardiovascular stability. Twenty-five patients devoid of major cardiovascular comorbidity were randomized and treated with AF HFR for 3 months. The same patients were subsequently treated by means of HFR with DS containing 3 mMol/L acetate for 3 months and finally with AF HFR for a further 3 months. Prior and subsequent to each treatment period, samples were collected for cTnT measurement. RESULTS A significant decrease was observed in cTnT levels throughout the first session of AF HFR (1.32 ± 0.35-1.12 ± 0.31 ng/mL, P < 0.05) with a subsequent rise being registered during HFR with acetate-containing DS (1.12 ± 0.31-1.28 ± 0.37 ng/mL, P < 0.05) and a further drop from 1.28 ± 0.37 to 1.21 ± 0.35 ng/mL in the last AF HFR period. During HFR with acetate-containing DS, a significant drop in systolic and diastolic arterial pressure was observed in conjunction with a higher heart rate at the end of the session. CONCLUSION We observed an increase in cTnT during HFR with acetate and drops manifested during HFR without acetate; it may therefore be concluded that the drop in cTnT level, significantly correlated with lack of acetate, is indicative of improvement of cardiac microvascular function.
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