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Cavallari G, Mancini E. The Nephrologist's Role in the Collaborative Multi-Specialist Network Taking Care of Patients with Diabetes on Maintenance Hemodialysis: An Overview. J Clin Med 2022; 11:jcm11061521. [PMID: 35329847 PMCID: PMC8949004 DOI: 10.3390/jcm11061521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/22/2022] Open
Abstract
Diabetes mellitus is the leading cause of renal failure in incident dialysis patients in several countries around the world. The quality of life for patients with diabetes in maintenance hemodialysis (HD) treatment is in general poor due to disease complications. Nephrologists have to cope with all these problems because of the “total care model” and strive to improve their patients’ outcome. In this review, an updated overview of the aspects the nephrologist must face in the management of these patients is reported. The conventional marker of glycemic control, hemoglobin A1c (HbA1c), is unreliable. HD itself may be responsible for dangerous hypoglycemic events. New methods of glucose control could be used even during dialysis, such as a continuous glucose monitoring (CGM) device. The pharmacological control of diabetes is another complex topic. Because of the risk of hypoglycemia, insulin and other medications used to treat diabetes may need dose adjustment. The new class of antidiabetic drugs dipeptidyl peptidase 4 (DPP-4) inhibitors can safely be used in non-insulin-dependent end-stage renal disease (ESRD) patients. Nephrologists should take care to improve the hemodynamic tolerance to HD treatment, frequently compromised by the high level of ultrafiltration needed to counter high interdialytic weight gain. Kidney and pancreas transplantation, in selected patients with diabetes, is the best therapy and is the only approach able to free patients from both dialysis and insulin therapy.
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Rosner MH, Reis T, Husain-Syed F, Vanholder R, Hutchison C, Stenvinkel P, Blankestijn PJ, Cozzolino M, Juillard L, Kashani K, Kaushik M, Kawanishi H, Massy Z, Sirich TL, Zuo L, Ronco C. Classification of Uremic Toxins and Their Role in Kidney Failure. Clin J Am Soc Nephrol 2021; 16:1918-1928. [PMID: 34233920 PMCID: PMC8729494 DOI: 10.2215/cjn.02660221] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in our understanding of uremic retention solutes, and improvements in hemodialysis membranes and other techniques designed to remove uremic retention solutes, offer opportunities to readdress the definition and classification of uremic toxins. A consensus conference was held to develop recommendations for an updated definition and classification scheme on the basis of a holistic approach that incorporates physicochemical characteristics and dialytic removal patterns of uremic retention solutes and their linkage to clinical symptoms and outcomes. The major focus is on the removal of uremic retention solutes by hemodialysis. The identification of representative biomarkers for different classes of uremic retention solutes and their correlation to clinical symptoms and outcomes may facilitate personalized and targeted dialysis prescriptions to improve quality of life, morbidity, and mortality. Recommendations for areas of future research were also formulated, aimed at improving understanding of uremic solutes and improving outcomes in patients with CKD.
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Affiliation(s)
- Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Thiago Reis
- Department of Nephrology, University of Brazil, Brasília, Brazil
- National Academy of Medicine, Rio de Janeiro, Brazil
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Justus-Liebig-University Giessen, Giessen, Germany
| | - Raymond Vanholder
- Department of Internal Medicine and Pediatrics, University Hospital, Ghent, Belgium
| | - Colin Hutchison
- Faculty of Medicine, University of Queensland, Herston, Australia
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Peter Stenvinkel
- Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Peter J. Blankestijn
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mario Cozzolino
- Renal Division, Università degli Studi di Milano, Milan, Italy
| | - Laurent Juillard
- University of Lyon, Villeurbanne, France
- Hôpital E. Herriot, Lyon, France
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Hideki Kawanishi
- Department of Artificial Organs, Tsuchiya General Hospital, Hiroshima, Japan
| | - Ziad Massy
- INSERM U1018, Villejuif, France
- Service de Néphrologie et Dialyse, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, France
| | - Tammy Lisa Sirich
- Nephrology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, Vicenza, Italy
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De Vos C, Lemarcq L, Dhondt A, Glorieux G, Van Biesen W, Eloot S. The impact of intradialytic cycling on the removal of protein-bound uraemic toxins: A randomised cross-over study. Int J Artif Organs 2020; 44:156-164. [PMID: 32820982 DOI: 10.1177/0391398820949880] [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: 11/15/2022]
Abstract
The evidence on impact of intradialytic exercise on the removal of urea, is conflictive. Impact of exercise on kinetics of serum levels of protein-bound uraemic toxins, known to exert toxicity and to have kinetics dissimilar of those of urea, has so far not been explored. Furthermore, if any effect, the most optimal intensity, time point and/or required duration of intradialytic exercise to maximise removal remain obscure. We therefore studied the impact of different intradialytic cycling schedules on the removal of protein-bound uraemic toxins during haemodialysis (HD).This randomised cross-over study included seven stable patients who were dialysed with an FX800 dialyser during three consecutive midweek HD sessions of 240 min: (A) without cycling; (B) cycling for 60 min between 60th and 120th minutes of dialysis; and (C) cycling for 60 min between 150th and 210th minutes, with the same cycling load as in session B. Blood and dialysate flows were respectively 300 and 500 mL/min. Blood was sampled from the blood inlet at different time points, and dialysate was partially collected (300 mL/h). Small water soluble solutes and protein-bound toxins were quantified and intradialytic reduction ratios (RR) and overall removal were calculated per solute.Total solute removal and reduction ratios were not different between the three test sessions, except for the reduction ratios RR60-120 and RR150-210 for potassium.In conclusion, we add evidence to the existing literature that, regardless of the timing within the dialysis session, intradialytic exercise has no impact on small solute clearance, and demonstrated also a lack of impact for protein-bound solutes.
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Laplante S, Liu FX, Culleton B, Bernardo A, King D, Hudson P. The Cost Effectiveness of High-Dose versus Conventional Haemodialysis: a Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:185-193. [PMID: 26691659 DOI: 10.1007/s40258-015-0212-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND End-stage renal disease (ESRD) is fatal if untreated. In the absence of transplant, approximately 50 % of dialysis patients die within 5 years. Although more frequent and/or longer haemodialysis (high-dose HD) improves survival, this regimen may add to the burden on dialysis services and healthcare costs. This systematic review summarised the cost effectiveness of high-dose HD compared with conventional HD. METHODS English language publications reporting the cost-utility/effectiveness of high-dose HD in adults with ESRD were identified via a search of MEDLINE, Embase, and the Cochrane Library. Publications comparing any form of high-dose HD with conventional HD were reviewed. RESULTS Seven publications (published between 2003 and 2014) reporting cost-utility analyses from the public healthcare payer perspective were identified. High-dose HD in-centre was compared with in-centre conventional HD in one US model; all other analyses (UK, Canada) compared high-dose HD at home with in-centre conventional HD (n = 5) or in-centre/home conventional HD (n = 1). The time horizon varied from one year to lifetime. Similar survival for high-dose HD and conventional HD was assumed, with the impact of higher survival only assessed in the sensitivity analyses of three models. High-dose HD at home was found to be cost effective compared with conventional HD in all six analyses. The analysis comparing high-dose HD in-centre with conventional in-centre HD produced an incremental cost-effectiveness ratio generally acceptable for the USA, but not for Europe, Canada or Australia. CONCLUSION High-dose HD can be cost effective when performed at home. Future analyses assuming survival benefits for high-dose HD compared with conventional HD are needed.
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Affiliation(s)
- S Laplante
- Baxter Healthcare Corporation, Deerfield, IL, 60015, USA
| | - F X Liu
- Baxter Healthcare Corporation, Deerfield, IL, 60015, USA
| | - B Culleton
- Baxter Healthcare Corporation, Deerfield, IL, 60015, USA
| | - A Bernardo
- Baxter Healthcare Corporation, Deerfield, IL, 60015, USA
| | | | - P Hudson
- Abacus International, Bicester, UK
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Protein-Bound Uremic Toxin Profiling as a Tool to Optimize Hemodialysis. PLoS One 2016; 11:e0147159. [PMID: 26799394 PMCID: PMC4723122 DOI: 10.1371/journal.pone.0147159] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/29/2015] [Indexed: 12/20/2022] Open
Abstract
Aim We studied various hemodialysis strategies for the removal of protein-bound solutes, which are associated with cardiovascular damage. Methods This study included 10 patients on standard (3x4h/week) high-flux hemodialysis. Blood was collected at the dialyzer inlet and outlet at several time points during a midweek session. Total and free concentration of several protein-bound solutes was determined as well as urea concentration. Per solute, a two-compartment kinetic model was fitted to the measured concentrations, estimating plasmatic volume (V1), total distribution volume (Vtot) and intercompartment clearance (K21). This calibrated model was then used to calculate which hemodialysis strategy offers optimal removal. Our own in vivo data, with the strategy variables entered into the mathematical simulations, was then validated against independent data from two other clinical studies. Results Dialyzer clearance K, V1 and Vtot correlated inversely with percentage of protein binding. All Ks were different from each other. Of all protein-bound solutes, K21was 2.7–5.3 times lower than that of urea. Longer and/or more frequent dialysis that processed the same amount of blood per week as standard 3x4h dialysis at 300mL/min blood flow showed no difference in removal of strongly bound solutes. However, longer and/or more frequent dialysis strategies that processed more blood per week than standard dialysis were markedly more adequate. These conclusions were successfully validated. Conclusion When blood and dialysate flow per unit of time and type of hemodialyzer are kept the same, increasing the amount of processed blood per week by increasing frequency and/or duration of the sessions distinctly increases removal.
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Hai X, Landeras V, Dobre MA, DeOreo P, Meyer TW, Hostetter TH. Mechanism of Prominent Trimethylamine Oxide (TMAO) Accumulation in Hemodialysis Patients. PLoS One 2015; 10:e0143731. [PMID: 26650937 PMCID: PMC4674074 DOI: 10.1371/journal.pone.0143731] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/08/2015] [Indexed: 02/07/2023] Open
Abstract
Large size, protein binding and intracellular sequestration are well known to limit dialytic removal of compounds. In studying the normal renal and dialytic handling of trimethylamine oxide (TMAO), a molecule associated with cardiovascular disease in the general population, we discovered two largely unrecognized additional limitations to sustained reduction of a solute by chronic hemodialysis. We measured solute levels and handling in subjects on chronic hemodialysis (ESRD, n = 7) and compared these with levels and clearance in normal controls (NLS, n = 6). The ESRD patients had much higher peak predialysis plasma levels of TMAO than NLS (77 ± 26 vs 2±1 μM, mean ± SD, p<0.05). For comparison, predialysis BUN levels in ESRD subjects were 45±11 mg/dl and 15±3 mg/dl in NLS. Thus TMAO levels in ESRD average about 40 fold those in NLS while BUN is 3 fold NLS. However, the fractional reduction of TMAO concentration during dialysis, was in fact greater than that of urea (86±3 vs 74±6%, TMAO vs urea, p < 0.05) and its dialytic clearance while somewhat lower than that of urea was comparable to creatinine's. Also production rates were similar (533±272 vs 606 ± 220 μ moles/day, ESRD vs NLS, p>0.05). However, TMAO has a volume of distribution about one half that of urea. Also in NLS the urinary clearance of TMAO was high (219±78 ml/min) compared to the urinary urea and creatinine clearances (55±14 and 119±21 ml/min, respectively). Thus, TMAO levels achieve multiples of normal much greater than those of urea due mainly to 1) TMAO's high clearance by the normal kidney relative to urea and 2) its smaller volume of distribution. Modelling suggests that only much more frequent dialysis would be required to lower levels Thus, additional strategies such as reducing production should be explored. Furthermore, using urea as the sole marker of dialysis adequacy may be misleading since a molecule, TMAO, that is dialyzed readily accumulates to much higher multiples of normal with urea based dialysis prescriptions.
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Affiliation(s)
- Xin Hai
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Veeda Landeras
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Mirela A Dobre
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Peter DeOreo
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Timothy W Meyer
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Thomas H Hostetter
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
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Vinsonneau C, Allain-Launay E, Blayau C, Darmon M, Ducheyron D, Gaillot T, Honore PM, Javouhey E, Krummel T, Lahoche A, Letacon S, Legrand M, Monchi M, Ridel C, Robert R, Schortgen F, Souweine B, Vaillant P, Velly L, Osman D, Van Vong L. Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD). Ann Intensive Care 2015; 5:58. [PMID: 26714808 PMCID: PMC4695466 DOI: 10.1186/s13613-015-0093-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/27/2015] [Indexed: 12/12/2022] Open
Abstract
Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.
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Affiliation(s)
| | | | | | | | | | | | - Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Etienne Javouhey
- Réanimation pédiatrique spécialisée, CHU Lyon, 69677, Bron, France.
| | | | | | | | | | - Mehran Monchi
- Réanimation polyvalente, CH Melun, 77000, Melun, France.
| | | | | | | | | | | | | | - David Osman
- CHU Bicêtre, 94, Le Kremlin Bicêtre, France.
| | - Ly Van Vong
- Réanimation polyvalente, CH Melun, 77000, Melun, France.
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Vanholder RC, Eloot S, Glorieux GLRL. Future Avenues to Decrease Uremic Toxin Concentration. Am J Kidney Dis 2015; 67:664-76. [PMID: 26500179 DOI: 10.1053/j.ajkd.2015.08.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 08/19/2015] [Indexed: 01/13/2023]
Abstract
In this article, we review approaches for decreasing uremic solute concentrations in chronic kidney disease and in particular, in end-stage renal disease (ESRD). The rationale to do so is the straightforward relation between concentration and biological (toxic) effect for most toxins. The first section is devoted to extracorporeal strategies (kidney replacement therapy). In the context of high-flux hemodialysis and hemodiafiltration, we discuss increasing dialyzer blood and dialysate flows, frequent and/or extended dialysis, adsorption, bioartificial kidney, and changing physical conditions within the dialyzer (especially for protein-bound toxins). The next section focuses on the intestinal generation of uremic toxins, which in return is stimulated by uremic conditions. Therapeutic options are probiotics, prebiotics, synbiotics, and intestinal sorbents. Current data are conflicting, and these issues need further study before useful therapeutic concepts are developed. The following section is devoted to preservation of (residual) kidney function. Although many therapeutic options may overlap with therapies provided before ESRD, we focus on specific aspects of ESRD treatment, such as the risks of too-strict blood pressure and glycemic regulation and hemodynamic changes during dialysis. Finally, some recommendations are given on how research might be organized with regard to uremic toxins and their effects, removal, and impact on outcomes of uremic patients.
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Affiliation(s)
| | - Sunny Eloot
- Nephrology Department, University Hospital, Gent, Belgium
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Once upon a time in dialysis: the last days of Kt/V? Kidney Int 2015; 88:460-5. [DOI: 10.1038/ki.2015.155] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/04/2014] [Indexed: 11/09/2022]
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10
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Eloot S, Van Biesen W, Axelsen M, Glorieux G, Pedersen RS, Heaf JG. Protein-bound solute removal during extended multipass versus standard hemodialysis. BMC Nephrol 2015; 16:57. [PMID: 25896788 PMCID: PMC4404563 DOI: 10.1186/s12882-015-0056-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Multipass hemodialysis (MPHD) is a recently described dialysis modality, involving the use of small volumes of dialysate which are repetitively recycled. Dialysis regimes of 8 hours for six days a week using this device result in an increased removal of small water soluble solutes and middle molecules compared to standard hemodialysis (SHD). Since protein-bound solutes (PBS) exert important pathophysiological effects, we investigated whether MPHD results in improved removal of PBS as well. Methods A cross-over study (Clinical Trial NCT01267760) was performed in nine stable HD patients. At midweek a single dialysis session was performed with either 4 hours SHD using a dialysate flow of 500 mL/min or 8 hours MPHD with a dialysate volume of 50% of estimated body water volume. Blood and dialysate samples were taken every hour to determine concentrations of p-cresylglucuronide (PCG), hippuric acid (HA), indole acetic acid (IAA), indoxyl sulfate (IS), and p-cresylsulfate (PCS). Dialyser extraction ratio, reduction ratio, and solute removal were calculated for these solutes. Results Already at 60 min after dialysis start, the extraction ratio in the hemodialyser was a factor 1.4-4 lower with MPHD versus SHD, resulting in significantly smaller reduction ratios and lower solute removal within a single session. Even when extrapolating our findings to 3 times 4 h SHD and 6 times 8 h MPHD per week, the latter modality was at best similar in terms of total solute removal for most protein-bound solutes, and worse for the highly protein-bound solutes IS and PCS. When efficiency was calculated as solute removal/litre of dialysate used, MPHD was found superior to SHD. Conclusion When high water consumption is a concern, a treatment regimen of 6 times/week 8 h MPHD might be an alternative for 3 times/week 4 h SHD, but at the expense of a lower total solute removal of highly protein-bound solutes.
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Affiliation(s)
- Sunny Eloot
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Mette Axelsen
- Institute of Public Health, Aarhus University, Nordre Ringgade 1, 8000, Aarhus C, Denmark.
| | - Griet Glorieux
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | | | - James Goya Heaf
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Malchesky PS. Dr. Sunny Eloot to Serve as a Co-Editor Representative of the European Society of Artificial Organs. Artif Organs 2015; 39:90-2. [DOI: 10.1111/aor.12479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Lewicki MC, Polkinghorne KR, Kerr PG. Debate: Should dialysis at home be mandatory for all suitable ESRD patients?: home-based dialysis therapies are the second choice after transplantation. Semin Dial 2014; 28:147-54. [PMID: 25481976 DOI: 10.1111/sdi.12322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Since their inception in the 1960s, home-based dialysis therapies have been viable alternatives to conventional thrice weekly in center hemodialysis. In spite of this, uptake of these therapies has been steadily declining over past decades with utilization varying globally; dependent on training support, funding models, and prevailing Nephrologist beliefs. In the Australian context, home dialysis (predominantly peritoneal dialysis and extended hours nocturnal hemodialysis) is now again increasing in popularity--with enthusiasm driven not only by evidence of an array of physiological and psychological patient benefit but also significant economic advantage: critical in the current climate where dialysis therapies in Australia take approximately $1 billion dollars per year from the healthcare budget. When assessing the significant advantages of home-based therapies, it is important to consider not only the increasing body of evidence around improved survival but also that for dramatically better health-related quality of life, decreased economic burden and the overall benefits of undertaking treatment in the home. With patient-centered care an increasingly important aspect of our decision making paradigm, home-based dialysis should be considered as the default option in all patients transitioning to renal replacement therapy.
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Affiliation(s)
- Michelle C Lewicki
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia
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Thakkar EA, Gaikwad RV. Therapeutic efficacy of different Hemodialysis prescriptions in canine azotemia. Vet World 2014. [DOI: 10.14202/vetworld.2014.1150-1156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Basile C, Schneditz D. Haemodialysis adequacy monitoring for phosphate: an old problem with new solutions? Nephrol Dial Transplant 2014; 30:9-11. [DOI: 10.1093/ndt/gfu351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Épuration extrarénale en réanimation adulte et pédiatrique. Recommandations formalisées d’experts sous l’égide de la Société de réanimation de langue française (SRLF), avec la participation de la Société française d’anesthésie-réanimation (Sfar), du Groupe francophone de réanimation et urgences pédiatriques (GFRUP) et de la Société francophone de dialyse (SFD). ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13546-014-0917-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Eloot S, Vanholder R, Dequidt C, Van Biesen W. Removal of Different Classes of Uremic Toxins in APD vs CAPD: A Randomized Cross-Over Study. Perit Dial Int 2014; 35:436-42. [PMID: 24584609 DOI: 10.3747/pdi.2013.00202] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/13/2013] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ AIM In this study, we investigated, and this for the different classes of uremic toxins, whether increasing dialysate volume by shifting from continuous ambulatory peritoneal dialysis (CAPD) to higher volume automated peritoneal dialysis (APD) increases total solute clearance. ♦ METHODS Patients on peritoneal dialysis were randomized in a cross-over design to one 24-hour session of first a CAPD regimen (3*2 L of Physioneal 1.36% and 1*2 L of icodextrin) or APD (consisting of 5 cycles of 2 L Physioneal 1.36 and 1 cycle of 2 L Extraneal), and the other week the alternate regime, each patient serving as his/her own control. Dialysate, blood and urine samples were collected and frozen for later batch analysis of concentrations of urea, creatinine, phosphorus, uric acid, hippuric acid, 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid, indoxyl sulfate, indole acetic acid, and p-cresyl sulfate. For the protein-bound solutes, total and free fractions were determined. Total, peritoneal and renal clearance (K) and mass removal (MR) of each solute were calculated, using validated models. ♦ RESULTS In 15 patients (11 male, 3 diabetics, 56 ± 16 years, 8 on CAPD, time on peritoneal dialysis 12 ± 14 months, and residual renal function of 9.9 ± 5.4 mL/min) dialysate over plasma ratio for creatinine (D/Pcrea) was 0.62 ± 0.10. Drained volume and obtained ultrafiltration were higher with APD vs CAPD (13.3 ± 0.5 L vs 8.5 ± 0.7 L and 1.3 ± 0.5 L vs 0.5 ± 0.7 L), whereas urine output was lower (1.0 ± 0.5 L vs 1.4 ± 0.6 L). Total clearance and MR tended to be higher for CAPD vs APD for all small and water soluble solutes, but mainly because of higher renal contribution, with no difference in the peritoneal contribution. For the protein-bound solutes, no differences in clearance or mass removal were observed. ♦ CONCLUSION Although the drained dialysate volume nearly doubled, APD did not result in better peritoneal clearance or solute removal vs classic CAPD. APD resulted in better ultrafiltration, but at the expense of residual urinary output and clearance.
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Affiliation(s)
- Sunny Eloot
- Renal Division, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Raymond Vanholder
- Renal Division, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Clement Dequidt
- Renal Division, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Wim Van Biesen
- Renal Division, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
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Eloot S, Ledebo I, Ward RA. Extracorporeal Removal of Uremic Toxins: Can We Still Do Better? Semin Nephrol 2014; 34:209-27. [DOI: 10.1016/j.semnephrol.2014.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rhee CM, Leung AM, Kovesdy CP, Lynch KE, Brent GA, Kalantar-Zadeh K. Updates on the management of diabetes in dialysis patients. Semin Dial 2014; 27:135-45. [PMID: 24588802 PMCID: PMC3960718 DOI: 10.1111/sdi.12198] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) in the U.S. and many countries globally. The role of improved glycemic control in ameliorating the exceedingly high mortality risk of diabetic dialysis patients is unclear. The treatment of diabetes in ESRD patients is challenging, given changes in glucose homeostasis, the unclear accuracy of glycemic control metrics, and the altered pharmacokinetics of glucose-lowering drugs by kidney dysfunction, the uremic milieu, and dialysis therapy. Up to one-third of diabetic dialysis patients may experience spontaneous resolution of hyperglycemia with hemoglobin A1c (HbA1c) levels <6%, a phenomenon known as "Burnt-Out Diabetes," which remains with unclear biologic plausibility and undetermined clinical implications. Conventional methods of glycemic control assessment are confounded by the laboratory abnormalities and comorbidities associated with ESRD. Similar to more recent approaches in the general population, there is concern that glucose normalization may be harmful in ESRD patients. There is uncertainty surrounding the optimal glycemic target in this population, although recent epidemiologic data suggest that HbA1c ranges of 6% to 8%, as well as 7% to 9%, are associated with increased survival rates among diabetic dialysis patients. Lastly, many glucose-lowering drugs and their active metabolites are renally metabolized and excreted, and hence, require dose adjustment or avoidance in dialysis patients.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Angela M. Leung
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Katherine E. Lynch
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Gregory A. Brent
- Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
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Leypoldt JK, Agar BU, Culleton BF. Simplified phosphorus kinetic modeling: predicting changes in predialysis serum phosphorus concentration after altering the hemodialysis prescription. Nephrol Dial Transplant 2014; 29:1423-9. [DOI: 10.1093/ndt/gfu032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Fluck RJ, Fouque D, Lockridge RS. Nephrologists' perspectives on dialysis treatment: results of an international survey. BMC Nephrol 2014; 15:16. [PMID: 24428875 PMCID: PMC3912927 DOI: 10.1186/1471-2369-15-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 01/03/2014] [Indexed: 02/02/2023] Open
Abstract
Background In-centre haemodialysis (ICHD) is the most common dialysis method used by patients worldwide. However, quality of life and clinical outcomes in patients treated via ICHD have not improved for some time. ‘High-dose’ haemodialysis (HD) regimens – which are longer and/or more frequent than conventional regimens and are particularly suitable to delivery in the home – may offer a route to improved outcomes and quality of life. This survey aimed to determine nephrologists’ views on the validity of alternatives to ICHD, particularly home HD and high-dose HD. Methods A total of 1,500 nephrologists from Europe, Canada and the United States were asked to respond to an online questionnaire that was designed following previous qualitative research. Certified nephrologists in practice for 2–35 years who managed >25 adult dialysis patients were eligible to take part. Results A total of 324 nephrologists completed the survey. ICHD was the most common type of dialysis used by respondents’ current patients (90%), followed by peritoneal dialysis (8%) and home HD (2%). The majority of respondents believed that: home HD provides better quality of life; increasing the frequency of dialysis beyond three times per week significantly improves clinical outcomes; and longer dialysis sessions performed nocturnally would result in significantly better clinical outcomes than traditional ICHD. Conclusions Survey results indicated that many nephrologists believe that home HD and high-dose HD are better for the patient. However, the majority of their patients were using ICHD. Education, training and support on alternative dialysis regimens are needed.
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Eloot S, Van Biesen W, Glorieux G, Neirynck N, Dhondt A, Vanholder R. Does the adequacy parameter Kt/V(urea) reflect uremic toxin concentrations in hemodialysis patients? PLoS One 2013; 8:e76838. [PMID: 24236005 PMCID: PMC3827207 DOI: 10.1371/journal.pone.0076838] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 08/31/2013] [Indexed: 11/18/2022] Open
Abstract
Hemodialysis aims at removing uremic toxins thus decreasing their concentrations. The present study investigated whether Kt/Vurea, used as marker of dialysis adequacy, is correlated with these concentrations. Predialysis blood samples were taken before a midweek session in 71 chronic HD patients. Samples were analyzed by colorimetry, HPLC, or ELISA for a broad range of uremic solutes. Solute concentrations were divided into four groups according to quartiles of Kt/Vurea, and also of different other parameters with potential impact, such as age, body weight (BW), Protein equivalent of Nitrogen Appearance (PNA), Residual Renal Function (RRF), and dialysis vintage. Dichotomic concentration comparisons were performed for gender and Diabetes Mellitus (DM). Analysis of Variance in quartiles of Kt/Vurea did not show significant differences for any of the solute concentrations. For PNA, however, concentrations showed significant differences for urea (P<0.001), uric acid (UA), p-cresylsulfate (PCS), and free PCS (all P<0.01), and for creatinine (Crea) and hippuric acid (HA) (both P<0.05). For RRF, concentrations varied for β2-microglobulin (P<0.001), HA, free HA, free indoxyl sulfate, and free indole acetic acid (all P<0.01), and for p-cresylglucuronide (PCG), 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid (CMPF), free PCS, and free PCG (all P<0.05). Gender and body weight only showed differences for Crea and UA, while age, vintage, and diabetes mellitus only showed differences for one solute concentration (UA, UA, and free PCS, respectively). Multifactor analyses indicated a predominant association of concentration with protein intake and residual renal function. In conclusion, predialysis concentrations of uremic toxins seem to be dependent on protein equivalent of nitrogen appearance and residual renal function, and not on dialysis adequacy as assessed by Kt/Vurea. Efforts to control intestinal load of uremic toxin precursors by dietary or other interventions, and preserving RRF seem important approaches to decrease uremic solute concentration and by extension their toxicity.
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Affiliation(s)
- Sunny Eloot
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
- * E-mail:
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Nathalie Neirynck
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Annemieke Dhondt
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
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Souza LE, de Queiroz RE, Libório AB. Unmeasured anions and cations in advanced chronic kidney disease. Kidney Int 2013; 84:413-4. [DOI: 10.1038/ki.2013.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Cationic uremic toxins affect human renal proximal tubule cell functioning through interaction with the organic cation transporter. Pflugers Arch 2013; 465:1701-14. [DOI: 10.1007/s00424-013-1307-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 05/31/2013] [Accepted: 06/02/2013] [Indexed: 01/03/2023]
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Comparison of toxin removal outcomes in online hemodiafiltration and intra-dialytic exercise in high-flux hemodialysis: a prospective randomized open-label clinical study protocol. BMC Nephrol 2012. [PMID: 23176731 PMCID: PMC3561063 DOI: 10.1186/1471-2369-13-156] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Maintenance hemodialysis (HD) patients universally suffer from excess toxin load. Hemodiafiltration (HDF) has shown its potential in better removal of small as well as large sized toxins, but its efficacy is restricted by inter-compartmental clearance. Intra-dialytic exercise on the other hand is also found to be effective for removal of toxins; the augmented removal is apparently obtained by better perfusion of skeletal muscles and decreased inter-compartmental resistance. The aim of this trial is to compare the toxin removal outcome associated with intra-dialytic exercise in HD and with post-dilution HDF. Methods/design The main hypothesis of this study is that intra-dialytic exercise enhances toxin removal by decreasing the inter-compartmental resistance, a major impediment for toxin removal. To compare the HDF and HD with exercise, the toxin rebound for urea, creatinine, phosphate, and β2-microglobulin will be calculated after 2 hours of dialysis. Spent dialysate will also be collected to calculate the removed toxin mass. To quantify the decrease in inter-compartmental resistance, the recently developed regional blood flow model will be employed. The study will be single center, randomized, self-control, open-label prospective clinical research where 15 study subjects will undergo three dialysis protocols (a) high flux HD, (b) post-dilution HDF, (c) high flux HD with exercise. Multiple blood samples during each study session will be collected to estimate the unknown model parameters. Discussion This will be the first study to investigate the exercise induced physiological change(s) responsible for enhanced toxin removal, and compare the toxin removal outcome both for small and middle sized toxins in HD with exercise and HDF. Successful completion of this clinical research will give important insights into exercise effect on factors responsible for enhanced toxin removal. The knowledge will give confidence for implementing, sustaining, and optimizing the exercise in routine dialysis care. We anticipate that toxin removal outcomes from intra-dialytic exercise session will be comparable to that obtained by standalone HDF. These results will encourage clinicians to combine HDF with intra-dialytic exercise for significantly enhanced toxin removal. Trial registration ClinicalTrials.gov number, NCT01674153
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Eloot S, Vanholder R, Van Biesen W. Less water for haemodialysis: is multiple pass the future pace to go? Nephrol Dial Transplant 2012; 27:3975-8. [DOI: 10.1093/ndt/gfs435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Eloot S, Van Biesen W, Vanholder R. A Sad but Forgotten Truth: The Story of Slow-Moving Solutes in Fast Hemodialysis. Semin Dial 2012; 25:505-9. [DOI: 10.1111/j.1525-139x.2012.01107.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Eloot S, Schneditz D, Vanholder R. What can the dialysis physician learn from kinetic modelling beyond Kt/V(urea)? Nephrol Dial Transplant 2012; 27:4021-9. [PMID: 22923544 DOI: 10.1093/ndt/gfs367] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Vanholder R, Eloot S, Schepers E, Neirynck N, Glorieux G, Massy Z. an Obituary for GFR as the main marker for kidney function? Semin Dial 2011; 25:9-14. [PMID: 22141430 DOI: 10.1111/j.1525-139x.2011.01003.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This publication comments on the recently published findings of a study by Eloot et al. (cJASN, 6: 1266-1273, 2011) that evaluated the correlation between several formulae for calculating estimated GFR (eGFR) and different low molecular weight uremic toxins; eGFRs were based on serum creatinine (SCrea), cystatin C (Cys C), or a combination of both. Unexpectedly, the correlations for the different solutes were highly inconsistent, irrespective of the eGFR formula. On the other hand, the different eGFR formulae gave consistent results per solute. Correlation coefficients for some solutes were low (hippuric acid, p-cresylsulfate, indole acetic acid, uric acid, asymmetric dimethylarginine) to nonsignificant (carboxy-methyl-propyl-furanpropionic acid). These data point to the fact that eGFR is a deceiving predictor of uremic solute concentration and their biological action; this inconsistency is very likely the result of the impact of other factors affecting concentration, such as tubular secretion, generation by intestinal flora and metabolism.
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Eloot S, Vanholder R, Van Biesen W, Lameire N. The patient as a limit to dialysis technology. Clin J Am Soc Nephrol 2011; 6:2105-7. [PMID: 21852663 DOI: 10.2215/cjn.07320711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Eloot S, Dhondt A, Hoste E, Verstraete A, De Waele J, Colpaert K, Hoeksema H, Tromp F, Vanholder R. How to remove accumulated iodine in burn-injured patients. Nephrol Dial Transplant 2009; 25:1614-20. [PMID: 19965987 DOI: 10.1093/ndt/gfp647] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Absorption of large quantities of iodine, as induced by the use of topical antimicrobial povidone-iodine in burn-injured patients, may cause metabolic and electrolyte abnormalities as well as renal failure. To diminish iodine levels, haemodialysis was previously reported to be a suitable therapy. We therefore studied the kinetics of iodine in order to define the most optimal dialysis strategy. METHODS Two patients with elevated iodine levels (93.6 and 81.2 mg/L) underwent continuous dialysis with blood flows Q(B) 150 and 120 mL/min. Blood was sampled from the inlet and outlet dialysis line at several time points during a 7-h and 39-h 10-min period, respectively. Samples were analysed for iodine with the inductively coupled plasma mass spectrometry (ICPMS) method. Kinetic analysis was performed using one and two compartmental models, deriving kinetic parameters: plasmatic volume V(1), extraplasmatic volume V(2) and intercompartmental clearance K(12). The calibrated kinetic model of Patient 2 was further used to simulate different dialysis strategies: 12-h per day with Q(B) 240, 6-h per day with Q(B) 480 and 240, and 12-h every 2 days with Q(B) 240. For each strategy, the mean average plasmatic and extraplasmatic concentration (TAC(p) and TAC(ep)) was calculated during 48 h. RESULTS Iodine seemed to follow one compartmental kinetics when serum sample collections were limited to the first 7 h of dialysis (Patient 1), but iodine appeared to be distributed in two volumes (V(1)=19.4 L, V(2)=38.0 L and K(12)=55 mL/min) when a longer observation period was taken into account (Patient 2). The simulations disclosed that 12-h dialysis per day with Q(B) 240 or continuous dialysis with Q(B) 120 resulted in the lowest TAC(p) (18.2 and 19.0 microg/L) and TAC(ep) (34.4 and 36.1 microg/L). CONCLUSION In patients with elevated iodine levels, especially when associated with renal failure, haemodialysis with a minimum 12-h duration with sufficient blood flow should be the first choice to remove iodine.
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Affiliation(s)
- Sunny Eloot
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Belgium.
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Daugirdas JT, Tattersall J. Effect of treatment spacing and frequency on three measures of equivalent clearance, including standard Kt/V. Nephrol Dial Transplant 2009; 25:558-61. [DOI: 10.1093/ndt/gfp446] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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