1
|
Chen JY, Jiang MY, Huang YT, Hwang JC. Lower product of magnesium × potassium is associated with higher mortality in chronic hemodialysis patients: a cohort study. Sci Rep 2023; 13:22128. [PMID: 38092856 PMCID: PMC10719325 DOI: 10.1038/s41598-023-49372-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 12/07/2023] [Indexed: 12/17/2023] Open
Abstract
This study aimed to investigate the Mg × K product on the mortality risk of hemodialysis patients with concomitant hypokalemia and lower magnesium levels. This was a prospective observational study of patients in a HD center in southern Taiwan. A total of 444 HD patients were divided into 5 groups by the Mg × K product: group 1, bottom quintile, median Mg × K: 7.87, IQR: 7.03-8.12 (n = 89, age: 64 ± 13 years old); group 2, median Mg × K: 9.37, IQR: 8.97-9.86 (n = 89, age:62 ± 13 years old); group 3, median Mg × K: 10.95, IQR: 10.50-11.26 (n = 89, age:64 ± 13 years old); group 4, median Mg × K: 12.30, IQR: 11.87-12.82 (n = 89, 61 ± 12 years old); and group 5, top quintile, median Mg × K: 14.92, IQR:14.07-16.23 (n = 88, 62 ± 11 years old). The patients were followed up for 2 years to determine the risk of all-cause mortality. Patients with a lower Mg × K product had more comorbidities, malnutrition-inflammation status, and a higher mortality risk. Using multivariable Cox regression analysis, a higher Mg × K [HR, 0.89; 95%CI (0.81-0.98)] was found to be an independent predictor of better survival. HD patients with a lower Mg × K product had more comorbidities, a marked malnutrition-inflammation status, and were associated with long-term mortality. A higher Mg × K value is a favorable survival factor.
Collapse
Affiliation(s)
- Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist., Tainan City, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ming-Yan Jiang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist., Tainan City, Taiwan
| | - Yun-Ting Huang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist., Tainan City, Taiwan
| | - Jyh-Chang Hwang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist., Tainan City, Taiwan.
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
| |
Collapse
|
2
|
Balsamello C, Rombolà G, Costantino ML, Casagrande G. Can the response to dialysis treatment be predicted by using patient-specific modeling of fluid and solute exchanges? A multicentric evaluation. Artif Organs 2023; 47:1326-1341. [PMID: 36995361 DOI: 10.1111/aor.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/15/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Parametric multipool kinetic models were used to describe the intradialytic trends of electrolytes, breakdown products, and body fluids volumes during hemodialysis. Therapy customization can be achieved by the identification of parameters, allowing patient-specific modulation of mass and fluid balance across dialyzer, capillary, and cell membranes. This study wants to evaluate the possibility to use this approach to predict the patient's intradialytic response. METHODS 6 sessions of 68 patients (DialysIS© project) were considered. Data from the first three sessions were used to train the model, identifying the patient-specific parameters, that, together with the treatment settings and the patient's data at the session start, could be used for predicting the patient's specific time course of solutes and fluids along the sessions. Na+ , K+ , Cl- , Ca2+ , HCO3 - , and urea plasmatic concentrations and hematic volume deviations from clinical data were evaluated. RESULTS nRMSE predictive error is on average equal to 4.76% when describing the training sessions, and only increases by 0.97 percentage points on average in independent sessions of the same patient. CONCLUSIONS The proposed predictive approach represents a first step in the development of tools to support the clinician in tailoring the patient's prescription.
Collapse
Affiliation(s)
- Carlo Balsamello
- Department of Chemistry, Materials, and Chemical Engineering, Politecnico di Milano, Milano, Italy
| | - Giuseppe Rombolà
- Nephrology Dialysis and Kidney Transplant Unit, ASST-Settelaghi, Varese, Italy
| | - Maria Laura Costantino
- Department of Chemistry, Materials, and Chemical Engineering, Politecnico di Milano, Milano, Italy
| | - Giustina Casagrande
- Department of Chemistry, Materials, and Chemical Engineering, Politecnico di Milano, Milano, Italy
| |
Collapse
|
3
|
Andersen M, Bangsgaard KO, Heaf JG, Ottesen JT. Analytical solution of phosphate kinetics for hemodialysis. J Math Biol 2023; 87:11. [PMID: 37332042 DOI: 10.1007/s00285-023-01942-4] [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: 09/29/2022] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/20/2023]
Abstract
Chronic kidney diseases imply an ongoing need to remove toxins, with hemodialysis as the preferred treatment modality. We derive analytical expressions for phosphate clearance during dialysis, the single pass (SP) model corresponding to a standard clinical hemodialysis and the multi pass (MP) model, where dialysate is recycled and therefore makes a smaller clinical setting possible such as a transportable dialysis suitcase. For both cases we show that the convective contribution to the dialysate is negligible for the phosphate kinetics and derive simpler expressions. The SP and MP models are calibrated to clinical data of ten patients showing consistency between the models and provide estimates of the kinetic parameters. Immediately after dialysis a rebound effect is observed. We derive a simple formula describing this effect which is valid both posterior to SP or MP dialysis. The analytical formulas provide explanations to observations of previous clinical studies.
Collapse
Affiliation(s)
- M Andersen
- IMFUFA, Centre for Mathematical Modeling, Human Health and Disease, Roskilde University, Roskilde, Denmark.
| | - K O Bangsgaard
- DTU Compute, Technical University of Denmark, Kongens Lyngby, Denmark
| | - J G Heaf
- Department of Nephrology, University Hospital of Zealand, Roskilde, Denmark
| | - J T Ottesen
- IMFUFA, Centre for Mathematical Modeling, Human Health and Disease, Roskilde University, Roskilde, Denmark
| |
Collapse
|
4
|
Fishbane S, Ford M, Fukagawa M, McCafferty K, Rastogi A, Spinowitz B, Staroselskiy K, Vishnevskiy K, Lisovskaja V, Al-Shurbaji A, Guzman N, Bhandari S. Potassium responses to sodium zirconium cyclosilicate in hyperkalemic hemodialysis patients: post-hoc analysis of DIALIZE. BMC Nephrol 2022; 23:59. [PMID: 35135481 PMCID: PMC8826669 DOI: 10.1186/s12882-021-02569-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sodium zirconium cyclosilicate (SZC) is an effective and well-tolerated treatment for hyperkalemia in maintenance hemodialysis patients. In post-hoc analyses of the phase 3b DIALIZE study, we examined the spectrum of potassium responses to SZC. METHODS Post-hoc analyses with SZC and placebo included: the number of long interdialytic interval (LIDI) visits during the 4-week evaluation period where patients attained pre-dialysis serum potassium (sK+) concentrations of 4.0-5.0 and 4.0-5.5 mmol/L; potassium gradient (the difference between pre-dialysis sK+ and dialysate potassium) at days 36, 43, 50, and 57, and change from baseline to the end of treatment (EOT) using categories of potassium gradient (1 to < 2, 2 to < 3, 3 to < 4, and ≥ 4 mmol/L). RESULTS A greater proportion of patients achieved the ranges of pre-dialysis sK+ concentration with SZC versus placebo for ≥1, ≥ 2, ≥ 3, and 4 LIDI visits over 4 weeks; 23.7 and 48.5% of patients in the SZC group achieved pre-dialysis sK+ concentrations of 4.0-5.0 and 4.0-5.5 mmol/L, respectively, at all 4 LIDI visits. Baseline mean potassium gradient was similar with SZC and placebo. At day 57, mean (standard deviation) potassium gradient was 2.78 (0.08) mmol/L with SZC and 3.52 (0.08) mmol/L with placebo; mean difference (95% confidence interval) was - 0.74 mmol/L (- 0.97 to - 0.52). A greater reduction in potassium gradient category from baseline towards lower-risk categories at EOT was observed with SZC versus placebo. CONCLUSIONS These analyses expand our knowledge of the spectrum of potassium responses with SZC in hyperkalemic hemodialysis patients. TRIAL REGISTRATION NCT03303521 .
Collapse
Affiliation(s)
- Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, 100 Community Dr, Great Neck, NY, 11021, USA.
| | - Martin Ford
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Anjay Rastogi
- UCLA CORE Kidney Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Bruce Spinowitz
- Department of Medicine, New York-Presbyterian Queens, Queens, NY, USA
| | | | - Konstantin Vishnevskiy
- Propedeutics of Internal Diseases Chair, First Pavlov State Medical University of St Petersburg, St Petersburg, Russia
| | - Vera Lisovskaja
- Biometrics and Information, AstraZeneca BioPharmaceuticals R&D Gothenburg, Mölndal, Sweden
| | - Ayman Al-Shurbaji
- Global Medicines Development, AstraZeneca BioPharmaceuticals R&D Gothenburg, Mölndal, Sweden
| | - Nicolas Guzman
- Global Medicines Development, AstraZeneca BioPharmaceuticals R&D, Gaithersburg, MD, USA
| | - Sunil Bhandari
- Department of Renal and Transplant Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
| |
Collapse
|
5
|
Ni Z, Jin H, Lu R, Zuo L, Yu W, Ren Y, Yang Q, Xiao J, Zhang Q, Zhang L, Zhang X, Chen Q, Chen C, Shao G, Luo Q, Yao L, Qin S, Peng H, Zhao Q. Hyperkalaemia prevalence, recurrence and treatment in patients on haemodialysis in China: protocol for a prospective multicentre cohort study (PRECEDE-K). BMJ Open 2021; 11:e055770. [PMID: 34937724 PMCID: PMC8705221 DOI: 10.1136/bmjopen-2021-055770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Hyperkalaemia (HK) is a potentially life-threatening electrolyte imbalance associated with several adverse clinical outcomes and is common in patients with kidney failure. However, there is no evidence on the occurrence, recurrence and treatment of HK in patients on haemodialysis (HD) in China. METHODS AND ANALYSIS The HK Prevalence, Recurrence, and Treatment in Haemodialysis Study is a prospective, multicentre, observational, cohort study being conducted across 15-18 sites in China. Approximately 600 patients with end-stage kidney disease on HD are anticipated to be enrolled and will be followed up for 24 weeks. Patients will be in the long interdialytic interval (LIDI) at enrolment and will receive follow-up care every 4 weeks in LIDI for pre-dialysis and post-dialysis (at enrolment only) serum potassium measurements. To obtain pre-dialysis serum potassium levels in the short interdialytic interval (SIDI), a follow-up visit will be performed in the SIDI during the first week. Information on concomitant medications, blood gas analysis and biochemistry measurements will be obtained at enrolment and at each follow-up visit. The primary endpoint will be the proportion of patients experiencing HK (defined as serum potassium level >5.0 mmol/L) at the study enrolment or during the 24-week follow-up. The key secondary endpoint will be the proportion of patients experiencing HK recurrence (defined as any HK event after the first HK event) within 1-6 months (if applicable) during the 24-week follow-up, including enrolment assessment. ETHICS AND DISSEMINATION This study has been approved by Shanghai Jiaotong University School of Medicine, Renji Hospital Ethics Committee (2020-040). Other participating subcentres must also obtain ethics committee approval prior to the start of the study. The Good Clinical Practice regulations shall be strictly followed during the test implementation. Amendments to the protocol will be reviewed by the ethics committees. Written informed consent will be obtained from all participants before collection of any patient data and patient information. The findings of this study will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04799067).
Collapse
Affiliation(s)
- Zhaohui Ni
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haijiao Jin
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Renhua Lu
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Weimin Yu
- Department of Nephrology, Shanxi Bethune Hospital, Taiyuan, China
| | - Yuqing Ren
- Department of Nephrology, Yangquan Coal Industry (Group) General Hospital, Yangquan, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qinghong Zhang
- Department of Nephrology, Taihe Hospital, Shiyan, Hubei, China
| | - Lihong Zhang
- Department of Nephrology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xinzhou Zhang
- Department of Nephrology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Qinkai Chen
- Department of Nephrology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Chaosheng Chen
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guojian Shao
- Department of Nephrology, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Qun Luo
- Department of Nephrology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Li Yao
- Department of Nephrology, The first hospital of China Medical University, Shenyang, China
| | - Shuguang Qin
- Department of Nephrology, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Hui Peng
- Department of Nephrology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qing Zhao
- Medical Affaires, AstraZeneca Investment China Co, Shanghai, China
| |
Collapse
|
6
|
Ferreira JP, Couchoud C, Edet S, Brunet P, Frimat L. Adverse gastrointestinal events with sodium polystyrene sulphonate and calcium polystyrene sulphonate use in dialysis patients: a nationwide registry study. Nephrol Dial Transplant 2021; 36:339-345. [PMID: 33247730 DOI: 10.1093/ndt/gfaa229] [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: 06/03/2020] [Accepted: 07/16/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Sodium polystyrene sulphonate (SPS) and calcium polystyrene sulphonate (CPS) are commonly used cation-exchange resins for the treatment and control of hyperkalaemia. However, their use (particularly SPS) has been limited by reports of adverse gastrointestinal (GI) events. The safety of these compounds in patients undergoing dialysis requires larger investigation. AIMS To study the occurrence of adverse GI events (occlusion, perforation, thrombosis/ischaemia) in the periods of SPS or CPS exposition versus the periods without exposition in dialysis patients. METHODS Dialysis patients were extracted from the French National Registry and merged with the French hospital discharge database (between 2006 and 2017). For our primary analysis, we used patients who had any claim of SPS use (n = 43 771). Time-varying Cox models, negative binomial regression and pre- versus post-treatment average treatment effects. RESULTS The mean age was 66 ± 15 years, 37% were female and 92% were undergoing haemodialysis. Over a 1-year follow-up, patients on periods with SPS (on-SPS) did not present an increased risk of adverse GI events versus the periods without SPS (off-SPS): incidence rate (IR) (per 1000 person years) = 7.4 (6.4-8.7) versus 9.5 (8.1-11.0); adjusted hazard ratio (HR) (95% CI) = 0.81 (0.60-1.09), P = 0.17. Patients exposed to SPS did not experience a higher rate of adverse GI events in the year after SPS initiation versus the year before SPS initiation; P-value for parallel trend = 0.87. Patients on-CPS also did not show an increased risk of adverse GI events versus off-CPS: IR (per 1000 py) = 8.6 (5.1-11.9) versus 7.8 (5.1-11.9); adjusted HR (95% CI) = 0.76 (0.31-1.80), P = 0.52. The rates of adverse GI events in the periods on and off exposure were also similar over a follow-up of 5 years. CONCLUSION Our large, nationwide study shows that the incidence of adverse GI events in patients undergoing dialysis was low and that neither the use of SPS nor CPS was associated with increased GI events risk.
Collapse
Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, France
| | | | - Stéphane Edet
- Cellule Régionale Haute-Normandie, Centre Hospitalo-Universitaire de Rouen, France
| | - Philippe Brunet
- Centre de Néphrologie et de Transplantation Rénale, Hôpital de la Conception, APHM, Marseille, France
| | - Luc Frimat
- Nephrology Department, University of Lorraine, CHRU-Nancy, Vandoeuvre, France
| |
Collapse
|
7
|
Pietribiasi M, Waniewski J, Załuska W, Wójcik-Załuska A, Leypoldt JK. Comparison of two single-solute models of potassium kinetics during hemodialysis. Biocybern Biomed Eng 2020. [DOI: 10.1016/j.bbe.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
8
|
Leypoldt JK, Pietribiasi M, Ebinger A, Kraus MA, Collins A, Waniewski J. Acid-base kinetics during hemodialysis using bicarbonate and lactate as dialysate buffer bases based on the H + mobilization model. Int J Artif Organs 2020; 43:645-652. [PMID: 32126870 DOI: 10.1177/0391398820906524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The H+ mobilization model has been recently reported to accurately describe intradialytic kinetics of plasma bicarbonate concentration; however, the ability of this model to predict changing bicarbonate kinetics after altering the hemodialysis treatment prescription is unclear. METHODS We considered the H+ mobilization model as a pseudo-one-compartment model and showed theoretically that it can be used to determine the acid generation (or production) rate for hemodialysis patients at steady state. It was then demonstrated how changes in predialytic, intradialytic, and immediate postdialytic plasma bicarbonate (or total carbon dioxide) concentrations can be calculated after altering the hemodialysis treatment prescription. RESULTS Example calculations showed that the H+ mobilization model when considered as a pseudo-one-compartment model predicted increases or decreases in plasma total carbon dioxide concentrations throughout the entire treatment when the dialysate bicarbonate concentration is increased or decreased, respectively, during conventional thrice weekly hemodialysis treatments. It was further shown that this model allowed prediction of the change in plasma total carbon dioxide concentration after transfer of patients from conventional thrice weekly to daily hemodialysis using both bicarbonate and lactate as dialysate buffer bases. CONCLUSION The H+ mobilization model can predict changes in plasma bicarbonate or total carbon dioxide concentration during hemodialysis after altering the hemodialysis treatment prescription.
Collapse
Affiliation(s)
- John K Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Mauro Pietribiasi
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Anna Ebinger
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Michael A Kraus
- NxStage Medical, Inc. (Fresenius Medical Care), Lawrence, MA, USA
| | - Allan Collins
- NxStage Medical, Inc. (Fresenius Medical Care), Lawrence, MA, USA.,Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| |
Collapse
|
9
|
Delanaye P, Krzesinski F, Dubois BE, Delcour A, Robinet S, Piette C, Krzesinski JM, Lancellotti P. A simple modification of dialysate potassium: its impact on plasma potassium concentrations and the electrocardiogram. Clin Kidney J 2019; 14:390-397. [PMID: 33564443 PMCID: PMC7857800 DOI: 10.1093/ckj/sfz157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/02/2019] [Indexed: 11/14/2022] Open
Abstract
Background Sudden death is frequent in haemodialysis (HD) patients. Both hyperkalaemia and change of plasma potassium (K) concentrations induced by HD could explain this. The impact of increasing dialysate K by 1 mEq/L on plasma K concentrations and electrocardiogram (ECG) results before and after HD sessions was studied. Methods Patients with pre-dialysis K >5.5 mEq/L were excluded. ECG and K measurements were obtained before and after the first session of the week for 2 weeks. Then, K in the dialysate was increased (from 1 or 3 to 2 or 4 mEq/L, respectively). Blood and ECG measurements were repeated after 2 weeks of this change. Results Twenty-seven prevalent HD patients were included. As expected, a significant decrease in K concentrations was observed after the dialysis session, but this decrease was significantly lower after the switch to an increased dialysate K. The pre-dialysis K concentrations were not different after changing, but post-dialysis K concentrations were higher after switching (P < 0.0001), with a lower incidence of post-dialysis hypokalaemia. Regarding ECG, before switching, the QT interval (QT) dispersion increased during the session, whereas no difference was observed after switching. One week after switching, post-dialysis QT dispersion [38 (34-42) ms] was lower than post-dialysis QT dispersion 2 weeks and 1 week before switching [42 (38-57) ms, P = 0.0004; and 40 (35-50) ms, P = 0.0002]. Conclusions A simple increase of 1 mEq/L of K in the dialysate is associated with a lower risk of hypokalaemia and a lower QT dispersion after the dialysis session. Further study is needed to determine if such a strategy is associated with a lower risk of sudden death.
Collapse
Affiliation(s)
- Pierre Delanaye
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - François Krzesinski
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Bernard E Dubois
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Alexandre Delcour
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Sébastien Robinet
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Caroline Piette
- Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Jean-Marie Krzesinski
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.,Department of Cardiology, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
| |
Collapse
|
10
|
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
Collapse
Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| |
Collapse
|
11
|
Leypoldt JK, Kraus MA, Jaber BL, Weinhandl ED, Collins AJ. Effect of dialysate potassium and lactate on serum potassium and bicarbonate concentrations during daily hemodialysis at low dialysate flow rates. BMC Nephrol 2019; 20:252. [PMID: 31288787 PMCID: PMC6617706 DOI: 10.1186/s12882-019-1450-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/01/2019] [Indexed: 12/29/2022] Open
Abstract
Background Observational studies of hemodialysis patients treated thrice weekly have shown that serum and dialysate potassium and bicarbonate concentrations are associated with patient outcomes. The effect of more frequent hemodialysis on serum potassium and bicarbonate concentrations has rarely been studied, especially for treatments at low dialysate flow rate. Methods These post-hoc analyses evaluated data from patients who transferred from in-center hemodialysis (HD) to daily HD at low dialysate flow rates during the FREEDOM Study. The primary outcomes were the change in predialysis serum potassium and bicarbonate concentrations after transfer from in-center HD (mean during the last 3 months) to daily HD (mean during the first 3 months). Results After transfer from in-center HD to daily HD (data from 345 patients, 51 ± 15 years of age, mean ± standard deviation), predialysis serum potassium decreased (P < 0.001) by approximately 0.4 mEq/L when dialysate potassium concentration during daily HD was 1 mEq/L; no change occurred when dialysate potassium concentration during daily HD was 2 mEq/L. After transfer from in-center HD to daily HD (data from 284 patients, 51 ± 15 years of age), predialysis serum bicarbonate concentration decreased (P = 0.0022) by 1.0 ± 3.3 mEq/L when dialysate lactate concentration was 40 mEq/L but increased (P < 0.001) by 2.5 ± 3.5 mEq/L when dialysate lactate concentration was 45 mEq/L. These relationships were dependent on serum potassium and bicarbonate concentrations during in-center HD. Conclusions Control of serum potassium and bicarbonate concentrations during daily HD at low dialysate flow rates is readily achievable; the choice of dialysate potassium and lactate concentration can be informed when transfer is from in-center HD to daily HD. Electronic supplementary material The online version of this article (10.1186/s12882-019-1450-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | | | | | - Eric D Weinhandl
- NxStage Medical, Lawrence, MA, USA.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, USA
| | - Allan J Collins
- NxStage Medical, Lawrence, MA, USA.,Medical School, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
12
|
Ohnishi T, Kimachi M, Fukuma S, Akizawa T, Fukuhara S. Postdialysis Hypokalemia and All-Cause Mortality in Patients Undergoing Maintenance Hemodialysis. Clin J Am Soc Nephrol 2019; 14:873-881. [PMID: 31048327 PMCID: PMC6556735 DOI: 10.2215/cjn.07950718] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 04/01/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Almost half of patients on dialysis demonstrate a postdialysis serum potassium ≤3.5 mEq/L. We aimed to examine the relationship between postdialysis potassium levels and all-cause mortality. DESIGN, SETTING, PATIENTS, & MEASUREMENTS We conducted a cohort study of 3967 participants on maintenance hemodialysis from the Dialysis Outcomes and Practice Patterns Study in Japan (2009-2012 and 2012-2015). Postdialysis serum potassium was measured repeatedly at 4-month intervals and used as a time-varying variable. We estimated the hazard ratio of all-cause mortality rate using Cox hazard regression models, with and without adjusting for time-varying predialysis serum potassium. Models were adjusted for baseline characteristics and time-varying laboratory parameters. We also analyzed associations of combinations of pre- and postdialysis potassium with mortality. RESULTS The age of participants at baseline was 65±12 years (mean±SD), 2552 (64%) were men, and 96% were treated with a dialysate potassium level of 2.0 to <2.5 mEq/L. The median follow-up period was 2.6 (interquartile range, 1.3-2.8) years. During the follow-up period, 562 (14%) of 3967 participants died, and the overall mortality rate was 6.7 per 100 person-years. Compared with postdialysis potassium of 3.0 to <3.5 mEq/L, the hazard ratios of postdialysis hypokalemia (<3.0 mEq/L) were 1.84 (95% confidence interval, 1.44 to 2.34) in the unadjusted model, 1.44 (95% confidence interval, 1.14 to 1.82) in the model without adjusting for predialysis serum potassium, and 1.10 (95% confidence interval, 0.84 to 1.44) in the model adjusted for predialysis serum potassium. The combination of pre- and postdialysis hypokalemia was associated with the highest mortality risk (hazard ratio, 1.72; 95% confidence interval, 1.35 to 2.19, reference; pre- and postdialysis nonhypokalemia). CONCLUSIONS Postdialysis hypokalemia was associated with mortality, but this association was not independent of predialysis potassium.
Collapse
Affiliation(s)
- Tsuyoshi Ohnishi
- Department of Healthcare Epidemiology, School of Public Health and.,Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima City, Fukushima, Japan.,Institute for Health Outcomes and Process Evaluation Research (iHope International), Nakagyoku, Kyoto, Japan; and
| | - Miho Kimachi
- Department of Healthcare Epidemiology, School of Public Health and
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Sakyoku, Kyoto, Japan;
| | - Tadao Akizawa
- Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health and.,Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima City, Fukushima, Japan
| |
Collapse
|
13
|
Pietribiasi M, Waniewski J, Wójcik-Załuska A, Załuska W, Lindholm B. Model of fluid and solute shifts during hemodialysis with active transport of sodium and potassium. PLoS One 2018; 13:e0209553. [PMID: 30592754 PMCID: PMC6310262 DOI: 10.1371/journal.pone.0209553] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Mathematical models are useful tools to predict fluid shifts between body compartments in patients undergoing hemodialysis (HD). The ability of a model to accurately describe the transport of water between cells and interstitium (Jv,ISIC), and the consequent changes in intracellular volume (ICV), is important for a complete assessment of fluid distribution and plasma refilling. In this study, we propose a model describing transport of fluid in the three main body compartments (intracellular, interstitial and vascular), complemented by transport mechanisms for proteins and small solutes. Methods The model was applied to data from 23 patients who underwent standard HD. The substances described in the baseline model were: water, proteins, Na, K, and urea. Small solutes were described with two-compartment kinetics between intracellular and extracellular compartments. Solute transport across the cell membrane took place via passive diffusion and, for Na and K, through the ATPase pump, characterized by the maximum transport rate, JpMAX. From the data we estimated JpMAX and two other parameters linked to transcapillary transport of fluid and protein: the capillary filtration coefficient Lp and its large pores fraction αLP. In an Expanded model one more generic solute was included to evaluate the impact of the number of substances appearing in the equation describing Jv,ISIC. Results In the baseline model, median values (interquartile range) of estimated parameters were: Lp: 11.63 (7.9, 14.2) mL/min/mmHg, αLP: 0.056 (0.050, 0.058), and JpMAX: 5.52 (3.75, 7.54) mmol/min. These values were significantly different from those obtained by the Expanded model: Lp: 8.14 (6.29, 10.01) mL/min/mmHg, αLP: 0.046 (0.038, 0.052), and JpMAX: 16.7 (11.9, 25.2) mmol/min. The relative RMSE (root mean squared error)averaged between all simulated quantities compared to data was 3.9 (3.1, 5.6) %. Conclusions The model was able to accurately reproduce most of the changes observed in HD by tuning only three parameters. While the drop in ICV was overestimated by the model, the difference between simulations and data was less than the measurement error. The biggest change in the estimated parameters in the Expanded model was a marked increase of JpMAX indicating that this parameter is highly sensitive to the number of species modeled, and that the value of JpMAX should be interpreted only in relation to this factor.
Collapse
Affiliation(s)
- Mauro Pietribiasi
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
- * E-mail:
| | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
| | - Alicja Wójcik-Załuska
- Department of Rehabilitation and Physiotherapy, Medical University of Lublin, Lublin, Poland
| | - Wojciech Załuska
- Department of Nephrology, Medical University of Lublin, Lublin, Poland
| | - Bengt Lindholm
- Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
14
|
Wester M, van Gelder MK, Joles JA, Simonis F, Hazenbrink DHM, van Berkel TWM, Vaessen KRD, Boer WH, Verhaar MC, Gerritsen KGF. Removal of urea by electro-oxidation in a miniature dialysis device: a study in awake goats. Am J Physiol Renal Physiol 2018; 315:F1385-F1397. [PMID: 29993277 PMCID: PMC6293304 DOI: 10.1152/ajprenal.00094.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 01/09/2023] Open
Abstract
The key to success in developing a wearable dialysis device is a technique to safely and efficiently regenerate and reuse a small volume of dialysate in a closed-loop system. In a hemodialysis model in goats, we explored whether urea removal by electro-oxidation (EO) could be effectively and safely applied in vivo. A miniature dialysis device was built, containing 1 or 2 "EO units," each with 10 graphite electrodes, with a cumulative electrode surface of 585 cm2 per unit. The units also contained poly(styrene-divinylbenzene) sulfonate beads, FeOOH beads, and activated carbon for respective potassium, phosphate, and chlorine removal. Urea, potassium, and phosphate were infused to create "uremic" conditions. Urea removal was dependent on total electrode surface area [removal of 8 mmol/h (SD 1) and 16 mmol/h (SD 2) and clearance of 12 ml/min (SD 1) and 20 ml/min (SD 3) with 1 and 2 EO units, respectively] and plasma urea concentration but not on flow rate. Extrapolating urea removal with 2 EO units to 24 h would suffice to remove daily urea production, but for intermittent dialysis, additional units would be required. EO had practically no effects on potassium and phosphate removal or electrolyte balance. However, slight ammonium releasewas observed, and some chlorine release at higher dialysate flow rates. Minor effects on acid-base balance were observed, possibly partly due to infusion of chloride. Mild hemolysis occurred, which seemed related to urea infusion. In conclusion, clinically relevant urea removal was achieved in vivo by electro-oxidation. Efficacy and safety testing in a large-animal model with uremia is now indicated.
Collapse
Affiliation(s)
- Maarten Wester
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Maaike K van Gelder
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | | | - Diënty H M Hazenbrink
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Theo W M van Berkel
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Koen R D Vaessen
- Central Laboratory Animal Research Facility, Utrecht University , Utrecht , The Netherlands
| | - Walther H Boer
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Karin G F Gerritsen
- Department of Nephrology and Hypertension, University Medical Center Utrecht and Regenerative Medicine Utrecht, Utrecht University , Utrecht , The Netherlands
| |
Collapse
|
15
|
Long B, Warix JR, Koyfman A. Controversies in Management of Hyperkalemia. J Emerg Med 2018; 55:192-205. [DOI: 10.1016/j.jemermed.2018.04.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 02/07/2018] [Accepted: 04/10/2018] [Indexed: 12/24/2022]
|
16
|
Ferrey A, You AS, Kovesdy CP, Nakata T, Veliz M, Nguyen DV, Kalantar-Zadeh K, Rhee CM. Dialysate Potassium and Mortality in a Prospective Hemodialysis Cohort. Am J Nephrol 2018; 47:415-423. [PMID: 29879714 DOI: 10.1159/000489961] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies examining the association of dialysate potassium concentration and mortality in hemodialysis patients show conflicting findings. We hypothesized that low dialysate potassium concentrations are associated with higher mortality, particularly in patients with high pre-dialysis serum potassium concentrations. METHODS We evaluated 624 hemodialysis patients from the prospective Malnutrition, Diet, and Racial Disparities in Kidney Disease study recruited from 16 outpatient dialysis facilities over 2011-2015 who underwent protocolized collection of dialysis treatment characteristics every 6 months. We examined the association of dialysate potassium concentration, categorized as 1, 2, and 3 mEq/L, with all-cause mortality risk in the -overall cohort, and stratified by pre-dialysis serum potassium (< 5 vs. ≥5 mEq/L) using case-mix adjusted Cox models. RESULTS In baseline analyses, dialysate potassium concentrations of 1 mEq/L were associated with higher mortality, whereas concentrations of 3 mEq/L were associated with similar mortality in the overall cohort (reference: 2 mEq/L): adjusted hazard ratios (aHRs; 95% CI) 1.70 (1.01-2.88) and 0.95 (0.64-1.39), respectively. In analyses stratified by serum potassium, baseline dialysate potassium concentrations of 1 mEq/L were associated with higher mortality in patients with serum potassium ≥5 mEq/L but not in those with serum potassium < 5 mEq/L: aHRs (95% CI) 2.87 (1.51-5.46) and 0.74 (0.27-2.07), respectively (p interaction = 0.04). These findings were robust with incremental adjustment for serum potassium, potassium-binding resins, and potassium-modifying medications. CONCLUSION Low (1 mEq/L) dialysate potassium -concentrations were associated with higher mortality, particularly in hemodialysis patients with high pre-dialysis serum potassium. Further studies are needed to identify therapeutic strategies that mitigate inter-dialytic serum potassium accumulation and subsequent high dialysate serum potassium gradients in this population.
Collapse
Affiliation(s)
- Antoney Ferrey
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tracy Nakata
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Mary Veliz
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Danh V Nguyen
- Department of General Internal Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| |
Collapse
|
17
|
Bianchi C, Lanzarone E, Casagrande G, Costantino ML. A Bayesian approach for the identification of patient-specific parameters in a dialysis kinetic model. Stat Methods Med Res 2018; 28:2069-2095. [PMID: 29325494 DOI: 10.1177/0962280217745572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemodialysis is the most common therapy to treat renal insufficiency. However, notwithstanding the recent improvements, hemodialysis is still associated with a non-negligible rate of comorbidities, which could be reduced by customizing the treatment. Many differential compartment models have been developed to describe the mass balance of blood electrolytes and catabolites during hemodialysis, with the goal of improving and controlling hemodialysis sessions. However, these models often refer to an average uremic patient, while on the contrary the clinical need for customization requires patient-specific models. In this work, we assume that the customization can be obtained by means of patient-specific model parameters. We propose and validate a Bayesian approach to estimate the patient-specific parameters of a multi-compartment model, and to predict the single patient's response to the treatment, in order to prevent intra-dialysis complications. The likelihood function is obtained by means of a discretized version of the multi-compartment model, where the discretization is in terms of a Runge-Kutta method to guarantee convergence, and the posterior densities of model parameters are obtained through Markov Chain Monte Carlo simulation. Results show fair estimations and the applicability in the clinical practice.
Collapse
Affiliation(s)
- Camilla Bianchi
- 1 Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy
| | - Ettore Lanzarone
- 2 Istituto di Matematica Applicata e Tecnologie Informatiche (IMATI), Consiglio Nazionale delle Ricerche (CNR), Milan, Italy
| | - Giustina Casagrande
- 1 Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy
| | - Maria Laura Costantino
- 1 Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy
| |
Collapse
|
18
|
Morena M, Jaussent A, Chalabi L, Leray-Moragues H, Chenine L, Debure A, Thibaudin D, Azzouz L, Patrier L, Maurice F, Nicoud P, Durand C, Seigneuric B, Dupuy AM, Picot MC, Cristol JP, Canaud B. Treatment tolerance and patient-reported outcomes favor online hemodiafiltration compared to high-flux hemodialysis in the elderly. Kidney Int 2017; 91:1495-1509. [PMID: 28318624 DOI: 10.1016/j.kint.2017.01.013] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/09/2016] [Accepted: 01/05/2017] [Indexed: 12/18/2022]
Abstract
Large cohort studies suggest that high convective volumes associated with online hemodiafiltration may reduce the risk of mortality/morbidity compared to optimal high-flux hemodialysis. By contrast, intradialytic tolerance is not well studied. The aim of the FRENCHIE (French Convective versus Hemodialysis in Elderly) study was to compare high-flux hemodialysis and online hemodiafiltration in terms of intradialytic tolerance. In this prospective, open-label randomized controlled trial, 381 elderly chronic hemodialysis patients (over age 65) were randomly assigned in a one-to-one ratio to either high-flux hemodialysis or online hemodiafiltration. The primary outcome was intradialytic tolerance (day 30-day 120). Secondary outcomes included health-related quality of life, cardiovascular risk biomarkers, morbidity, and mortality. During the observational period for intradialytic tolerance, 85% and 84% of patients in high-flux hemodialysis and online hemodiafiltration arms, respectively, experienced at least one adverse event without significant difference between groups. As exploratory analysis, intradialytic tolerance was also studied, considering the sessions as a statistical unit according to treatment actually received. Over a total of 11,981 sessions, 2,935 were complicated by the occurrence of at least one adverse event, with a significantly lower occurrence in online hemodiafiltration with fewer episodes of intradialytic symptomatic hypotension and muscle cramps. By contrast, health-related quality of life, morbidity, and mortality were not different in both groups. An improvement in the control of metabolic bone disease biomarkers and β2-microglobulin level without change in serum albumin concentration was observed with online hemodiafiltration. Thus, overall outcomes favor online hemodiafiltration over high-flux hemodialysis in the elderly.
Collapse
Affiliation(s)
- Marion Morena
- Laboratoire de Biochimie, CHU de Montpellier, Montpellier, France; Institut de Recherche et de Formation en Dialyse, Montpellier, France; PhyMedExp, INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Audrey Jaussent
- Département de l'Information Médicale, CHU de Montpellier, Montpellier, France
| | - Lotfi Chalabi
- Association pour l'Installation à Domicile des Epurations Rénales (AIDER), Montpellier, France
| | | | - Leila Chenine
- Service de Néphrologie, CHU de Montpellier, Montpellier, France
| | | | - Damien Thibaudin
- Service de Néphrologie, CHU de Saint Etienne, Saint-Etienne, France
| | - Lynda Azzouz
- Association Régionale pour le Traitement de l'Insuffisance Rénale Chronique, Saint-Priest-en-Jarez, France
| | | | | | | | | | | | - Anne-Marie Dupuy
- Laboratoire de Biochimie, CHU de Montpellier, Montpellier, France
| | | | - Jean-Paul Cristol
- Laboratoire de Biochimie, CHU de Montpellier, Montpellier, France; Institut de Recherche et de Formation en Dialyse, Montpellier, France; PhyMedExp, INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France.
| | - Bernard Canaud
- Institut de Recherche et de Formation en Dialyse, Montpellier, France; Université de Montpellier, Néphrologie, Montpellier, France
| | | |
Collapse
|
19
|
Karaboyas A, Zee J, Brunelli SM, Usvyat LA, Weiner DE, Maddux FW, Nissenson AR, Jadoul M, Locatelli F, Winkelmayer WC, Port FK, Robinson BM, Tentori F. Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2016; 69:266-277. [PMID: 27866964 DOI: 10.1053/j.ajkd.2016.09.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/08/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sudden death is a leading cause of death in patients on maintenance hemodialysis therapy. During hemodialysis sessions, the gradient between serum and dialysate levels results in rapid electrolyte shifts, which may contribute to arrhythmias and sudden death. Controversies exist about the optimal electrolyte concentration in the dialysate; specifically, it is unclear whether patient outcomes differ among those treated with a dialysate potassium concentration of 3 mEq/L compared to 2 mEq/L. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 55,183 patients from 20 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 1 to 5 (1996-2015). PREDICTOR Dialysate potassium concentration at study entry. OUTCOMES Cox regression was used to estimate the association between dialysate potassium concentration and both all-cause mortality and an arrhythmia composite outcome (arrhythmia-related hospitalization or sudden death), adjusting for potential confounders. RESULTS During a median follow-up of 16.5 months, 24% of patients died and 7% had an arrhythmia composite outcome. No meaningful difference in clinical outcomes was observed for patients treated with a dialysate potassium concentration of 3 versus 2 mEq/L (adjusted HRs were 0.96 [95% CI, 0.91-1.01] for mortality and 0.98 [95% CI, 0.88-1.08] for arrhythmia composite). Results were similar across predialysis serum potassium levels. As in prior studies, higher serum potassium level was associated with adverse outcomes. However, dialysate potassium concentration had only minimal impact on serum potassium level measured predialysis (+0.09 [95% CI, 0.05-0.14] mEq/L serum potassium per 1 mEq/L greater dialysate potassium concentration). LIMITATIONS Data were not available for delivered (vs prescribed) dialysate potassium concentration and postdialysis serum potassium level; possible unmeasured confounding. CONCLUSIONS In combination, these results suggest that approaches other than altering dialysate potassium concentration (eg, education on dietary potassium sources and prescription of potassium-binding medications) may merit further attention to reduce risks associated with high serum potassium levels.
Collapse
Affiliation(s)
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, MA
| | | | | | - Allen R Nissenson
- DaVita Healthcare Partners, Inc, El Segundo, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michel Jadoul
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University, Nashville, TN
| |
Collapse
|
20
|
Patient-Specific Modeling of Multicompartmental Fluid and Mass Exchange during Dialysis. Int J Artif Organs 2016; 39:220-7. [DOI: 10.5301/ijao.5000504] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 12/19/2022]
Abstract
Background Dialysis is associated with a non-negligible rate of morbidity, requiring treatment customization. Many mathematical models have been developed describing solute kinetics during hemodialysis (HD) for an average uremic patient. The clinical need can be more adequately addressed by developing a patient-specific, multicompartmental model. Materials and Methods The data from 148 sessions (20 patients), recorded at the Regional Hospital of Lugano, Switzerland, were used to develop and validate the mathematical model. Diffusive and convective interactions among patient, dialysate and substitution fluid were considered. Three parameters, related to mass transfer efficiency at the cell membrane, at the dialyzer and at the capillary wall, were used to tune the model. The ability of the model to describe the clinical evolution of a specific HD session was evaluated by comparing model outputs with clinically acquired data on solutes and catabolite concentrations. Results The model developed in this study allows electrolyte and catabolite concentration trends during each HD session to be described. The errors obtained before the estimation of the patient-specific parameters drastically decrease after their identification. With the optimized model, plasmatic concentration trends can be described with an average percent error lower than 2.1% for Na+, CI-, Ca2+ and HCO3-, lower than 5% for K+ and lower than 8% for urea. Conclusions The peculiarity of the proposed model is the possibility it offers to perform a real-time simulation enabling quantitative appraisal of hematochemical quantities whose direct measurement is prohibitive. These will be beneficial to dialysis therapy planning, reducing intradialysis complications and improving patients’ quality of life.
Collapse
|
21
|
Palmer SC, Natale P, Ruospo M, Saglimbene VM, Rabindranath KS, Craig JC, Strippoli GFM. Antidepressants for treating depression in adults with end-stage kidney disease treated with dialysis. Cochrane Database Syst Rev 2016; 2016:CD004541. [PMID: 27210414 PMCID: PMC8520741 DOI: 10.1002/14651858.cd004541.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Depression affects approximately one-quarter of people treated with dialysis and is considered an important research uncertainty by patients and health professionals. Treatment for depression in dialysis patients may have different benefits and harms compared to the general population due to different clearances of antidepressant medication and the severity of somatic symptoms associated with end-stage kidney disease (ESKD). Guidelines suggest treatment of depression in dialysis patients with pharmacological therapy, preferably a selective serotonin reuptake inhibitor. This is an update of a review first published in 2005. OBJECTIVES To evaluate the benefit and harms of antidepressants for treating depression in adults with ESKD treated with dialysis. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 20 January 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antidepressant treatment with placebo or no treatment, or compared to another antidepressant medication or psychological intervention in adults with ESKD (estimated glomerular filtration rate < 15 mL/min/1.73 m(2)). DATA COLLECTION AND ANALYSIS Data were abstracted by two authors independently onto a standard form and subsequently entered into Review Manager. Risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data were calculated with 95% confidence intervals (95% CI). MAIN RESULTS Four studies in 170 participants compared antidepressant therapy (fluoxetine, sertraline, citalopram or escitalopram) versus placebo or psychological training for 8 to 12 weeks. In generally very low or ungradeable evidence, compared to placebo, antidepressant therapy had no evidence of benefit on quality of life, had uncertain effects on increasing the risk of hypotension (3 studies, 144 participants: RR 1.72, 95% CI 0.75 to 3.92), headache (2 studies 56 participants: RR 2.91, 95% CI 0.73 to 11.57), and sexual dysfunction (2 studies, 101 participants: RR 3.83, 95% CI 0.63 to 23.34), and increased nausea (3 studies, 114 participants: RR 2.67, 95% CI 1.26 to 5.68). There were few or no data for hospitalisation, suicide or all-cause mortality resulting in inconclusive evidence. Antidepressant therapy may reduce depression scores during treatment compared to placebo (1 study, 43 participants: MD -7.50, 95% CI -11.94 to -3.06). Antidepressant therapy was not statistically different from group psychological therapy for effects on depression scores or withdrawal from treatment and a range of other outcomes were not measured. AUTHORS' CONCLUSIONS Despite the high prevalence of depression in dialysis patients and the relative priority that patients place on effective treatments, evidence for antidepressant medication in the dialysis setting is sparse and data are generally inconclusive. The relative benefits and harms of antidepressant therapy in dialysis patients are poorly known and large randomised studies of antidepressants versus placebo are required.
Collapse
Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | | | - Marinella Ruospo
- DiaverumMedical Scientific OfficeLundSweden
- Amedeo Avogadro University of Eastern PiedmontDivision of Nephrology and Transplantation, Department of Translational MedicineVia Solaroli 17NovaraItaly28100
| | | | | | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum AcademyBariItaly
| | | |
Collapse
|
22
|
Treatment of hyperkalemia: something old, something new. Kidney Int 2016; 89:546-54. [DOI: 10.1016/j.kint.2015.11.018] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/23/2015] [Accepted: 11/11/2015] [Indexed: 11/19/2022]
|
23
|
Wells CC. ABCs of the Intensive Care Unit. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
24
|
Locatelli F, La Milia V, Violo L, Del Vecchio L, Di Filippo S. Optimizing haemodialysate composition. Clin Kidney J 2015; 8:580-9. [PMID: 26413285 PMCID: PMC4581377 DOI: 10.1093/ckj/sfv057] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022] Open
Abstract
Survival and quality of life of dialysis patients are strictly dependent on the quality of the haemodialysis (HD) treatment. In this respect, dialysate composition, including water purity, plays a crucial role. A major aim of HD is to normalize predialysis plasma electrolyte and mineral concentrations, while minimizing wide swings in the patient's intradialytic plasma concentrations. Adequate sodium (Na) and water removal is critical for preventing intra- and interdialytic hypotension and pulmonary edema. Avoiding both hyper- and hypokalaemia prevents life-threatening cardiac arrhythmias. Optimal calcium (Ca) and magnesium (Mg) dialysate concentrations may protect the cardiovascular system and the bones, preventing extraskeletal calcifications, severe secondary hyperparathyroidism and adynamic bone disease. Adequate bicarbonate concentration [HCO3−] maintains a stable pH in the body fluids for appropriate protein and membrane functioning and also protects the bones. An adequate dialysate glucose concentration prevents severe hyperglycaemia and life-threating hypoglycaemia, which can lead to severe cardiovascular complications and a worsening of diabetic comorbidities.
Collapse
Affiliation(s)
- Francesco Locatelli
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Vincenzo La Milia
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Leano Violo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Lucia Del Vecchio
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Salvatore Di Filippo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| |
Collapse
|
25
|
Leypoldt JK, Agar BU, Bernardo AA, Culleton BF. Prescriptions of dialysate potassium concentration during short daily or long nocturnal (high dose) hemodialysis. Hemodial Int 2015; 20:218-25. [DOI: 10.1111/hdi.12331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- John K. Leypoldt
- Medical Products (Renal); Baxter Healthcare Corporation; Deerfield Illinois USA
| | - Baris U. Agar
- Medical Products (Renal); Baxter Healthcare Corporation; Deerfield Illinois USA
| | | | - Bruce F. Culleton
- Medical Products (Renal); Baxter Healthcare Corporation; Deerfield Illinois USA
| |
Collapse
|
26
|
Human atrial cell models to analyse haemodialysis-related effects on cardiac electrophysiology: work in progress. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2014; 2014:291598. [PMID: 25587348 PMCID: PMC4284940 DOI: 10.1155/2014/291598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/05/2014] [Accepted: 11/12/2014] [Indexed: 11/25/2022]
Abstract
During haemodialysis (HD) sessions, patients undergo alterations in the extracellular environment, mostly concerning plasma electrolyte concentrations, pH, and volume, together with a modification of sympathovagal balance. All these changes affect cardiac electrophysiology, possibly leading to an increased arrhythmic risk. Computational modeling may help to investigate the impact of HD-related changes on atrial electrophysiology. However, many different human atrial action potential (AP) models are currently available, all validated only with the standard electrolyte concentrations used in experiments. Therefore, they may respond in different ways to the same environmental changes. After an overview on how the computational approach has been used in the past to investigate the effect of HD therapy on cardiac electrophysiology, the aim of this work has been to assess the current state of the art in human atrial AP models, with respect to the HD context. All the published human atrial AP models have been considered and tested for electrolytes, volume changes, and different acetylcholine concentrations. Most of them proved to be reliable for single modifications, but all of them showed some drawbacks. Therefore, there is room for a new human atrial AP model, hopefully able to physiologically reproduce all the HD-related effects. At the moment, work is still in progress in this specific field.
Collapse
|