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Chhabra R, Davenport A. Calcium mass balance in adults during single hemodialysis and hemodiafiltration treatments using lower calcium dialysate concentrations. Artif Organs 2024; 48:812-820. [PMID: 38837801 DOI: 10.1111/aor.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/11/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Debate continues as to the optimum hemodialysis (HD) dialysate calcium concentration. Although current guidelines advocate 1.25-1.5 mmol/L, some investigators have suggested these may cause calcium gains. As such we investigated whether using dialysate calcium of 1.25 mmol/L risked calcium gains, and whether there were differences between hemodiafiltration and high flux HD. METHODS We continuously collect an aliquot of effluent dialysate during dialysis sessions, and calculated dialysis calcium mass balance by the difference between the amount of calcium delivered as fresh dialysate and that lost in effluent dialysate. RESULTS We studied 106 stable outpatients, 64% male, mean age 64.4 ± 16.2 years, median dialysis vintage 32 (22-60) months. Most sessions (69%) used a 1.0 mmol/L calcium dialysate, with a median sessional loss of 13.7 (11.5-17.1) mmol, whereas using 1.25 mmol/L the median loss was 7.4 (4.9-10.1) mmol, but with 6.9% had a positive balance (p = 0.031 vs dialysate calcium 1.0 mmol/L). Most patients (85.8%) were treated by hemodiafiltration, but there was no difference in sessional losses (11.7 (8.4-15.8) vs 13.5 (8.1-16.8)) with high flux HD. Dialysis sessional calcium balance was associated with the use of lower dialysate calcium concentration (β -19.5, 95% confidence limits (95%CL) -27.7 to -11.3, p < 0.001), and sessional duration (β 0.07 (95% CL) 0.03-012, p = 0.002). CONCLUSION Ideally, the choice of dialysate calcium should be individualized, but clinicians should be aware, that even when using a dialysate calcium of 1.25 mmol/L, some patients are at risk of a calcium gain during hemodiafiltration and high-flux hemodialysis.
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Affiliation(s)
- Roohi Chhabra
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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Stegmayr BG, Lundberg LD. Hemodialysis patients have signs of a chronic thrombotic burden. BMC Nephrol 2024; 25:223. [PMID: 38997655 PMCID: PMC11245813 DOI: 10.1186/s12882-024-03654-3] [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: 10/24/2023] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Cardiovascular diseases are the dominant cause of morbidity in hemodialysis (HD) patients. Unless sufficient anticoagulation is used during HD, clotting may appear. The objective was to investigate if levels of fibrin degradation products (D-dimer) were increased before and during HD. METHODS The combined observational study included 20 patients performing a total of 60 hemodialysis divided into three sessions of low-flux dialysis. None of the patients suffered from any clinically evident thromboembolic event before or during the study. Median bolus anticoagulation (mainly tinzaparin) doses were 84 Units/kg bow. Blood samples were drawn before HD (predialysis), and at 30min and 180min during HD with focus on analyzing D-dimer levels and its relation to interdialytic weight gain (IDWG) and speed of fluid elimination by HD (UF-rate). RESULTS Predialysis, D-dimer levels (mean 0.767 ±0.821, min 0.136mg/L) were above the upper reference value in 95% of the sessions. D-dimer levels were lowered at 30min (p<0.001) and returned to predialysis levels at 180min. Predialysis D-dimer correlated with NT-pro-BNP, Troponin T, IDWG and UF-rate. Multiple regression analysis revealed that the D-dimer levels were significantly related to IDWG and the UF-rate. CONCLUSIONS D-dimer levels were elevated in a high proportion predialysis and during HD and related to the IDWG and the UF-rate. Awareness of D-dimer levels and future studies will help clarify if optimization of those variables, besides anticoagulation and biocompatibility measures, will eradicate the repeated subclinical thromboembolic events related to each HD; one reason that may explain organ damage and shortened life span of these patients.
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Affiliation(s)
- Bernd G Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.
| | - Lennart D Lundberg
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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Shaaker H, Davenport A. Does Dietary Intake Differ in Kidney Failure Patients With Sarcopenia and Frailty Treated by Hemodialysis. Gerontol Geriatr Med 2024; 10:23337214241253433. [PMID: 38765918 PMCID: PMC11100388 DOI: 10.1177/23337214241253433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/16/2023] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
Background: Inadequate nutrition is common for both sarcopenia and frailty. We investigated whether hemodialysis patients with sarcopenia and frailty have reduced dietary intakes. Methods: Dietary intake, and physical activity were analyzed, along with body composition and relevant clinical data. Results: We studied 51 hemodialysis patients; 52.9% male, age 60 ± 15 years; 33.3% sarcopenic, and 72.5% frail. Dietary protein and calories were similar for sarcopenic and non-sarcopenic patients 0.68 (0.38-3.5) vs. 0.68 (0.18-2.9) g protein/kg/day and 19.2 (8.2-77.5) vs. 15.2 (6.2-38.5) kcal/kg/day. More sarcopenic patients had low physical activity (88.2% vs. 58.8%, X2 4.6, p = .03). Frail and non-frail patients had similar intakes 0.67 (0.28-3.5) versus 0.83 (0.18-1.6) g protein/kg/day and 15.5 (8.1-77.5) vs. 18.8 (6.2-45.4) kcal/kg/day. Sarcopenia was associated with age [Odds ratio (OR) 1.09, 95% confidence interval (CI) [1.02, 1.18], p = .017], body mass index [OR 0.84, 95% CI [0.71, 0.99], p = .042] and lack of exercise [OR 7.62, 95% CI [1.16, 50.29], p = .035]. Frailty was associated with female gender [OR 17.79, 95% CI [2.09, 151.59], p = .008], age [OR 1.13, 95% CI [1.04, 1.22], p = .006], and dialysis vintage [OR 1.55, 95% CI [1.06, 2.26], p = .024]. Conclusion: Hemodialysis patients with sarcopenia and frailty did not have lower dietary protein and calorie intake. Frailty was associated with age and sarcopenia with a sedentary lifestyle.
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Affiliation(s)
- Haalah Shaaker
- University College London, UK
- King Abdulaziz University, Jeddah, Saudi Arabia
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Boldt D, Busse L, Chawla LS, Flannery AH, Khanna A, Neyra JA, Palmer P, Wilson J, Yessayan L. Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States. Ren Fail 2023; 45:2290932. [PMID: 38073554 PMCID: PMC11001369 DOI: 10.1080/0886022x.2023.2290932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists. METHODS The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals. RESULTS 150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock. CONCLUSIONS Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.
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Affiliation(s)
- David Boldt
- Department of Anesthesiology and Perioperative Medicine, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Laurence Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | | | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Ashish Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - James Wilson
- Department of Nephrology, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2023; 43:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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ElSayed H, Sayed KS, Gharib MS. Effect of dialyzer geometry on coagulation activation in the extracorporeal circuit in maintenance hemodialysis patients: Prospective randomized trial. Ther Apher Dial 2023. [PMID: 36762467 DOI: 10.1111/1744-9987.13975] [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: 11/04/2022] [Revised: 12/26/2022] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND AND OBJECTIVES The coagulation cascade is activated during hemodialysis (HD) due to interaction of blood with the dialysis circuit. There is a paucity of data on the effect of the physical structure of the dialyzers on coagulation activation during HD. We conducted this study to compare the effect of Helixone FX80 versus Platinum H4 dialyzers on coagulation activation during HD. METHODS Twenty patients on maintenance HD were enrolled in this randomized prospective crossover study. Each patient was dialyzed using Helixone FX80 and Platinum H4 dialyzers. Serum thrombin-antithrombin complex (TAT) was measured before (T0h) and at the end (T4H) of HD. RESULTS The absolute changes of serum TAT were comparable with the two dialyzers (median [IQR]: 1.15 [0.65, 1.75] for Helixone FX80 vs. 1.15 [0.67, 2.05] for Platinum H4, p = 0.371). CONCLUSION Helixone FX80 and Platinum H4 dialyzers have similar effects on coagulation activation during HD.
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Affiliation(s)
- Hesham ElSayed
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Khalid Samir Sayed
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Sary Gharib
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Law S, Davenport A. The effect of changing dialysate bicarbonate concentration on serum bicarbonate, body weight and normalized nitrogen appearance rate. Artif Organs 2022; 47:891-897. [PMID: 36519969 DOI: 10.1111/aor.14483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/25/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Most hemodialysis machines deliver a fixed bicarbonate concentration. Higher concentrations may improve acidosis, but risk post-hemodialysis alkalosis, whereas lower concentrations potentially increase acidosis but reduce alkalosis. We reviewed the effects of lowering dialysate bicarbonate. METHODS We reviewed peri-dialysis chemistries in patients switching to a lower bicarbonate dialysate at 4 time points over 19 months. RESULTS We studied 126 patients, mean age 63.7 ± 16.3 years, 57.9% males. Post-hemodialysis alkalosis fell from 1.6 to 0.3% sessions, but pre-hemodialysis acidosis increased from 11.9 to 23.8% sessions (p = 0.005) reducing dialysate bicarbonate from 32 to 28 mmol/L. After 3 months, pre-hemodialysis serum bicarbonate fell (21.1 ± 2.3 to 19.8 ± 2.2 mmol/L), and post-hemodialysis (24.9 ± 2.1 to 22.5 ± 2.0 mmol/L, p < 0.001) with a fall in pre-hemodialysis weight from 74.6 ± 20.7 to 71.7 ± 18.2 kg, normalized protein nitrogen accumulation rate 0.8 ± 0.28 to 0.77 ± 0.2 g/kg/day, p < 0.05, and serum albumin 39.7 ± 4.2 to 37.7 ± 4.9 g/L, p < 0.001. Thereafter, apart from pre- and post-hemodialysis serum bicarbonate, weight and normalized protein nitrogen accumulation stabilized, although albumin remained lower (37.6 ± 4.0 g/L, p < 0.001). On multivariate logistic analysis, serum bicarbonate increased more with lower pre-hemodialysis bicarbonate standardized coefficient β 0.5 (95% confidence interval -0.6 to -0.42), increased normalized protein nitrogen accumulation β 0.2 (0.96 to 2.38), p < 0.001, and session time β 0.09, (0.47 to 5.98), p < 0.022, and less with lower dialysate bicarbonate 0.0-0.23 (-1.54 to -0.74), p < 0.001. CONCLUSION Increases in SE-Bic with hemodialysis, depend on the bicarbonate gradient, session time and nPNA. Lower D-Bic reduces post-hemodialysis alkalosis but increases pre-hemodialysis acidosis and may initially have adverse effects on weight and normalized protein nitrogen accumulation.
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Affiliation(s)
- Steven Law
- UCL Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences University College London London UK
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences University College London London UK
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Sudusinghe D, Riddell A, Gandhi T, Chowdary P, Davenport A. Increased risk of dialysis circuit clotting in hemodialysis patients with COVID-19 is associated with elevated FVIII, fibrinogen and D-dimers. Hemodial Int 2022; 27:38-44. [PMID: 36081392 PMCID: PMC9537782 DOI: 10.1111/hdi.13046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Severe COVID-19 infections increase the risk of thrombotic events and Intensive Care Units reported increased extracorporeal circuit clotting (ECC) in COVID-19 patients with acute kidney injury. We wished to determine whether hemodialysis (HD) patients with COVID-19 also have increased risk of circuit clotting. METHODS We reviewed coagulation studies and HD records, 4 weeks before and after COVID-19 polymerase chain reaction detection in HD patients between April 2020 and June 2021. FINDINGS Sixty-eight (33.5%) of 203 HD patients with COVID-19, 65% male, mean age 64.9 ± 15.3 years, experienced some circuit clotting, and no clotting recorded prior to positive test results. In those who experienced ECC, prothrombin, activated partial thromboplastin or thrombin times were not different, whereas median factor VIII (273 [168-419] vs. 166 [139-225] IU/dl, p < 0.001), D-dimers (2654 [1381-6019] vs. 1351 [786-2334] ng/ml, p < 0.05), and fibrinogen (5.6 ± 1.4 vs. 4.9 ± 1.4 g/L, p < 0.05) were greater. Antithrombin (94 [83-112] vs. 89 [84-103] IU/dl), protein C (102 [80-130] vs. 86 [76-106] IU/dl), protein S (65 [61-75] vs. 65 [52-79] IU/dl) and platelet counts (193 [138-243] vs. 174 [138-229] × 109 /L) did not differ. On multivariable logistic analysis, circuit clotting was associated with log factor VIII (odds ratio [OR] 14.8 (95% confidence limits [95% CL] 1.12-19.6), p = 0.041), fibrinogen (OR 1.57 [95% CL 1.14-21.7], p = 0.006) and log D dimer (OR 4.8 [95% CL 1.16-12.5], p = 0.028). DISCUSSION Extracorporeal circuit clotting was increased within 4 weeks of testing positive for COVID-19. Clotting was associated with increased factor VIII, fibrinogen and D-dimer, suggesting that the risk of circuit clotting was related to the inflammatory response to COVID-19.
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Affiliation(s)
- Dinesha Sudusinghe
- Department of Physiology, Faculty of Medical SciencesUniversity of Sri JayewardenepuraNugegodaSri Lanka
| | - Anne Riddell
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK,Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Tejas Gandhi
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK,Research Department of HaematologyCancer Institute UCLLondonUK
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical SciencesUniversity College LondonLondonUK
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Hendra H, Sridharan S, Farrington K, Davenport A. Characteristics of Frailty in Haemodialysis Patients. Gerontol Geriatr Med 2022; 8:23337214221098889. [PMID: 35548325 PMCID: PMC9083032 DOI: 10.1177/23337214221098889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 01/29/2023] Open
Abstract
Background: Both frailty and cachexia increase mortality in haemodialysis (HD) patients. The clinical frailty score (CFS) is a seven-point scale and less complex than other cachexia and frailty assessments. We wished to determine the characteristics of frail HD patients using the CFS. Methods: Single centre cross-sectional study of HD patients completing physical activity questionnaires with bioimpedance measurements of body composition and hand grip strength (HGS). Results: We studied 172 HD patients. The CFS classified 54 (31.4%) as frail, who were older (70.4±12.2 vs 56.2 ± 16.1 years, p < 0.001), greater modified Charlson co-morbidity (3 (2–3) versus 1.5 (0–3), p < 0.001), and body fat (33 (25.4–40.2) versus 26.2 (15.8–34) %, p < 0.01), but lower total energy expenditure (1720 (1574–1818) versus 1870 (1670–2194) kcal/day, p < 0.01), lean muscle mass index (9.1 (7.7–10.1) versus 9.9 (8.9–10.8) kg/m2), and HGS (15.3 (10.3–21.9) versus 23.6 (16.7–34.4) kg), both p < 0.001. On multivariable logistic analysis, frailty was independently associated with lower active energy expenditure (odds ratio (OR) 0.98, 95% confidence limits (CL) 0.98–0.99, p = 0.001), diabetes (OR 5.09, CL 1.06–16.66) and HGS (OR 0.92, CL 0.86–0.98). Discussion: Frail HD patients reported less active energy expenditure, associated with reduced muscle mass and strength. Frail patients were more likely to have greater co-morbidity, particularly diabetes. Whether physical activity programmes can improve frailty remains to be determined.
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Affiliation(s)
- Heidy Hendra
- UCL Department of Nephrology, University College London, London NW, UK
| | | | - Ken Farrington
- University of Hertfordshire, Hatfield, UK
- Renal Unit, Lister Hospital, Corey’s Mill Lane, ST, UK
| | - Andrew Davenport
- UCL Department of Nephrology, University College London, London NW, UK
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Davenport A. Peri-dialytic hypoglycaemia with haemodialysis and on-line post-dilutional haemodiafiltration. Ther Apher Dial 2022; 26:1148-1155. [PMID: 35261192 DOI: 10.1111/1744-9987.13835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We wished to determine whether peri-dialytic hypoglycaemia is a clinical risk in contemporary dialysis patients using glucose containing dialysate. METHODS We measured blood glucose pre- and post-haemodialysis or haemodiafiltration, using 5.5 mmol/L glucose dialysate, and body composition by bioimpedance. RESULTS 239 patients were studied, mean age 65±15.4 years, 59.4% male, 46.4% diabetes, 81.6% treated by haemodiafiltration, Five haemodiafiltration patients (2.1%) had hypoglycaemia, with 82 (33%) a blood glucose <5.5 mmol/L, with fewer diabetics (19.8 vs 74.7%, p=0.001, and %body fat 27.7(20.6-32.6) vs 34.7(26.6-42.8)%, p=0.001. Low post-dialysis blood glucose was negatively associated with glycated haemoglobin (OR 0.94 (0.84-0.97), p=0.004), weight (OR 0.94 (0.89-0.98), p=0.009), and % body fat (OR 0.92 (0.86-0.98), p=0.013). CONCLUSIONS Although hypoglycaemia occurred in 2%, 33% had a blood glucose below dialysate glucose. Low post-dialysis glucose was associated with lower glycated haemoglobin and body fat, suggesting nutritional status is important in determining the risk of peri-dialytic hypoglycaemia.
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Affiliation(s)
- Andrew Davenport
- UCL Department of Renal Medicine Royal Free Hospital University College London Rowland Hill Street London NW3 2PF
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11
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Riddell A, Chowdary P, Davenport A. The effect of SARS-Co-V2 infection on prothrombotic and anticoagulant factors in dialysis patients. Artif Organs 2022; 46:1328-1333. [PMID: 35167146 PMCID: PMC9111238 DOI: 10.1111/aor.14206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/11/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with COVID-19 infection are at increased risk of thrombosis. We wished to determine whether this was is due to an increase in prothrombotic or reduction in anticoagulant factors, and whether heparin would be an appropriate anticoagulant. METHODS We measured routine coagulation and prothrombtic factors in dialysis patients after a positive COVID-19 test between March 2020 -April 2021. RESULTS Routine coagulation tests were measured in 227 dialysis patients, 148 males (65.2%), median age 67.5 (53.8-77.0) years. The international normalised ratio was prolonged in 11.5%, activated partial thromboplastin time in 48.5%, thrombin time in 57%. Factor VIII was increased in 59.1%, fibrinogen in 73.8%, and D-dimer 95.5%. Protein C was reduced in 15.3%, protein S in 28%, and antithrombin (AT) in 12.1%. Two patients were Lupus anticoagulant positive , and two Factor VLeiden positive. Factor VIII levels increased with clinical disease; outpatients 159 (136-179) IU/dL, hospitalised but not ventilated 228 (167-311) IU, ventilated 432 (368-488) IU/dL (p<0.01). Overall 75% had an AT level ≥ 88 IU/dL (reference range 79-106), but only 11.7% of non-hospitalised patientscompared to 45% of those who died, p<0.01, Fibrinogen,D-dimers, proteins S or C did not differ with clinical disease severity, whether patients required hospital admission or not and between survivors and those who died. CONCLUSION COVID-19 dialysis patients have increased levels of fibrinogen and D-Dimers, but only factor VIII levels in the clotting profile increased with clinical disease severity increasing systemic hypercoagulability. AT concentrations are maintained and as such should not compromise anticoagulation with heparins.
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Affiliation(s)
- Anne Riddell
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free Hospital.,Research Department of Haematology, Cancer Institute UCL
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, Faculty of Medical Sciences, University College London, London, UK
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Davenport A. Application of the Clinical Frailty Score and body composition and upper arm strength in haemodialysis patients. Clin Kidney J 2021; 15:553-559. [PMID: 35211309 PMCID: PMC8862041 DOI: 10.1093/ckj/sfab228] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/21/2022] Open
Abstract
Background To improve outcomes, simple screening tests are required to detect patients at increased risk of mortality. As patients with muscle weakness and wasting are at increased risk of death, we wished to review the use of the Clinical Frailty Score (CFS). Patients and methods Dialysis staff graded haemodialysis (HD) patients attending for routine outpatient sessions using the CFS, a functional scoring scale, for patients who require help with their instrumental activities of daily living, classified as clinically frail with scores >4, which were compared with contemporaneous Stoke–Davies comorbidity scores, post-HD body composition measured by bioimpedance, hand grip strength (HGS) and standard laboratory investigations. Results The results from 2089 patients (60.2% male) were reviewed, with 890 (42.6%) classified as frail. Frail patients were older [mean ± standard deviation (SD) 71.5 ± 15.6 versus 59.1 ± 15.6 years) and female (50.7% versus 37.3%) and had greater comorbidity {median 2 [interquartile range (IQR) 1–3] versus 1 [0–2]}, body mass index (BMI) (26.0 ± 6.7 versus 25.5 ± 5.4 kg/m2), C-reactive protein (CRP) [8 (IQR 3–20) versus 5 (2–11) mg/L], lower serum albumin (37.6 ± 4.7 versus 40.1 ± 4.7 g/L), lean BMI (8.9 ± 1.7 versus 9.7 ± 1.6 kg/m2) and HGS [13.4 (IQR 9.6–18.8) versus 20.9 (14.5–29) kg] (all P < 0.001). Frailty was independently associated in a multivariable logistic model with age {odds ratio [OR] 2.33 [95% confidence limit (CL) 2.01–2.7]}, body fat mass [OR 1.02 (CL 1.01–1.03)], log CRP [OR 1.63 (CL 1.28–2.07)] (all P < 0.001) and comorbidity [OR 1.45 (CL 1.17–1.8); P = 0.001] and negatively associated with albumin [OR 0.95 (CL 0.92–0.98) and HGS [OR 0.91 (CL 0.9–0.93)] (both P < 0.001). Conclusion Frail patients are at increased risk of mortality and, as such, simple reliable screening tools are required to rapidly detect patients at risk. The CFS is a useful screening tool that can be readily performed by dialysis staff to identify frail patients. Frailty in HD patients was associated with increasing age, comorbidity, fat weight and inflammation and reduced muscle strength and muscle mass. There is an overlap between frailty and both sarcopenia and protein energy wasting, which requires additional assessments, potentially including body composition, strength, dietary assessments and laboratory investigations. In addition, as the CFS offers a scale, patient trajectories can potentially be serially monitored over time, thus allowing patient-specific interventions or holistic care plans.
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Affiliation(s)
- Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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13
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Vanommeslaeghe F, Josipovic I, Boone M, van der Tol A, Dhondt A, Van Biesen W, Eloot S. How biocompatible haemodialysers can conquer the need for systemic anticoagulation even in post-dilution haemodiafiltration: a cross-over study. Clin Kidney J 2021; 14:1752-1759. [PMID: 34548919 PMCID: PMC8447252 DOI: 10.1093/ckj/sfaa219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/31/2020] [Indexed: 01/27/2023] Open
Abstract
Background While systemic anticoagulation is most widely used in haemodialysis (HD), contraindications to its use might occur in particular settings. The Solacea™ haemodialyser with an asymmetric triacetate membrane claims improved biocompatibility and has already shown promising results when used in combination with only half dose of anticoagulation. To quantify the performance of the Solacea™ when further decreasing anticoagulation to zero, fibre blocking was assessed by micro-computed tomography (micro-CT). Methods Ten maintenance HD patients underwent six dialysis sessions at midweek using a Solacea™ 19H dialyser, consecutively in pre-dilution haemodiafiltration (pre-HDF), HD and post-dilution HDF (post-HDF). After the first three sessions with only a quarter of their regular anticoagulation dose (one-quarter), the last three sessions were performed without anticoagulation (zero). Dialyser fibre blocking was quantified in the dialyser outlet potting using a 3D micro-CT scanning technique post-dialysis. Results Even in case of reduced (one-quarter) anticoagulation, the relative number of open fibres post-dialysis was almost optimal, i.e. 0.96 (0.87-0.99) with pre-HDF, 0.99 (0.97-0.99) with HD and 0.97 (0.92-0.99) with post-HDF. Fibre patency was mildly decreased for pre-HDF and HD when anticoagulation was decreased from one-quarter to zero, i.e. to 0.76 (0.61-0.85) with pre-HDF (P = 0.004) and to 0.80 (0.77-0.89) with HD (P = 0.013). Comparing the results for zero anticoagulation, post-HDF [i.e. 0.94 (0.82-0.97)] performed as well as HD and pre-HDF. Conclusions The Solacea™ dialyser provides promising results for use in conditions where systemic anticoagulation is contraindicated. Post-HDF, although inducing haemoconcentration in the dialyser, is equally effective for fibre patency in case of zero anticoagulation as pre-HDF and HD when using Solacea™.
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Affiliation(s)
| | - Iván Josipovic
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Matthieu Boone
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Ghent, Belgium
| | | | - Annemie Dhondt
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Sunny Eloot
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
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14
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Jain N, Corken AL, Kumar A, Davis CL, Ware J, Arthur JM. Role of Platelets in Chronic Kidney Disease. J Am Soc Nephrol 2021; 32:1551-1558. [PMID: 34140394 PMCID: PMC8425650 DOI: 10.1681/asn.2020121806] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 02/04/2023] Open
Abstract
Platelet-dependent mechanisms for excessive clotting and bleeding in CKD remain undefined. Moreover, platelets' contribution to inflammation, and specifically to CKD, are equally elusive. To date, descriptions of changes in the functional properties of circulating platelets during CKD have provided confusing interpretations. Experimental approaches that can advance our understanding of platelet dysfunction in CKD are needed, and studies that provide mechanistic insights into the dynamic relationships between thrombosis, bleeding, and inflammation associated with CKD will be essential to improve clinical management and outcomes for this vulnerable population. This article summarizes existing literature characterizing platelets in CKD and identifies areas that need further investigation.
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Affiliation(s)
- Nishank Jain
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
| | - Adam L. Corken
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Amudha Kumar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Clayton L. Davis
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jerry Ware
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - John M. Arthur
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
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Yoowannakul S, Vongsanim S, Tangvoraphonkchai K, Mohamed A, Davenport A. Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00321-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Quality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms.
Methods
We reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW).
Results
We studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times.
We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times.
Conclusion
We found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.
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16
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Tangwonglert T, Davenport A. Does Pulse Wave Velocity Increase Over Time in Hemodialysis Patients? Blood Purif 2020; 50:546-551. [PMID: 33352556 DOI: 10.1159/000512354] [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: 08/19/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Arterial stiffness, measured by pulse wave velocity (PWV), is reported to be increased in hemodialysis (HD) patients and increases cardiovascular mortality. Previous studies have reported an association between extracellular water (ECW) and PWV. We wished to review whether PWV increases over time and whether this is associated with ECW. METHODS We reviewed repeat aortic PWV measurements using an oscillograph method along with corresponding ECW measured by multifrequency bioimpedance in HD patients a minimum of 5 years apart. RESULTS Twenty-four patients (16 [66.7%] male and 11 [45.8%] diabetic, mean age 61.7 ± 15.2 years) had PWV and ECW initially measured after 46 (26-124) months of HD and then after 112 (97-202) months. Overall, there was no change in PWV or ECW (9.4 ± 2.2 vs. 8.1 ± 2.5 cm/s; 14.7 ± 2.5 vs. 15.2 ± 2.9 L, respectively), whereas the ECW/total body water ratio increased (0.399 ± 0.015 vs. 0.408 ± 0.021, p < 0.05). We found no association between changes in PWV and ECW (r = -0.05, p = 0.84), whereas there was an association with the change in peri-dialytic systolic blood pressure (SBP) (r = 0.59, p = 0.007). CONCLUSION In our small observational study, there was no overall change in PWV, after 5 years of HD, with PWV increasing in 50% and falling in 50%. Changes in PWV were not associated with changes in ECW but were associated with changes in peri-dialytic SBP. Our study demonstrates that PWV does not increase in all HD patients with time, and interventional studies are required to determine whether targeted blood pressure control reduces PWV in HD patients.
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Affiliation(s)
- Theerasak Tangwonglert
- Nephrology Division, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, University College London, London, United Kingdom,
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17
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Yoowannakul S, Vongsanim S, Kotecha T, Fontana M, Davenport A. Hemodialysis patients with less extracellular water overload and smaller cardiac atrial chamber sizes are at greater risk of a fall in blood pressure during dialysis. Ther Apher Dial 2020; 25:16-23. [PMID: 32216122 DOI: 10.1111/1744-9987.13490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/24/2020] [Accepted: 03/19/2020] [Indexed: 11/27/2022]
Abstract
Intradialytic hypotension is the most common complication of hemodialysis (HD) treatments. Excessive ultrafiltration results in reduced cardiac preload. We aimed to determine whether a fall in systolic blood pressure during HD was greater in patients starting HD with (a) less overhydration measured by extracellular water (ECW) and (b) lower cardiac preload by cardiac magnetic resonance imaging (MRI). Pre-HD measurements of ECW and total body water (TBW) were performed using multifrequency bioimpedance (MFBIA). Cardiac chamber sizes and functions were determined by MRI. Twenty-six patients, 18 males (69.2%), 11 (42.3%) with diabetes, mean age 63.9 ± 15.9 years were studied. Systolic blood pressure (SBP) fell in 15 (57.7%) patients, and either did not change or increased in 9. There was no difference in demographics between groups. Patients with a fall in SBP had lower pre-HD ECW/TBW (0.400 ± 0.018 vs 0.418 ± 0.021), indexed right ventricular end-diastolic volume (81.2 ± 37.6 vs 100.8 ± 33.7 mL/m2 ), and indexed left atrial size (13.7 ± 3.9 vs 18.3 ± 5.0 mL/m2 ), all P < .05, respectively. There were univariate correlations between the change in SBP and pre-HD ECW/TBW for the trunk (r = .50, P = .009) and indexed left atrial volume (r = .54, P = .005). A fall in blood pressure occurred more commonly in patients starting HD with lower overhydration as measured by bioimpedance, and those with smaller cardiac chamber sizes. Patients with the lowest ECW/TBW and smallest cardiac chamber sizes had the greatest falls in SBP. This study reinforces the importance of determining physiological target weights and avoiding inappropriately low target weights for HD patients.
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Affiliation(s)
- Suree Yoowannakul
- Department of Nephrology Royal Free Hospital, University College London, London, UK
| | - Surachet Vongsanim
- Department of Nephrology Royal Free Hospital, University College London, London, UK
| | - Tushar Kotecha
- National Amyloid Centre, Royal Free Hospital, Department of Medicine, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, London, UK
| | - Marianna Fontana
- National Amyloid Centre, Royal Free Hospital, Department of Medicine, University College London, London, UK
| | - Andrew Davenport
- Department of Nephrology Royal Free Hospital, University College London, London, UK
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18
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François K, Orlando C, Jochmans K, Cools W, De Meyer V, Tielemans C, Wissing KM. Hemodialysis Does Not Induce Detectable Activation of the Contact System of Coagulation. Kidney Int Rep 2020; 5:831-838. [PMID: 32518865 PMCID: PMC7270976 DOI: 10.1016/j.ekir.2020.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/18/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Systemic anticoagulation is administered during hemodialysis to prevent clotting of the extracorporeal circuit. The role of contact system activation in thrombin generation during hemodialysis using current era dialyzer membranes is unknown. Methods We performed a single-center randomized crossover study. Ten patients treated with hemodialysis underwent 3 standardized hemodialysis sessions. For every patient, each session was performed with a different type of dialyzer membrane (polyphenylene [PP], polymethylmetacrylate [PMMA], polyethylenimine-coated polyacrylonitrile [AN69ST]). Blood samples were collected before and 5, 15, 30, 90, and 240 minutes after blood pump start to evaluate coagulation activation (thrombin–antithrombin complex [TAT], prothrombin fragment 1+2 [PF1+2], activated factor XII [FXIIa], kallikrein, activated factor XI [FXIa]). Plasma of healthy volunteers (n = 20) was used as a reference. Results Baseline TAT and PF1+2 levels were higher in hemodialysis patients compared to healthy controls (median [interquartile range] for TAT: 3.3 [2.9–4.2] vs. 2.4 [2.3–2.5] μg/l [P = 0.0002] and for PF1+2: 647 [478–737] vs. 138 [125–254] pmol/l [P < 0.0002]). Despite the use of systemic anticoagulation, TAT further increased during treatment, with the increase starting after 30 minutes (median TAT at t240: 9.0 μg/l (PP), 5.5 μg/l (PMMA), and 7.2 μg/l (AN69ST), all P < 0.05 vs. baseline). Contact system markers FXIIa and kallikrein did not differ significantly between dialysis patients and healthy controls, whereas baseline FXIa levels were significantly lower in dialysis patients compared to healthy controls (P = 0.001). Levels of all contact system markers remained unchanged during hemodialysis with all types of dialyzer membranes. Conclusion Routine hemodialysis using systemic heparin anticoagulation induces coagulation activation without measurable contact system activation.
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Affiliation(s)
- Karlien François
- Division of Nephrology and Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christelle Orlando
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kristin Jochmans
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Wilfried Cools
- Interfaculty Center for Data Processing & Statistics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Vicky De Meyer
- Division of Nephrology and Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christian Tielemans
- Division of Nephrology and Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Karl Martin Wissing
- Division of Nephrology and Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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19
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Shan L, Sun Y, Shan F, Li L, Xu ZP. Recent advances in heparinization of polymeric membranes for enhanced continuous blood purification. J Mater Chem B 2020; 8:878-894. [PMID: 31956883 DOI: 10.1039/c9tb02515d] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Continuous blood purification technology such as hemodiafiltration has been used worldwide for saving patients suffering from severe diseases or organ function failure, especially in the intensive care unit and emergency setting. The filters as core devices are commonly made of polymer materials as hollow fiber membranes. However, the membrane is often inductively blocked by blood clot formation due to its interactions with blood components. Heparin is the anticoagulant often used in clinical practice for anti-coagulation. Recently, heparin is also employed to modify the hollow fiber membranes either chemically or physically to improve the filtration performance. This review summarizes recent advances in methodology for surface heparinization of such hollow fiber membranes, and their filtration performance improvement. The review also provides expert opinions for further research in this rapidly expanding field.
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Affiliation(s)
- Liang Shan
- Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao 266003, China and Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane 4072, Australia.
| | - Yunbo Sun
- Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Feng Shan
- Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Li Li
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane 4072, Australia.
| | - Zhi Ping Xu
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane 4072, Australia.
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20
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Yoowannakul S, Vongsanim S, Tangvoraphonkchai K, Mohamed A, Davenport A. Falls in systolic blood pressure during dialysis which require no nursing intervention are associated with increased patient intra-dialytic symptom self-reporting and prolonged post-dialysis recovery times. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-019-0249-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Abstract
Background
Haemodialysis (HD) patients may suffer symptoms during dialysis and take time to recover post HD. We wished to determine whether patients with symptomatic intra-dialytic hypotension (IDH), requiring nursing interventions, or an asymptomatic fall in systolic blood pressure (SBP) reported more symptoms during dialysis.
Methods
Six hundred three HD patients completed self-reported intra-dialytic symptom questionnaires and recovery using a visual analogue scale, which were compared with their dialysis session records.
Results
Twenty-nine (4.8%) of patients suffered symptomatic IDH, and 187 (31.0%) had a fall in SBP of > 20 mmHg. Symptomatic patients had greater total symptom scores (30 (23–44) vs 23 (10–38), p < 0.05, versus asymptomatic patients, with increased low blood pressure, dizziness, cramps, palpitations and feeling cold reported (all p < 0.05). Patients with a SBP fall of > 20 mmHg had greater total scores compared with those with a SBP increase of > 10 mmHg (26 (13–38) vs 17 (7–34), p < 0.05), with more dizziness, cramps, backache, shortness of breath and headache reported (all p < 0.05). Although ultrafiltration rates were similar, HD weight loss was greater for patients with a SBP fall of > 20 mmHg (2.5 ± 1.1 vs 2.0 ± 1.3%, p < 0.05). Patients with highest symptoms scores (highest vs lowest quartile) had longer recovery times (40.3 vs 7.6% > 4 h), p < 0.001.
Multivariable analysis showed that patients reporting more intradialytic symptoms had higher psychological distress thermometer scores (odds ratio (OR) 1.34 (95% confidence limits 1.26–1.44)), systolic blood pressure < 100 mmHg (OR 2.53 (1.04–6.1)), whereas symptom scores were lower for male gender (OR 0.34 (0.22–0.51)), and with increasing age (OR 0.99 (0.97–0.99)).
Conclusion
Patients with both symptomatic and asymptomatic IDH, self-reported more symptoms during dialysis, and those patients reporting more symptoms had longer recovery times. We found that younger, female patients, those with greater psychological distress, and lower systolic blood pressure self-reported more intra-dialytic symptoms. More attention is required to prevent falls in intra-dialytic blood pressure to improve the patient experience of HD and shorten post-dialysis recovery times.
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Yoowannakul S, Leung TS, Davenport A. Pilot Study to Detect Changes in Blood Flow in the External Auditory Meatus During Hemodialysis. Ther Apher Dial 2019; 24:307-311. [PMID: 31442360 DOI: 10.1111/1744-9987.13433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/19/2019] [Accepted: 08/20/2019] [Indexed: 11/28/2022]
Abstract
Blood flow to internal organs is reported to fall during hemodialysis (HD). As such, noninvasive monitoring devices are required to detect changes in perfusion, which could then be used for therapeutic interventions. We report on a pilot study monitoring blood flow in the outer auditory meatus. We measured the maximum pulse wave amplitude and indicators of blood flow by analyzing red and green color changes in the outer auditory meatus from video recordings made using an otoscope fitted with a digital camera during HD treatments. We studied 61 patients, 43 (71.5%) male, mean age 64.9 ± 12.7 years. Weight fell from 72.8 ± 22.5 kg predialysis to 71.5 ± 22.1 kg postdialysis (P < 0.001). BP did not significantly change (predialysis 142 ± 29/67 ± 18 to 143 ± 25/68 ± 17 mm Hg postdialysis). The maximum pulse wave amplitude in the external auditory meatus fell from 0.21 (0.1-0.55) to 0.14 (0.04-0.4) after 90 min, P < 0.001, and remained low thereafter, and the change at the end of the dialysis session was associated with percentage weight loss (r = -0.37, P = 0.003). Green and red pixel values did not change (predialysis 0.339 [0.333-0.345] to 0.302 [0.291-0.33] post, and 0.301 [0.293-0.328] predialysis to 0.339 [0.334-0.347] post, respectively). This pilot study showed that the maximum pulse wave amplitude measured in the external auditory meatus fell during the dialysis session, and that the fall was associated with fluid removal. This could potentially lead to the development of a monitoring device, which could fit in the ear and record during the dialysis session.
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Affiliation(s)
| | - Terence S Leung
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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22
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Ichinose M, Sasagawa N, Chiba T, Toyama K, Kayamori Y, Kang D. Protein C and protein S deficiencies may be related to survival among hemodialysis patients. BMC Nephrol 2019; 20:191. [PMID: 31138132 PMCID: PMC6540392 DOI: 10.1186/s12882-019-1344-8] [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: 11/07/2018] [Accepted: 04/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background Thrombophilia due to protein C (PC) and protein S (PS) deficiencies is highly prevalent among patients with stage 5 chronic kidney disease and is reported to arise due to extracorporeal circulation during hemodialysis (HD). This study aimed to evaluate the relationship between HD treatment and thrombophilia. Methods A total of 114 Japanese patients on maintenance HD (62 men, 52 women) were followed during 2008–2011. Their survival rates were compared against the duration of HD. Prior to each HD, coagulation/fibrinolysis parameters and PC and PS activities were measured using standard techniques. The patients were divided into two groups: Group 1, with PC and/or PS deficiencies (n = 32), and Group 2, without PC and PS deficiencies (n = 82). The influence of such deficiencies and duration of dialysis on survival was examined. Time-to-event analysis was applied using Kaplan-Meier estimates, and the log-rank test was proposed to test the equivalence of relative survival data. Hazard ratios and 95% confidence intervals (CI) were calculated. Results Of the 114 patients, 37 died (Group 1, 22; Group 2, 15). The hazard ratio (95% CI) was higher (p = 0.004) in Group 1 than Group 2. Gene analyses of PC and PS were performed in 14 patients from Group 1. No mutations in either protein were observed. We analyzed the causes of death in both groups; however, the estimated thrombophilia-related incidence of death could not be determined due to small sample size of HD patients. Conclusions Our results suggest that PC and PS deficiencies may be related to survival in HD patients. However, this finding warrants additional research.
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Affiliation(s)
- Mayuri Ichinose
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Naru Sasagawa
- Vascular Access Center, Yokohama Dai-ichi Hospital, Yokohama, Japan
| | - Tetsuo Chiba
- Vascular Access Center, Yokohama Dai-ichi Hospital, Yokohama, Japan
| | - Katsuhide Toyama
- Department of Internal Medicine, Yokohama Dai-ichi Hospital, Yokohama, Japan
| | - Yuzo Kayamori
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dongchon Kang
- Department of Clinical Chemistry and Laboratory Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Yoowannakul S, Tangvoraphonkchai K, Davenport A. Patient-reported intra-dialytic symptoms and post-dialysis recovery times are influenced by psychological distress rather than dialysis prescription. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0211-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Knehtl M, Jakopin E, Dvorsak B, Bevc S, Ekart R, Hojs R. The effect of high-flux hemodialysis and post-dilution hemodiafiltration on platelet closure time in patients with end stage renal disease. Hemodial Int 2019; 23:319-324. [PMID: 30924268 DOI: 10.1111/hdi.12756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We aimed to compare prospectively the effect of high-flux hemodialysis and post-dilution hemodiafiltration on platelets. METHODS Twenty-two hemodialysis patients were treated with one high-flux hemodialysis and one post-dilution hemodiafiltration procedure. PFA-100 closure times (collagen/epinephrine-CEPI and collagen/adenosine diphosphate-CADP) were measured before and after the procedure, as well as platelet count, hemoglobin, hematocrit, and red blood cell count. All pre-dialysis and post-dialysis samples were taken from the afferent line. FINDINGS The platelet count after vs. before hemodialysis did not change significantly (229.3 ± 55.0 x109 /L vs. 233.6 ± 55.8 × 109 /L; P = 0.269), but was significantly lower after post-dilution hemodiafiltration (215.5 ± 51.7 × 109 /L vs. 245.3 ± 59.9 × 109 /L; P < 0.0001). CEPI after vs. before hemodialysis was not significantly prolonged (192.9 ± 60.8 s vs. 173.4 ± 52.5 s; P = 0.147), and the same applied to CADP (143.6 ± 40.3 s vs. 142.6 ± 38.4 s; P = 0.897). CEPI after vs. before post-dilution hemodiafiltration was significantly prolonged (268.3 ± 41.3 s vs. 176.4 ± 54.0 s; P < 0.0001) as was CADP (221.0 ± 53.9 s vs.133.9 ± 31.1 s; P < 0.0001). DISCUSSION Only after post-dilution hemodiafiltration, we found a lower platelet count and prolonged platelet closure times.
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Affiliation(s)
- Masa Knehtl
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Eva Jakopin
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Benjamin Dvorsak
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Sebastjan Bevc
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Radovan Hojs
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Davenport A. Moving beyond small solute clearance: What evidence is there for more permeable dialyzers and haemodiafiltration? Hemodial Int 2018; 22:S24-S28. [PMID: 30411460 DOI: 10.1111/hdi.12700] [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: 11/29/2022]
Abstract
Dialyzers were initially developed for diffusive clearance of uraemic toxins. Diffusion most effectively clears small uncharged solutes from plasma water, such as urea. Sessional urea clearance targets have been shown to be important for short-term patient survival, but over the longer term, although low-flux dialysis can prolong patient survival, accumulation of middle-sized uraemic toxins, such as β2 microglobulin can lead to disabling arthropathy. Although the introduction of high-flux dialyzers, designed to increase β2 microglobulin clearance, has reduced the prevalence of arthropathy; this has not been translated into a demonstrable significant improvement in patient survival. However, analysis of individual patients recruited into trials of haemo-diafiltration reported that greater convective clearance was associated with better survival, although the individual trials reported mixed outcomes. Most haemodiafiltration trials were not designed to study the effect of convective dose, so although reported patient survival was greater for those receiving greater convective volume exchange, these results could potentially be confounded by patient or center effects. An alternative approach to increasing middle-sized solute clearances would be to use more permeable dialyzers, but as yet there are no trials reporting survival with larger cutoff dialyzers. As such, although there is increasing evidence that increasing middle-sized molecular uraemic solute clearance is associated with improved patient survival, further prospective trials are required to determine whether as with Kt/Vurea there is a threshold effect of how much convective or middle-sized solute clearance is required to improve patient survival.
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Affiliation(s)
- Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, London, United Kingdom
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Salame C, Eaton S, Grimble G, Davenport A. Protein Losses and Urea Nitrogen Underestimate Total Nitrogen Losses in Peritoneal Dialysis and Hemodialysis Patients. J Ren Nutr 2018; 28:317-323. [PMID: 29709365 DOI: 10.1053/j.jrn.2018.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/02/2017] [Accepted: 01/29/2018] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Muscle wasting is associated with increased mortality and is commonly reported in dialysis patients. Hemodialysis (HD) and peritoneal dialysis (PD) treatments lead to protein losses in effluent dialysate. We wished to determine whether changes in current dialysis practice had increased therapy-associated nitrogen losses. DESIGN Cross-sectional cohort study. METHODS Measurement of total protein, urea and total nitrogen in effluent dialysate from 24-hour collections from PD patients, and during haemodiafiltration (HDF) and haemodialysis (HD) sessions. SUBJECTS One hundred eight adult dialysis patients. INTERVENTION Peritoneal dialysis, high-flux haemodialysis and haemodiafiltration. MAIN OUTCOME MEASURE Total nitrogen and protein losses. RESULTS Dialysate protein losses were measured in 68 PD and 40 HD patients. Sessional losses of urea (13.9 [9.2-21.1] vs. 4.8 [2.8-7.8] g); protein (8.6 [7.2-11.1] vs. 6.7 [3.9-11.1] g); and nitrogen (11.5 [8.7-17.7] vs. 4.9 [2.6-9.5] g) were all greater for HD than PD, P < .001. Protein-derived nitrogen was 71.9 (54.4-110.4) g for HD and 30.8 (16.1-59.6) g for PD. Weekly protein losses were lower with HD 25.9 (21.5-33.4) versus 46.6 (27-77.6) g/week, but nitrogen losses were similar. We found no difference between high-flux HD and HDF: urea (13.5 [8.8-20.6] vs. 15.3 [10.5-25.5] g); protein (8.8 [7.3-12.2] vs. 7.6 [5.8-9.0] g); and total nitrogen (11.6 [8.3-17.3] vs. 10.8 [8.9-22.5] g). Urea nitrogen (UN) only accounted for 45.1 (38.3-51.0)% PD and 63.0 (55.3-62.4)% HD of total nitrogen losses. CONCLUSION Although sessional losses of protein and UN were greater with HD, weekly losses were similar between modalities. We found no differences between HD and HDF. However, total nitrogen losses were much greater than the combination of protein and UN, suggesting greater nutritional losses with dialysis than previously reported.
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Affiliation(s)
- Clara Salame
- UCL Division of Medicine, University College London, London, United Kingdom
| | - Simon Eaton
- Development Biology and Cancer Programme, Great Ormond Street Institute of Child Health London, University College London, London, United Kingdom
| | - George Grimble
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, United Kingdom
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, United Kingdom.
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