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Valga F, Monzon T, Vega-Diaz N, Santana A, Moscol G, Ruiz-Santana S, Rodriguez-Perez JC. Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study. Nefrologia 2023; 43 Suppl 2:47-56. [PMID: 38245440 DOI: 10.1016/j.nefroe.2023.05.009] [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: 08/23/2022] [Accepted: 02/20/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Hypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl-) and mortality in incident chronic hemodialysis (HD) patients. METHOD Retrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan-Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. RESULTS During the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl- and interdialytic weight gain (r=-0.15) (p=0.0038). Patients belonging to the quartile with lower Cl- levels had less probability of survival than patients in the quartile with higher Cl- levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl- levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77-0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83-0.97; p<0.0057). CONCLUSIONS Lower Cl- levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.
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Affiliation(s)
- Francisco Valga
- Nephrology Department, Doctor Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain; Doctoral School, Biomedicine Research Program, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - Tania Monzon
- Nephrology Department, Doctor Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain; Doctoral School, Biomedicine Research Program, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Nicanor Vega-Diaz
- Doctoral School, Biomedicine Research Program, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain; Avericum S.L Hemodialysis Centers, Las Palmas de Gran Canaria, Spain
| | - Angelo Santana
- Mathematics Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Giancarlo Moscol
- Oncology Department, MD Anderson Cancer Center, Houston, TX, USA
| | - Sergio Ruiz-Santana
- Doctoral School, Biomedicine Research Program, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain; Intensive Care Unit, Doctor Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Jose Carlos Rodriguez-Perez
- Nephrology Department, Doctor Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain; University Fernando Pessoa-Canarias, Las Palmas, Spain
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Canaud B, Leray-Moragues H, Chenine L, Morena M, Miller G, Canaud L, Cristol JP. Comparative Clinical Performances of Tunneled Central Venous Catheters versus Arterio-Venous Accesses in Patients Receiving High-Volume Hemodiafiltration: The Case for High-Flow DualCath, a Tunneled Two-Single-Lumen Silicone Catheter. J Clin Med 2023; 12:4732. [PMID: 37510847 PMCID: PMC10381463 DOI: 10.3390/jcm12144732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Tunneled central venous catheters (CVC) are mainly considered as a rescue vascular access option in dialysis but are still used on approximately one quarter of prevalent patients worldwide even though they are associated with poor performances and higher risks. STUDY DESIGN in this retrospective single-center study, we aimed to report on the clinical performances achieved with high-flow tunneled CVCs (DualCath or DCath) and compared them with arteriovenous accesses (AVAs, e.g., AV fistula, AV graft, and Thomas Shunt) in a hospital-based dialysis unit. METHODS Sixty-eight stage 5 chronic kidney disease dialysis-dependent patients (CKD5D) receiving high volume hemodiafiltration were followed-up with for 30 months. The study consisted of two phases: baseline cross-sectional and longitudinal follow-ups of key performance indicators. Clinical performances consisting of effective blood flow and blood volume, recirculation, urea and ionic Kt/V, total Kt, ultrafiltration volume, and percent reduction in β2-M were measured monthly as part of quality control in our unit. RESULTS At baseline, the effective blood flow using a DCath was close to 400 mL/min, similar to an AVA. Recirculation with a DCath (7%, 6-13%) was higher than with an AVA. The diffusive dialysis dose delivered with a DCath (spKt and eKt/V) and convective dialysis dose achieved with a DCath were slightly lower than those achieved with AVAs, but they were still much higher than is recommended by guidelines. The percent reduction in β2-M achieved with a DCath was also 4 to 10% lower than that achieved with an AVA. On longitudinal follow-up, the main clinical performance indicators of DCaths (total Kt and total ultrafiltration volume, L/session) were maintained as very stable over time and close to those achieved with AVAs. CONCLUSIONS As shown in this study, high-flow DualCath tunneled two-single-lumen silicone catheters may be used to deliver high volume hemodiafiltration in a reliable and consistent manner without compromising clinical performance. These results relied on the specific design of the two silicone cannulas and the strict adherence to best catheter practices.
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Affiliation(s)
- Bernard Canaud
- School of Medicine, Montpellier University, 34090 Montpellier, France
- MTX Consulting International, Rue des Carmelites, 34090 Montpellier, France
| | - H Leray-Moragues
- AIDER-Santé, CHARLES, Mion Foundation, 34000 Montpellier, France
| | - Leila Chenine
- Nephrology, Intensive Care, Dialysis & Transplantation, Lapeyronie University Hospital, 34090 Montpellier, France
| | - Marion Morena
- PhyMedExp, Department of Biochemistry and Hormonology, INSERM, CNRS, University Hospital Center of Montpellier, University of Montpellier, 34000 Montpellier, France
| | - George Miller
- Medical Components, Inc., Clinical Affairs, Harleysville, PA 19438, USA
| | - Ludovic Canaud
- Chest and Vascular Surgery Department, CHU Montpellier, 34000 Montpellier, France
| | - Jean Paul Cristol
- AIDER-Santé, CHARLES, Mion Foundation, 34000 Montpellier, France
- PhyMedExp, Department of Biochemistry and Hormonology, INSERM, CNRS, University Hospital Center of Montpellier, University of Montpellier, 34000 Montpellier, France
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Valga F, Monzón T, Vega-Diaz N, Rodriguez-Perez JC, Ruiz-Santana S. Inflammation and hemodialysis adequacy: are C-reactive protein levels influenced by the dose of dialysis? Nefrologia 2022; 42:163-170. [PMID: 36153912 DOI: 10.1016/j.nefroe.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/06/2021] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the "dialysis dose" (Kt / V) using ionic dialysance. METHODS Multicenter cross-sectional study. 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into two groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS Median CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (p = 0.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log INL (p < 0.001) and inversely proportional with serum albumin values (p = 0.014), Kt/V (p = 0.037) and serum iron (p < 0.001). CONCLUSION The poorer adequacy in terms of dialysis doses, lower Kt / V values, may contribute to a higher degree of inflammation in chronic hemodialysis patients.
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Affiliation(s)
- Francisco Valga
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain.
| | - Tania Monzón
- Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gram Canaria, Spain.
| | - Nicanor Vega-Diaz
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain.
| | - José Carlos Rodriguez-Perez
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain.
| | - Sergio Ruiz-Santana
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
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Locatelli F, Del Vecchio L. Dialysis dose and mortality: where is the limit? Nephrol Dial Transplant 2021; 36:2170-2172. [PMID: 34791439 DOI: 10.1093/ndt/gfab265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
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5
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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Valga F, Monzón T, Vega-Diaz N, Rodriguez-Perez JC, Ruiz-Santana S. Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose? Nefrologia 2021; 42:S0211-6995(21)00112-0. [PMID: 34238598 DOI: 10.1016/j.nefro.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/06/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance. METHODS Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001). CONCLUSION The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients.
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Affiliation(s)
- Francisco Valga
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, España; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España.
| | - Tania Monzón
- Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, España
| | - Nicanor Vega-Diaz
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, España; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
| | - José Carlos Rodriguez-Perez
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, España; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
| | - Sergio Ruiz-Santana
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, España; Programa de Doctorado en Investigación en Biomedicina, Facultad de Ciencias de la Salud, Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
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Béguin L, Krummel T, Longlune N, Galland R, Couchoud C, Hannedouche T. Dialysis dose and mortality in hemodialysis: Is higher better? Nephrol Dial Transplant 2021; 36:2300-2307. [PMID: 34145896 DOI: 10.1093/ndt/gfab202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The effect of dialysis dose on mortality remains unsettled. Current guidelines recommend to target a spKt/V at 1.20 to 1.40 per tri-weekly dialysis session. However, the optimal dialysis dose remains mostly disputed. METHODS In a nationwide registry of all incident patients receiving thrice-weekly hemodialysis, 32 283 patients had available data on dialysis dose, estimated by Kt/V and its variants Kt and Kt/A. Survival was analyzed with a multivariate Cox model and a concurrent risk model accounting for renal transplantation. A predictive model of Kt in the upper quartile was developed. RESULTS Regardless of the indicator, a higher dose of dialysis was consistently associated with better survival. The survival differential of Kt was the most discriminating, but marginally, compared to the survival differential according to Kt/V and Kt/A. Patient survival was higher in the upper quartile of Kt (> 69L/s), then deteriorated as the Kt decreased with a difference in survival between the upper and lower quartile of 23.6% at five years. Survival differences across Kt distribution were similar after accounting for kidney transplantation as a competing risk. Predictive factors for Kt in the upper quartile were arteriovenous fistula versus catheters and graft, hemodiafiltration versus hemodialysis, scheduled dialysis start versus emergency start, long weekly dialysis duration, spKt/V measurement versus double pool eKt/V. CONCLUSION Our data confirm the existence of a relationship between dialysis dose and survival, which persisted despite correcting for known confounders. A model for predicting a high dose of dialysis is proposed with practical relevance.
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Affiliation(s)
- Lisa Béguin
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Thierry Krummel
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Cécile Couchoud
- Registre REIN, Agence de Biomédecine, Saint Denis La Plaine Cedex, France
| | - Thierry Hannedouche
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,School of Medicine, University of Strasbourg, Strasbourg, France
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Petitclerc T, Ridel C. Routine online assessment of dialysis dose: Ionic dialysance or UV-absorbance monitoring? Semin Dial 2021; 34:116-122. [PMID: 33529406 DOI: 10.1111/sdi.12949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/01/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
For three-weekly hemodialysis, a single-pool Kt/V target of at least 1.4 together with a minimal dialysis dose Kt at 45 L for men and 40 L for women per each session is currently recommended. Fully automatic online calculation of Kt and Kt/V from conductivity or UV-absorbance measurements in the dialysate is standardly implemented on some hemodialysis monitors and makes it possible to estimate the dialysis dose without the need for blood or dialysate samples. Monitoring the UV-absorbance of the spent dialysate is the most direct method for estimating Kt/V as it does not require an estimate of V. Calculation of ionic dialysance from conductivity measurements is the most direct method for estimating Kt and BSA-scaled dialysis dose. Both ionic dialysance monitoring and UV-absorbance monitoring may help detect a change in urea clearance occurring during the session, but this change must be interpreted differently depending on the monitoring being considered. An abrupt decrease in urea clearance results in a decrease in ionic dialysance but, paradoxically, a sudden increase in estimated urea clearance provided by dialysate UV-absorbance monitoring. Healthcare teams who monitor both ionic dialysance and UV-absorbance in their hemodialysis units must be clearly informed of this difficulty.
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10
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Marrocos MSM, Castro CN, Barbosa WA, Sizo AM, Rodrigues FT, de Lima RA, Rodrigues SM. Comparison of dialysis dose through real-time Kt/V by ultraviolet absorbance of spent dialysate, single-pool Daugirdas II, and Kt/BSA according to sex and age. J Bras Nefrol 2021; 43:52-60. [PMID: 33316025 PMCID: PMC8061950 DOI: 10.1590/2175-8239-jbn-2020-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 09/09/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Kt/V OnLine (Kt/VOL) avoids inaccuracies associated with the estimation of urea volume distribution (V). The study aimed to compare Kt/VOL, Kt/V Daugirdas II, and Kt/BSA according to sex and age. METHODS Urea volume distribution and body surface area were obtained by Watson and Haycock formulas in 47 patients. V/BSA was considered as a conversion factor from Kt/V to Kt/BSA. Dry weight was determined before the study. Kt/VOL was obtained on DIALOG machines. RESULTS Pearson correlation between Kt/VOL vs Kt/VII and Kt/VOL vs Kt/BSA was significant for males (r = 0.446, P = 0.012 and r = -0.476 P = 0.007) and individuals < 65 years (0.457, P = 0.019 and -0.549 P = 0.004), but not for females and individuals ≥ 65 years. V/BSA between individuals < 65 and individuals ≥ 65 years were 18.28 ± 0.15 and 18.18 ± 0.16 P = 0.000). No agreement between Kt/VII vs Kt/BSA. Men and individuals > 65 years received a larger dialysis dose than, respectively, females and individuals < 65 years, in the comparison between Kt/VOL versus Kt/VII. V/BSA ratios among men and women were respectively 18.29 ± 0.13 and 18.12 ± 0.15 P = 0.000. CONCLUSIONS Kt/VOL allows recognition of real-time dose regardless of sex and age.
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Colussi G, Brunati CCM, Gervasi F, Montoli A, Vergani D, Curci F, Minetti E. A simple method for the calculation of dialysis Kt factor as a quantitative measure of removal efficiency of uremic retention solutes: Applicability to high-dialysate vs low-dialysate volume technologies. PLoS One 2020; 15:e0233331. [PMID: 32469929 PMCID: PMC7259768 DOI: 10.1371/journal.pone.0233331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/02/2020] [Indexed: 12/03/2022] Open
Abstract
Dialysis urea removal metrics may not translate into proportional removal efficiency of non-urea solutes. We show that the Kt factor (plasma volume totally cleared of any solutes) differentiates removal efficiency of non-urea solutes in different technologies, and can easily be calculated by instant blood-dialysate collections. We performed mass balances of urea, creatinine, phosphorus and beta2-microglobulin by whole dialysate collection in 4 low-flux and 3 high-flux hemodialysis, 2 high-volume post-hemodiafiltration and 7 short-daily dialysis with the NxStage-One system. Instant dialysate/blood determinations were also performed at different times, and Kt was calculated as the product of the D/P ratio by volume of delivered dialysate plus UF. There were significant differences in single session and weekly Kt (whole dialysate and instant calculations) between methodologies, most notably for creatinine, phosphorus and beta2-microglobulin. Urea Kt messured in balance studies was almost equal to that derived from the usual plasma kinetic model-based Daugirdas’ equation (eKt/V) and independent V calculation, indicating full correspondence. Non-urea solute Kt as a fraction of urea Kt (i.e. fractional removal relative to urea) showed significant differences between technologies, indicating non-proportional removal of non-urea solutes and urea. Instant Kt was higher than that in full balances, accounting for concentration disequilibrium between arterial and systemic blood, but measured and calculated quantitative solute removal were equal, as were qualitative Kt comparisons between technologies. Thus, we show that urea metrics may not reliably express removal efficiency of non-urea solutes, as indicated by Kt. Kt can easily be measured without whole dialysate collection, allowing to expand the metrics of dialytic efficiency to almost any non-urea solute removed by dialysis.
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Affiliation(s)
- Giacomo Colussi
- Division of Nephrology, Dialysis and Renal Transplantation, ASST GOM Niguarda, Milan, Italy
- Ambrosiana Clinic-Sacra Famiglia Foundation, Milan, Italy
- * E-mail: ,
| | | | - Francesca Gervasi
- Division of Nephrology, Dialysis and Renal Transplantation, ASST GOM Niguarda, Milan, Italy
- Nephrology School, Milano-Bicocca University, Milan, Italy
| | - Alberto Montoli
- Division of Nephrology, Dialysis and Renal Transplantation, ASST GOM Niguarda, Milan, Italy
| | - Denise Vergani
- Division of Nephrology, Dialysis and Renal Transplantation, ASST GOM Niguarda, Milan, Italy
| | - Federica Curci
- Division of Nephrology, Dialysis and Renal Transplantation, ASST GOM Niguarda, Milan, Italy
| | - Enrico Minetti
- Division of Nephrology, Dialysis and Renal Transplantation, ASST GOM Niguarda, Milan, Italy
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O'Brien FJ, Sirich TL, Taussig A, Fung E, Ganesan LL, Plummer NS, Brakeman P, Sutherland SM, Meyer TW. Plasma pseudouridine levels reflect body size in children on hemodialysis. Pediatr Nephrol 2020; 35:305-312. [PMID: 31728748 DOI: 10.1007/s00467-019-04369-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/16/2019] [Accepted: 09/13/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dialysis in children as well as adults is prescribed to achieve a target spKt/Vurea, where Vurea is the volume of distribution of urea. Waste solute production may however be more closely correlated with body surface area (BSA) than Vurea which rises in proportion with body weight. Plasma levels of waste solutes may thus be higher in smaller patients when targeting spKt/Vurea since they have higher BSA relative to body weight. This study measured levels of pseudouridine (PU), a novel marker solute whose production is closely proportional to BSA, to test whether prescription of dialysis to a target spKt/Vurea results in higher plasma levels of PU in smaller children. METHODS PU and urea nitrogen (ureaN) were measured in plasma and dialysate at the midweek hemodialysis session in 20 pediatric patients, with BSA ranging from 0.65-1.87m2. Mathematical modeling was employed to estimate solute production rates and average plasma solute levels. RESULTS The dialytic clearance (Kd) of PU was proportional to that of ureaN (average KdPU/KdUreaN 0.69 ± 0.13, r2 0.84, p < 0.001). Production of PU rose in proportion with BSA (r2 0.57, p < 0.001). The pretreatment plasma level of PU was significantly higher in smaller children (r2 0.20, p = 0.051) while the pretreatment level of ureaN did not vary with size. CONCLUSIONS Prescribing dialysis based on urea kinetics may leave uremic solutes at higher levels in small children. Measurement of a solute produced proportional to BSA may provide a better index of dialysis adequacy than measurement of urea.
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Affiliation(s)
- Frank J O'Brien
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Tammy L Sirich
- Departments of Medicine, VA Palo Alto HCS and Stanford University, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Abigail Taussig
- Departments of Medicine, VA Palo Alto HCS and Stanford University, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Enrica Fung
- Loma Linda University School of Medicine and VA Loma Linda HCS, Loma Linda, CA, USA
| | | | - Natalie S Plummer
- Departments of Medicine, VA Palo Alto HCS and Stanford University, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Paul Brakeman
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | | | - Timothy W Meyer
- Departments of Medicine, VA Palo Alto HCS and Stanford University, 3801 Miranda Ave, Palo Alto, CA, 94304, USA.
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13
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Maduell F, Broseta JJ, Rodas L, Montagud‐Marrahi E, Rodriguez‐Espinosa D, Hermida E, Arias‐Guillén M, Fontseré N, Vera M, Gómez M, González B, Rico N. Comparison of Solute Removal Properties Between High‐Efficient Dialysis Modalities in Low Blood Flow Rate. Ther Apher Dial 2019; 24:387-392. [DOI: 10.1111/1744-9987.13440] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Lida Rodas
- Department of NephrologyHospital Clínic Barcelona Barcelona Spain
| | | | | | - Evelyn Hermida
- Department of NephrologyHospital Clínic Barcelona Barcelona Spain
| | | | - Néstor Fontseré
- Department of NephrologyHospital Clínic Barcelona Barcelona Spain
| | - Manel Vera
- Department of NephrologyHospital Clínic Barcelona Barcelona Spain
| | - Miquel Gómez
- Department of NephrologyHospital Clínic Barcelona Barcelona Spain
| | | | - Nayra Rico
- Department of BiochemistryHospital Clínic Barcelona Barcelona Spain
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14
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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: 108] [Impact Index Per Article: 21.6] [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.
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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
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Arias-Guillén M, Masso E, Gomez M, Rodas L, Broseta J, Vera M, Rios J, Fontseré N, Maduell F. Are Currently Used Bioimpedance Methods in Hemodialysis Comparable for Calculating Dialysis Dose? Ther Apher Dial 2019; 24:154-162. [PMID: 31325207 DOI: 10.1111/1744-9987.13424] [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: 02/12/2019] [Revised: 07/13/2019] [Accepted: 07/16/2019] [Indexed: 11/27/2022]
Abstract
Bioelectrical impedance analysis has increasingly been incorporated into hemodialysis units (HD) as a useful, noninvasive technique for evaluating overall fluid status. The aims of this study were to verify whether the information obtained from two different bioelectrical impedance analysis methods (spectroscopy bioimpedance [BCM] and single-frequency bioelectric impedance vector analysis [SF-BIVA]) was comparable for analyzing fluid status, and to determine their impact when used to calculate dialysis dose. This observational cross-sectional study included 78 HD patients who underwent one measurement with BCM and one with SF-BIVA in the same dialysis session. For calculating the dialysis dose, total body water or urea distribution volume (V) was calculated by the Watson formula and compared with the V obtained from the two devices. The difference in V between the two devices was 5.4 L (P < 0.001). Given the existent correlation between VBCM and VSF-BIVA , we were able to apply a formula (corrected V = VSF-BIVA = 1.04 × VBCM + 4.85, r = 0.93), allowing comparison of the two bioimpedance methods. The mean dialysis dose for BCM device (KtID /VBCM ) was 2.49 ± 0.85, much higher than KtID /VSF-BIVA (2.06 ± 0.72) mainly due to the V obtained with the different devices, with KtID /VWatson being 2.03 ± 0.67. The results on volume distribution showed an acceptable correlation but the devices were not comparable due to intermethod differences observed. Dialysis centers using SF-BIVA will obtain much lower dialysis dose, but by applying our formula, the Kt/V would resemble that obtained by the BCM device.
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Affiliation(s)
- Marta Arias-Guillén
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain
| | - Elisabet Masso
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain
| | - Miquel Gomez
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain
| | - Lida Rodas
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain.,Spanish Kidney Research Network, ISCIII-RETIC (REDinREN), Madrid, Spain
| | - Jose Broseta
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain.,Spanish Kidney Research Network, ISCIII-RETIC (REDinREN), Madrid, Spain
| | - Manel Vera
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain
| | - Jose Rios
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Hospital Clínic, Barcelona, Spain
| | - Néstor Fontseré
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain
| | - Francisco Maduell
- Hospital Clinic Barcelona - Nephrology and Renal Transplantation, Barcelona, Spain.,Spanish Kidney Research Network, ISCIII-RETIC (REDinREN), Madrid, Spain
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16
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Hanoy M, Le Roy F, Guerrot D. Prescription de la dose de dialyse. Nephrol Ther 2019; 15 Suppl 1:S101-S107. [DOI: 10.1016/j.nephro.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
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17
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Farrington K, Davenport A. Would prescribing target Kt dose adjusted for body surface area improve hemodialysis outcomes? Kidney Int 2019; 90:1160-1162. [PMID: 27884309 DOI: 10.1016/j.kint.2016.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
The use of Kt/V to prescribe and monitor hemodialysis adequacy remains the current standard, although it is increasingly questioned. Alternative proposals for dose prescription and monitoring have been advocated. In a noninterventional, prospective study reported in this issue, Maduell et al., utilizing online ionic dialysance, explore the association between outcome measures (mortality and hospitalization rates) and the extent to which delivered Kt dose achieved minimal target Kt doses calculated from individual estimates of body surface area.
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Affiliation(s)
- Ken Farrington
- Renal Unit, Lister Hospital, Stevenage, United Kingdom; University of Hertfordshire, Hatfield, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK.
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18
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Leypoldt JK, Weinhandl ED, Collins AJ. Volume of urea cleared as a therapy dosing guide for more frequent hemodialysis. Hemodial Int 2018; 23:42-49. [PMID: 30255600 DOI: 10.1111/hdi.12692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/05/2018] [Indexed: 01/29/2023]
Abstract
INTRODUCTION With dialysis delivery systems that operate at low dialysate flow rates, prescriptions for more frequent hemodialysis (HD) employ dialysate volume as the primary parameter for small solute removal rather than blood-side urea dialyzer clearance (K). Such delivery systems, however, yield dialysate concentrations that almost completely saturate with blood (water), suggesting that the volume of urea cleared (the product of K and treatment time or Kt) can be readily estimated from the prescribed dialysate volume to target small solute removal. Methods For more frequent HD, we examined the volume of urea cleared per treatment required to achieve a minimal dose of small solute removal, comparing results based on body surface area (BSA) with those based on KDOQI clinical practice guidelines, that is, a weekly stdKt/V of 2.1. Estimates of the target volume of urea cleared were calculated for 4, 5, and 6 treatments per week, and compared for patients with different anthropometric estimates of total body water volume (Vant ). BSA was assumed proportional to Vant 0.8 , and residual kidney function was neglected. Findings Whether based on BSA or weekly stdKt/V of 2.1, the target volume of urea cleared per treatment required to achieve a minimal dose of small solute removal was lower at higher treatment frequency. As with conventional thrice-weekly HD, target volumes of urea cleared for more frequent HD based on BSA were larger for patients with small Vant and smaller for patients with large Vant than those based on a weekly stdKt/V of 2.1. Discussion Prescription of more frequent HD using the volume of urea cleared per treatment, calculated from the prescribed dialysate volume, is simple in principle and can be readily implemented in clinical practice when using dialysis delivery systems that operate at low dialysate flow rates. Other aspects of dialysis adequacy require additional consideration.
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Affiliation(s)
| | - Eric D Weinhandl
- NxStage Medical, Lawrence, Massachusetts, USA.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allan J Collins
- NxStage Medical, Lawrence, Massachusetts, USA.,Medical School, University of Minnesota, Minneapolis, Minnesota, USA
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19
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Pérez-García R, Jaldo M, Alcázar R, de Sequera P, Albalate M, Puerta M, Ortega M, Ruiz MC, Corchete E. Unlike Kt, high Kt/V is associated with greater mortality: The importance of low V. Nefrologia 2018; 39:58-66. [PMID: 30075965 DOI: 10.1016/j.nefro.2018.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 02/26/2018] [Accepted: 04/03/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Kt/V has been used as a synonym for haemodialysis dose. Patient survival improved with a Kt/V>1; this target was subsequently increased to 1.2 and 1.3. The HEMO study revealed no significant relationship between Kt/V and mortality. The relationship between Kt/V and mortality often shows a J-shaped curve. Is V the confounding factor in this relationship? The objective of this study is to determine the relationship between mortality and Kt/V, Kt and body water content (V) and lean mass (bioimpedance). METHODS We studied a cohort of 127 prevalent haemodialysis patients, who we followed-up for an average of 36 months. Kt was determined by ionic dialysance, and V and nutrition parameters by bioimpedance. Kt/V, Kt corrected for body surface area (Kt/BSA) and target Kt/BSA were calculated. The mean data from 18,998 sessions were used as haemodialysis parameters, with a mean of 155 sessions per patient. RESULTS Mean age was 70.4±15.3 years and 61% were male; 76 were dialysed via an arteriovenous fistula and 65 were on online haemodiafiltration. Weight was 70.6 (16.8)kg; BSA 1.8 (0.25) m2; total body water (V) 32.2 (7.41) l and lean mass index (LMI) 11.1 (2.7)kg/m2. Mean Kt/V was 1.84 (0.44); Kt 56.1 (7)l and Kt/BSA 52.8 (10.4)l. The mean target Kt/BSA was 49.7 (4.5)l. Mean Kt/BSA-target Kt/BSA +6.4 (7.0)l. Patients with a higher Kt/V had worse survival rates than others; with Kt this is not the case. Higher Kt/V values are due to a lower V, with poorer nutrition parameters. LMI and serum albumin were the parameters that best independently predicted the risk of death and are lower in patients with a higher Kt/V and lower V. CONCLUSION Kt/V is not useful for determining dialysis doses in patients with low or reduced body water. Kt or the Kt/BSA are proposed as an alternative.
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Affiliation(s)
- Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España.
| | - Maite Jaldo
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Roberto Alcázar
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Marta Albalate
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Marta Puerta
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Mayra Ortega
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - M Caridad Ruiz
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Elena Corchete
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
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Abstract
BACKGROUND Kt/Vurea reflects the efficacy of haemodialysis scaled to patient size (urea distribution volume). The guidelines recommend monthly Kt/V measurements based on blood samples. Modern haemodialysis machines are equipped with accessories monitoring the dose online at every session without extra costs, blood samples and computers. OBJECTIVE To describe the principles, devices, benefits and shortcomings of online monitoring of haemodialysis dose. DESIGN A critical literature overview and discussion. RESULTS UV absorbance methods measure Kt/V, ionic dialysance Kt (product of clearance and treatment time; cleared volume without scaling). Both are easy and useful methods, but comparison is difficult due to problems in scaling of the dialysis dose to the patient's size. CONCLUSIONS The best dose estimation method is the one which predicts the quality of life and survival most accurately. There is some evidence on the predictive value of ionic dialysance Kt, but more documentation is required on the UV method. Online monitoring is a useful tool in everyday quality assurance, but blood samples are still required for more accurate kinetic modelling. LEARNING OUTCOMES After reading this article the reader should be able to: Understand the elements of the Kt/V equation for dialysis dose. Compare and contrast different methods of measurement of dialysis dose. Reflect on the importance of adequate dialysis dose for patient survival and life quality.
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Affiliation(s)
- Aarne Vartia
- Retired from Savonlinna Central Hospital, Savonlinna, Finland
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21
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Sridharan S, Vilar E, Davenport A, Ashman N, Almond M, Banerjee A, Roberts J, Farrington K. Scaling Hemodialysis Target Dose to Reflect Body Surface Area, Metabolic Activity, and Protein Catabolic Rate: A Prospective, Cross-sectional Study. Am J Kidney Dis 2017; 69:358-366. [DOI: 10.1053/j.ajkd.2016.07.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 07/18/2016] [Indexed: 11/11/2022]
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22
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Abstract
Hemodialysis treatment time and Kt/V can both be considered to be primary measures of hemodialysis adequacy, because when either goes to zero, mortality is certain in patients without residual kidney function. Treatment time is important, but it needs to be adjusted based on surface-area-normalized Kt/V, residual kidney function, and expected ultrafiltration rate. Rescaling dose of dialysis measured as Kt/V to body surface area prevents ultrashort dialysis in small patients, women, and children with minimal residual kidney function. Most if not all of the observational studies of associations between outcome and dialysis session length are probably confounded by dose targeting bias. Once adequate Kt/V (taking into account body surface area) has been provided, adequate dialysis time probably is most relevant in terms of limiting the need for a high fluid removal rate. The latter may adversely impact survival by causing recurrent ischemia to cardiovascular and other tissues. There is little high-quality evidence at this time to support a minimum 4-hour treatment time for all patients, regardless of body size, solute removal, or residual kidney function. On the other hand, there is little evidence that prolonging weekly treatment time up to 24 hours per week is harmful. The final decision regarding treatment time is best individualized, based on patient acceptability and experience, residual kidney function, body surface-area-normalized Kt/V, and expected ultrafiltration rate.
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Affiliation(s)
- John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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23
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Davenport A. Is Hemodialysis Patient Survival Dependent upon Small Solute Clearance (Kt/V)?: If So How Can Kt/V be Adjusted to Prevent Under Dialysis in Vulnerable Groups? Semin Dial 2017; 30:86-92. [PMID: 28074616 DOI: 10.1111/sdi.12566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Small solute clearance achieved during a single hemodialysis session has been traditionally evaluated by urea clearance, normalized for total body water (Kt/Vurea) for more than 30 years. By consensus, the target sessional KtVurea for thrice weekly treatments has been increased from 0.9 to 1.2 over the years. Although this is supported by observational studies, there is a fundamental lack of prospective studies to support this threshold target. In clinical practice achieving sessional Kt/Vurea targets are most closely followed in the US. Yet there appears to be a paradox in that by following Kt/Vurea targets in the US hemodialysis patient survival is better for men and the obese, the opposite of what is seen in the general population. Delivery of a lower dose of hemodialysis to women and smaller men can be explained by underestimation of total body water. The advent of bioimpedance techniques which can measure both body water and body composition will potentially allow a rescaling and re-evaluation of the importance of small solute clearances (Kt/Vurea) in the hemodialysis patient population.
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Affiliation(s)
- Andrew Davenport
- University College London Centre for Nephrology, Royal Free Hospital, London, United Kingdom
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24
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Hemodialysis patients receiving a greater Kt dose than recommended have reduced mortality and hospitalization risk. Kidney Int 2016; 90:1332-1341. [DOI: 10.1016/j.kint.2016.08.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/05/2016] [Accepted: 08/18/2016] [Indexed: 01/02/2023]
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25
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Daugirdas JT. Kt/V (and especially its modifications) remains a useful measure of hemodialysis dose. Kidney Int 2015; 88:466-73. [PMID: 26176827 DOI: 10.1038/ki.2015.204] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/15/2015] [Accepted: 05/20/2015] [Indexed: 11/09/2022]
Abstract
Removal of small molecular weight solutes shows a strong relationship to hemodialysis outcomes. In contrast, survival with high-flux dialysis or hemodiafiltration is only slightly better than with low-flux hemodialysis. Despite laboratory evidence regarding toxicity of protein-bound uremic solutes, few data exist showing that increased removal of this class of molecules impacts outcomes. In the FHN trials, there was no effect of frequent dialysis, including frequent and long dialysis, on nutrition or control of anemia, outcomes expected to be sensitive to uremic toxin removal; the main benefit appeared to be better volume control. Scaling of hemodialysis dose to total body water may not be optimal. Kt/V scaling to body surface area and use of a continuous measure such as standard Kt/V reduces the likelihood of underdialysis of small patients, including children, and women. Minimum hemodialysis time may best be considered in respect to ultrafiltration rate, and a maximum target ultrafiltration rate unscaled to body size may be optimal. Intensive, extended dialysis may cause adverse effects to residual kidney function, and more information needs to be collected to better understand how urine volume modifies dose requirements, and how to maximize the chances of preserving residual kidney function.
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Affiliation(s)
- John T Daugirdas
- University of Illinois College of Medicine, Chicago, Illinois, USA
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26
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Abstract
Current views regarding hemodialysis adequacy reach beyond indices of small solute removal such as Kt/V. Nevertheless, new Kt/V-based constructs such as the standard Kt/V, which adjusts not only for dialysis frequency, but which also represents removal of sequestered solutes rather than easily removed urea, continue to be useful. The scaling of dialysis dose to measures of size other than body water results in higher recommended doses of dialysis for children, small patients, and women, compared with the current body water-based scaling approach. Aside from small solute removal, increasing weekly time on dialysis results in slower removal of fluid with better tolerance and with increased removal of phosphorus, although both salt and water and phosphorus control often respond to efforts to reduce intake. The intermediate term benefits of removing larger middle molecules such as beta-2-microglobulin appear to be modest, and the benefits of removal of protein-bound uremic toxins remain to be proved in controlled trials.
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Debowska M, Paniagua R, Ventura MDJ, Ávila-Díaz M, Prado-Uribe C, Mora C, García-López E, Qureshi AR, Lindholm B, Waniewski J. Dialysis adequacy indices and body composition in male and female patients on peritoneal dialysis. Perit Dial Int 2014; 34:417-25. [PMID: 24497588 DOI: 10.3747/pdi.2013.00018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Creatinine clearance scaled to body surface area (BSA) and urea KT/V normalized to total body water (TBW) are used as indices for peritoneal dialysis (PD) adequacy. We investigated relationships of indices of dialysis adequacy (including KT/V, KT, clearance, dialysate over plasma concentration ratio) and anthropometric and body composition parameters (BSA, TBW, body mass index (BMI), weight, height, fat mass (FM), and fat-free mass (FFM)) in male and female patients on continuous ambulatory peritoneal dialysis. METHODS Ninety-nine stable patients (56 males) performed four 24-hr collections of drained dialysate for four dialysis schedules with three daily exchanges of glucose 1.36% and one night exchange of either: 1) glucose 1.36%, 2) glucose 2.27%, 3) glucose 3.86% or 4) icodextrin 7.5%. RESULTS KT and dialysate over plasma concentration ratio, CD/CP, for urea and creatinine were similar for males and females and, in general, did not depend on body-size parameters including V (= TBW), which means that the overall capacity of the transport system in females and males is similar. However, after normalization of KT to V or 1.73/BSA yielding KT/V and creatinine clearance, Cl(1.73/BSA), respectively, the normalized indices were substantially higher in females than in males and correlated inversely with body-size parameters, especially in males. CONCLUSIONS As KT/V depends strongly on body size, treatment target values for KT/V should take body size and therefore also gender into account. As KT is less influenced by body size, body composition and gender, KT should be considered as a potential auxiliary index in PD.
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Affiliation(s)
- Malgorzata Debowska
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Ramón Paniagua
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - María-de-Jesús Ventura
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Marcela Ávila-Díaz
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Carmen Prado-Uribe
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Carmen Mora
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Elvia García-López
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Bengt Lindholm
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
| | - Jacek Waniewski
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Department for Mathematical Modelling of Physiological Processes, Warsaw, Poland; Unidad de Investigacion Medica en Enfermedades Nefrologicas, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, Mexico; and Karolinska Institutet, Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden
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Fontseré N, Mestres G, Burrel M, Barrufet M, Montaña X, Arias M, Ojeda R, Maduell F, Campistol JM. Observational Study of Surveillance Based on the Combination of Online Dialysance and Thermodilution Methods in Hemodialysis Patients with Arteriovenous Fistulas. Blood Purif 2014; 37:67-72. [DOI: 10.1159/000358039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/12/2013] [Indexed: 11/19/2022]
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Maduell F, Ramos R, Palomares I, Martin-Malo A, Molina M, Bustamante J, Perez-Garcia R, Grassmann A, Merello JI. Impact of targeting Kt instead of Kt/V. Nephrol Dial Transplant 2013; 28:2595-603. [DOI: 10.1093/ndt/gft255] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Grangé S, Hanoy M, Le Roy F, Guerrot D, Godin M. Monitoring of hemodialysis quality-of-care indicators: why is it important? BMC Nephrol 2013; 14:109. [PMID: 23705852 PMCID: PMC3701507 DOI: 10.1186/1471-2369-14-109] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 05/03/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Meeting specific guideline targets is associated with improved survival rates and reduced hospitalizations in the dialysis population. This prospective work evaluated the adequacy of hemodialysis quality indicators in an in-center hemodialysis population with severe comorbidities, and assessed whether clinical practice could impact intermediate outcomes. METHODS All the chronic hemodialysis patients treated in Rouen University Hospital hemodialysis Unit between January 2009 and April 2010 were included in this observational study. Every quarter, mean levels and prevalence of conformity were collected for the following indicators: anemia, dialysis dose, serum calcium and phosphorus, PTH, 25OH-vitamin D, albumin, serum bicarbonate, LDL-cholesterol, serum β2-microglobulin, systolic and diastolic blood pressure, intradialytic hypotension and vascular access. Conformity of quality-of-care indicators was determined according to targets defined by international guidelines, whenever available. RESULTS Altogether, 124 patients were included in the study. Thirty-three patients were evaluated during the entire follow-up period. An improvement in the percentage of conformity was observed for hemoglobin, dialysis dose, phosphates, PTH, serum bicarbonate and β2-microglobulin in the global population. Failure to improve conformity rates for several indicators, including serum albumin, was found, possibly depending on patients' comorbidities rather than on quality of care. CONCLUSION Overall, this study shows that following quality-of-care indicators can improve clinical practice by identifying center-specific weaknesses, prompting the establishment of corrective measures. Finally, we suggest that the definition and targets of some indicators, especially hypertension and LDL-cholesterol, be reviewed, since evidence of their association with mortality is not demonstrated.
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Affiliation(s)
- Steven Grangé
- Nephrology department, Rouen University Hospital, 1 Avenue de Germont 76031 Rouen Cedex, Rouen, France
| | - Mélanie Hanoy
- Nephrology department, Rouen University Hospital, 1 Avenue de Germont 76031 Rouen Cedex, Rouen, France
| | - Frank Le Roy
- Nephrology department, Rouen University Hospital, 1 Avenue de Germont 76031 Rouen Cedex, Rouen, France
| | - Dominique Guerrot
- Nephrology department, Rouen University Hospital, 1 Avenue de Germont 76031 Rouen Cedex, Rouen, France
- INSERM Unit 1096, Rouen University Medical School, Rouen, France
| | - Michel Godin
- Nephrology department, Rouen University Hospital, 1 Avenue de Germont 76031 Rouen Cedex, Rouen, France
- INSERM Unit 1096, Rouen University Medical School, Rouen, France
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Szamosfalvi B, Yee J. Considerations in the critically ill ESRD patient. Adv Chronic Kidney Dis 2013; 20:102-9. [PMID: 23265602 DOI: 10.1053/j.ackd.2012.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/25/2012] [Accepted: 10/25/2012] [Indexed: 12/21/2022]
Abstract
ESRD patients are admitted more frequently to intensive care units (ICUs) and have higher mortality risks than the general population, and the main causes of critical illness among ESRD patients are cardiovascular events, sepsis, and bleeding. Once in the ICU, hemodynamic stabilization and fluid-electrolyte management pose major challenges in oligoanuric patients. Selection of renal replacement therapy (RRT) modality is influenced by the outpatient modality and access, as well as severity of illness, renal provider experience, and ICU logistics. Currently, most patients receive intermittent hemodialysis or continuous RRT with temporary vascular access catheters. Acute peritoneal dialysis (PD) is less frequently utilized, and utility of outpatient PD is reduced after an ICU admission. Thus, preservation of current vascular accesses, while limiting venous system damage for future access creations, is relevant. Also, dosing of small-solute clearance with urea kinetic modeling is difficult and may be supplanted by novel online clearance techniques. Medication dosing, coordinated with delivered RRT, is essential for septic patients treated with antibiotics. A comprehensive, standardized approach by a multidisciplinary team of providers, including critical care specialists, nephrologists, and pharmacists, represents a nexus of care that can reduce readmission rates, morbidity, and mortality of vulnerable ESRD patients.
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Ramirez SPB, Kapke A, Port FK, Wolfe RA, Saran R, Pearson J, Hirth RA, Messana JM, Daugirdas JT. Dialysis dose scaled to body surface area and size-adjusted, sex-specific patient mortality. Clin J Am Soc Nephrol 2012; 7:1977-87. [PMID: 22977208 PMCID: PMC3513738 DOI: 10.2215/cjn.00390112] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 08/15/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES When hemodialysis dose is scaled to body water (V), women typically receive a greater dose than men, but their survival is not better given a similar dose. This study sought to determine whether rescaling dose to body surface area (SA) might reveal different associations among dose, sex, and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Single-pool Kt/V (spKt/V), equilibrated Kt/V, and standard Kt/V (stdKt/V) were computed using urea kinetic modeling on a prevalent cohort of 7229 patients undergoing thrice-weekly hemodialysis. Data were obtained from the Centers for Medicare & Medicaid Services 2008 ESRD Clinical Performance Measures Project. SA-normalized stdKt/V (SAN-stdKt/V) was calculated as stdKt/V × ratio of anthropometric volume to SA/17.5. Patients were grouped into sex-specific dose quintiles (reference: quintile 1 for men). Adjusted hazard ratios (HRs) for 1-year mortality were calculated using Cox regression. RESULTS spKt/V was higher in women (1.7 ± 0.3) than in men (1.5 ± 0.2; P<0.001), but SAN-stdKt/V was lower (women: 2.3 ± 0.2; men: 2.5 ± 0.3; P<0.001). For both sexes, mortality decreased as spKt/V increased, until spKt/V was 1.6-1.7 (quintile 4 for men: HR, 0.62; quintile 3 for women: HR, 0.64); no benefit was observed with higher spKt/V. HR for mortality decreased further at higher SAN-stdKt/V in both sexes (quintile 5 for men: HR, 0.69; quintile 5 for women: HR, 0.60). CONCLUSIONS SA-based dialysis dose results in dose-mortality relationships substantially different from those with volume-based dosing. SAN-stdKt/V analyses suggest women may be relatively underdosed when treated by V-based dosing. SAN-stdKt/V as a measure for dialysis dose may warrant further study.
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Depner T. Optimizing the Measurement of Dialysis: Which Denominator? Clin J Am Soc Nephrol 2012; 7:1920-3. [DOI: 10.2215/cjn.11251012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Martínez Fernández G, Ortega Cerrato A, Masiá Mondéjar J, Pérez Rodríguez A, Llamas Fuentes F, Gómez Roldán C, Pérez-Martínez J. Efficacy of dialysis in peritoneal dialysis: utility of bioimpedance to calculate Kt/V and the search for a target Kt. Clin Exp Nephrol 2012; 17:261-7. [DOI: 10.1007/s10157-012-0671-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 07/12/2012] [Indexed: 10/28/2022]
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Daugirdas JT, Greene T, Chertow GM, Depner TA. Can rescaling dose of dialysis to body surface area in the HEMO study explain the different responses to dose in women versus men? Clin J Am Soc Nephrol 2010; 5:1628-36. [PMID: 20595687 PMCID: PMC2974404 DOI: 10.2215/cjn.02350310] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 05/13/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the Hemodialysis (HEMO) Study, the lower death rate in women but not in men assigned to the higher dose (Kt/V) could have resulted from use of "V" as the normalizing factor, since women have a lower anthropometric V per unit of surface area (V/SA) than men. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The effect of Kt/V on mortality was re-examined after normalizing for surface area and expressing dose as surface area normalized standard Kt/V (SAn-stdKt/V). RESULTS Both men and women in the high-dose group received approximately 16% more dialysis (when expressed as SAn-stdKt/V) than the controls. SAn-stdKt/V clustered into three levels: 2.14/wk for conventional dose women, 2.44/wk for conventional dose men or 2.46/wk for high-dose women, and 2.80/wk for high-dose men. V/SA was associated with the effect of dose assignment on the risk of death; above 20 L/m(2), the mortality hazard ratio = 1.23 (0.99 to 1.53); below 20 L/m(2), hazard ratio = 0.78 (0.65 to 0.95), P = 0.002. Within gender, V/SA did not modify the effect of dose on mortality. CONCLUSIONS When normalized to body surface area rather than V, the dose of dialysis in women in the HEMO Study was substantially lower than in men. The lowest surface-area-normalized dose was received by women randomized to the conventional dose arm, possibly explaining the sex-specific response to dialysis dose. Results are consistent with the hypothesis that when dialysis dose is expressed as Kt/V, women, due to their lower V/SA ratio, require a higher amount than men.
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Affiliation(s)
- John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612-7323, USA.
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Daugirdas JT, Hanna MG, Becker-Cohen R, Langman CB. Dose of dialysis based on body surface area is markedly less in younger children than in older adolescents. Clin J Am Soc Nephrol 2010; 5:821-7. [PMID: 20299373 PMCID: PMC2863971 DOI: 10.2215/cjn.08171109] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 02/10/2010] [Indexed: 11/23/2022]
Abstract
UNLABELLED BACKGROUND AND OBSERVATIONS: The current denominator for dosing dialysis is the urea distribution volume (V). Normalizing Kt/V to body surface area (S) has been proposed, but the implications of doing this in children have not been examined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Dialysis dose given to children and adolescents was calculated in terms of conventional V-based scaling and surface-area-normalized standard Kt/V (SAN-stdKt/V) calculated as stdKt/V x (Vant/S)/17.5, where Vant was an anthropometric estimate of V calculated using the Morgenstern equation. Formal 2-pool modeling was used to compute all dialysis adequacy outputs. RESULTS In 34 children (11 girls, 23 boys) dialyzed 3 times a week, age range 1.4 to 18 years, the mean delivered equilibrated Kt/V (eKt/V) was 1.40, and the mean stdKt/V was 2.49, both of which tended to be higher in younger children. The ratio of Vant to S was 15.6 +/- 2.69 and was strongly associated with age between ages 2 and 16. SAN-stdKt/V averaged 2.21 and was strongly correlated with age between ages 2 and 16. If one considers a desired target for SAN-stdKt/V to be 2.45, all children less than 10 years of age were below target, despite having relatively high values of eKt/V and stdKt/V. CONCLUSIONS If a surface-area-based denominator were to be adopted for dialysis dosing, most children under 10 years of age would receive markedly less dialysis than adolescent patients and would require 6- to 8-hour hemodialysis sessions or, for the youngest children, treatments given more frequently than 3 times/wk.
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Affiliation(s)
- John T Daugirdas
- University of Illinois at Chicago, 820 S. Wood Street, N/C 793, Chicago, IL 60612, USA.
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Basile C, Vernaglione L, Lomonte C, Bellizzi V, Libutti P, Teutonico A, Di Iorio B. Comparison of alternative methods for scaling dialysis dose. Nephrol Dial Transplant 2009; 25:1232-9. [DOI: 10.1093/ndt/gfp603] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lowrie EG. Illustrating Use of a Clinical Data System: The NMC-FMC System. Clin J Am Soc Nephrol 2009; 4 Suppl 1:S41-8. [DOI: 10.2215/cjn.02680409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lowrie EG. Does a statistical method suggest a new pathobiology for hemodialysis patients? J Am Soc Nephrol 2009; 20:1867-9. [PMID: 19713306 DOI: 10.1681/asn.2009060649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
Small patients require higher Kt/V, the ratio of dialysis dose (the product of small-molecule clearance (K) and dialysis session length (t) to body water volume (V), than large patients. The errors implicit in Kt/V for judging hemodialysis dose are reviewed; methods for prescribing hemodialysis based on new technology are discussed; and thoughts about future development are suggested.
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Daugirdas JT, Levin NW, Kotanko P, Depner TA, Kuhlmann MK, Chertow GM, Rocco MV. Comparison of proposed alternative methods for rescaling dialysis dose: resting energy expenditure, high metabolic rate organ mass, liver size, and body surface area. Semin Dial 2008; 21:377-84. [PMID: 18945324 PMCID: PMC2692384 DOI: 10.1111/j.1525-139x.2008.00483.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A number of denominators for scaling the dose of dialysis have been proposed as alternatives to the urea distribution volume (V). These include resting energy expenditure (REE), mass of high metabolic rate organs (HMRO), visceral mass, and body surface area. Metabolic rate is an unlikely denominator as it varies enormously among humans with different levels of activity and correlates poorly with the glomerular filtration rate. Similarly, scaling based on HMRO may not be optimal, as many organs with high metabolic rates such as spleen, brain, and heart are unlikely to generate unusually large amounts of uremic toxins. Visceral mass, in particular the liver and gut, has potential merit as a denominator for scaling; liver size is related to protein intake and the liver, along with the gut, is known to be responsible for the generation of suspected uremic toxins. Surface area is time-honored as a scaling method for glomerular filtration rate and scales similarly to liver size. How currently recommended dialysis doses might be affected by these alternative rescaling methods was modeled by applying anthropometric equations to a large group of dialysis patients who participated in the HEMO study. The data suggested that rescaling to REE would not be much different from scaling to V. Scaling to HMRO mass would mandate substantially higher dialysis doses for smaller patients of either gender. Rescaling to liver mass would require substantially more dialysis for women compared with men at all levels of body size. Rescaling to body surface area would require more dialysis for smaller patients of either gender and also more dialysis for women of any size. Of these proposed alternative rescaling measures, body surface area may be the best, because it reflects gender-based scaling of liver size and thereby the rate of generation of uremic toxins.
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Affiliation(s)
| | | | | | - Thomas A. Depner
- Department of Medicine, University of California-Davis, Sacramento, California
| | | | | | - Michael V. Rocco
- Section of Nephrology, Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
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Daugirdas JT, Depner TA, Greene T, Kuhlmann MK, Levin NW, Chertow GM, Rocco MV. Surface-area-normalized Kt/V: a method of rescaling dialysis dose to body surface area-implications for different-size patients by gender. Semin Dial 2008; 21:415-21. [PMID: 18945330 PMCID: PMC2692381 DOI: 10.1111/j.1525-139x.2008.00482.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Dialysis is measured as Kt/V, which scales the dose (Kt) to body water content (V). Scaling dialysis dose to body surface area (S(dub)) has been advocated, but the implications of such rescaling have not been examined. We developed a method of rescaling measured Kt/V to S(dub) and studied the effect of such alternative scaling on the minimum adequacy values that might then be applied in male and female patients of varying body size. We examined anthropometric estimates of V and S (Watson vs. Dubois estimates) in 1765 patients enrolled in the HEMO study after excluding patients with amputations. An S-normalized target stdKt/V was defined, and an adequacy ratio (R) was computed for each patient as R = D/N where D = delivered stdKt/V (calculated using the Gotch-Leypoldt equation for stdKt/V) and N = the S-normalized minimum target value. In the HEMO data set, we determined the extent to which baseline (prerandomization) stdKt/V values would have exceeded such an S-based minimum target stdKt/V. The median V(wat):S(dub) ratios were significantly higher in men (21.34) than in women (18.50). The average of these (20) was used to normalize the current suggested minimally adequate value (stdKt/V > or = 2.0/week) to the S-normalized target value (stdKt/S > or = 40 L/M(2)), assuming that average modeled V = average anthropometric V. To achieve this S-normalized target, the required single-pool (sp) Kt/V was always higher in women than in men at any level of body size. For small patients (V(wat) = 25L), required stdKt/V values were 2.05 and 2.21/week for men and women, respectively, corresponding to spKt/V values of 1.31 and 1.52/session. On the other hand, large (V(wat) = 50L) male patients would need spKt/V values of only 1.0/session. Prerandomization baseline dialysis sessions in the HEMO study were found to meet such a new S-based standard in almost all (766/773) men and in 885/992 women. An analysis of scaling dose to anthropometrically estimated liver size (L) showed similar gender ratios for V(wat):L and V(wat):S(dub), providing a potential physiologic explanation underpinning S-based scaling. S-based scaling of the dialysis dose would require considerably higher doses in small patients and in women, and would allow somewhat lower doses in larger male patients. Current dialysis practice would largely meet such an S-based adequacy standard if the dose were normalized to a V(wat):S(dub) ratio of 20.
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Maduell F, Vera M, Arias M, Serra N, Blasco M, Bergadá E, Fontsere N, Cases A, Campistol JM. Influence of the Ionic Dialysance Monitor on Kt Measurement in Hemodialysis. Am J Kidney Dis 2008; 52:85-92. [DOI: 10.1053/j.ajkd.2008.03.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 03/11/2008] [Indexed: 11/11/2022]
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Abstract
Current guidelines suggest a minimum Kt/V of 1.2 for three weekly hemodialysis sessions; however, using V as a normalizing factor has been questioned. Parameters such as weight(0.67) (W(0.67)) and body surface area (BSA) that reflect the metabolic rate may be preferable. To determine this, we studied 328 hemodialysis patients (221 male) with a target Kt/V of 1.2. Using this relationship and the individual's Watson Volume, we calculated the Kt, Kt/BSA, and Kt/W(0.67) equivalent to the target and measured the effects of body size and gender on these parameters for each patient. The target corresponded to a range of equivalent Kt/BSA and Kt/W(0.67) each significantly higher in males than females and in larger than smaller males. V/BSA and V/W(0.67), the conversion factors of Kt/V to Kt/BSA and Kt/W(0.67) respectively, were significantly greater in males than females and heavier than lighter men. Our study shows that if Kt/BSA and Kt/W(0.67) reflect the true required dose, prescribing a target Kt/V of 1.2 would underestimate this in females and in small males. Further work is required to develop clinical outcome-based adequacy targets.
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Abstract
The basics of targeting, writing, adjusting, and monitoring a hemodialysis prescription are reviewed for patients being dialyzed 3 or 4 times a week. K/DOQI 2006 adequacy guidelines and practice recommendations are reviewed, and a practical method using a variety of nomograms is suggested to monitor and adjust the desired level of Kt/V.
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Affiliation(s)
- John T Daugirdas
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois 60527, USA
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47
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Lowrie EG. The kinetic behaviors of urea and other marker molecules during hemodialysis. Am J Kidney Dis 2007; 50:181-3. [PMID: 17660018 DOI: 10.1053/j.ajkd.2007.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 06/19/2007] [Indexed: 11/11/2022]
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48
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Morton AR, Singer MA. The problem with Kt/V: dialysis dose should be normalized to metabolic rate not volume. Semin Dial 2007; 20:12-5. [PMID: 17244112 DOI: 10.1111/j.1525-139x.2007.00232.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Current estimates of hemodialysis adequacy are based on calculations of small solute clearance or changes in online measurements of ionic conductance. A minimum target value of the widely used, dimensionless parameter, Kt/V(urea) has been adopted nationally and internationally to represent appropriate dialysis delivery. Based on the principles of allometry, which permit the calculation of scaling equations between the mass of an organism and other parameters, we propose that dialysis dose should be normalized to waste product generation (estimated by metabolic rate). The allometric equations predict a nonlinear correlation between body mass and dialysis dose, such that smaller individuals require proportionately ''more'' dialysis than larger persons. The argument we present is congruent with outcome data as it relates to sex, race, and body size, as well as supportive of studies suggesting that certain groups (e.g., pregnant women, critically ill patients, diabetics) require greater dialysis delivery than the hemodialysis population in general.
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49
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Lowrie EG, Li Z, Ofsthun NJ, Lazarus JM. Evaluating a new method to judge dialysis treatment using online measurements of ionic clearance. Kidney Int 2006; 70:211-7. [PMID: 16723982 DOI: 10.1038/sj.ki.5001507] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
New technology now supports direct online measurements of total dialysis dose per treatment, Kt. An outcome-based, nonlinear method for estimating target Kt in terms of ionic clearance measurements and body surface area (BSA) has been described recently. This is a validation study of the new method that evaluates the relationship between the (actual Kt-target Kt) difference and death risk. Patients with Kt measurements during March 2004 were identified (N=59,644). Target Kt was determined for each patient using the new method. Patients were then grouped by (actual Kt-target Kt) decile. They were also grouped by (actual URR-target URR) decile. Cox analysis-based risk profiles were constructed using those groupings. The (actual Kt-target Kt) difference profiles suggested improving death risk as Kt increased from below target to equal target. Risk ratios then flattened and remained so until (actual Kt-target Kt) reached the highest decile at which it appeared to improve, suggesting a possible biphasic profile. The (URR-target URR) risk profile was U-shaped. Death risk was related to the difference between the actual Kt and a target Kt value selected using the new nonlinear method. The method is therefore valid for prescribing and monitoring hemodialysis treatment.
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Affiliation(s)
- E G Lowrie
- Fresenius Medical Care North America, Lexington, Massachusetts, USA.
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