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Tange Y, Murata A, Yoshitake S. Efficacy of combined disinfection with a nitric oxide donor in controlling biofilm formation on the reverse osmosis water pathway for hemodialysis. JOURNAL OF WATER AND HEALTH 2023; 21:1591-1599. [PMID: 37902212 PMCID: wh_2023_220 DOI: 10.2166/wh.2023.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
The water treatment system for hemodialysis (HD) is used to treat multiple patients requiring HD simultaneously. This system requires a large amount of purified reverse osmosis (RO) water. However, a major drawback of this method is the formation of biofilms in dialysate pathways. The purpose of this study was to investigate the efficacy of NOC 18, a nitric oxide (NO) donor that can be used at neutral pH, in disinfecting the RO water pathway. Silicone tubes were obtained from the terminal sites of two different HD units. The biofilm coverage and mean biofilm thickness on the tube lumen were evaluated by scanning electron microscopy. The results demonstrated that treatment with NOC 18 alone and in conjunction with sodium hypochlorite reduced biofilm coverage and mean biofilm thickness. Thus, NO donor is a potential disinfectant that enhances bacterial dispersion from biofilms formed on the silicone tube lumen and reduces biofilm coverage and thickness on the RO water pathway at neutral pH. Furthermore, combined disinfection with the NO donor and sodium hypochlorite might enhance biofilmremoval efficacy in clinical practice.
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Affiliation(s)
- Yoshihiro Tange
- Department of Advanced Medical Sciences, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu City, Oita 879-5593, Japan E-mail:
| | - Ayane Murata
- Department of Medical Engineering, Kyushu University of Health and Welfare, 1714-1 Yoshinomachi, Nobeoka City, Miyazaki 882-8508, Japan
| | - Shigenori Yoshitake
- Department of Clinical Psychology, Kyushu University of Health and Welfare, 1714-1 Yoshinomachi, Nobeoka City, Miyazaki 882-8508, Japan
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Rasuli L, Dehghani MH, Aghaei M, Mahvi AH, Mubarak NM, Karri RR. Occurrence and fate of bacterial endotoxins in the environment (air, water, wastewater) and remediation technologies: An overview. CHEMOSPHERE 2022; 303:135089. [PMID: 35623438 DOI: 10.1016/j.chemosphere.2022.135089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/10/2022] [Accepted: 05/21/2022] [Indexed: 12/07/2022]
Abstract
Endotoxins as the outer membrane of most Gram-Negative Bacteria (GNB) and typical toxic biochemical produced by microorganisms are identified as one of the emerging pollutants. These microbial by-products are harmful compounds that can be present in various environments including air, water, soil, and other ecosystems which was discussed in detail in this review. Environmental and occupational exposure caused by endotoxin occurs in water and wastewater treatment plants, industrial plants, farming, waste recovery, and composting facilities. Even though the health risk related to endotoxin injection in intravenous and dialysis are well identified, the harmful effects of ingestion, inhalation, and other way of exposure are not well quantified and there is insufficient information on the potential health risks of endotoxins exposure in water environments, and another exposures. Because of limited studies, the outbreaks of diseases related to endotoxins in the various source of exposure not been well documented. Endotoxin removal from different environments are investigated in this review. The results of various studies have shown that conventional treatment methods have been unable to remove endotoxins from water and wastewater, therefore, monitoring the effectiveness of these processes in controlling this contaminant and also using the appropriate removal method is essential. However, management of water and wastewater treatment processes and the use of advanced processes such as Advanced Oxidation Processes (AOPs) can be effective in monitoring and reducing endotoxin levels during water and wastewater treatment. One of the limitations of endotoxin monitoring is the lack of sufficient information to develop monitoring levels. In addition, the lack of guidelinesand methods of controlling them at high levels may cause irreparable disaster.
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Affiliation(s)
- Leila Rasuli
- Qazvin University of Medical Science, Qazvin, Iran
| | - Mohammad Hadi Dehghani
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Institute for Environmental Research, Center for Solid Waste Research, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mina Aghaei
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Mahvi
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Institute for Environmental Research, Center for Solid Waste Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Nabisab Mujawar Mubarak
- Petroleum and Chemical Engineering, Faculty of Engineering, Universiti Teknologi Brunei, Bandar Seri Begawan, BE1410, Brunei Darussalam
| | - Rama Rao Karri
- Petroleum and Chemical Engineering, Faculty of Engineering, Universiti Teknologi Brunei, Bandar Seri Begawan, BE1410, Brunei Darussalam
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Nozaki H, Tange Y, Inada Y, Uchino T, Azuma N. Leakage of Endotoxins through the Endotoxin Retentive Filter: An in vitro Study. Blood Purif 2022; 51:831-839. [PMID: 35021168 DOI: 10.1159/000520792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ultrapurification of dialysis fluid has enabled highly efficient dialysis treatments. Online hemodiafiltration is one such treatment that uses a purified dialysis fluid as a supplemental fluid. In this method, an endotoxin retentive filter (ETRF) is used in the final step of dialysis fluid purification, with the aim of preventing leakage of endotoxins. Sodium hypochlorite and peracetic acid are used as disinfecting agents for the dialysis fluid pipes containing the ETRF; however, the effects of these agents on ETRF membrane pores have not been fully clarified. METHODS Water permeability (flux) and endotoxin permeability were assessed in 3 types of ETRFs made with different membrane materials: polyester polymer alloy (PEPA), polyether sulfone (PES), and polysulfone (PS). High-concentration sodium hypochlorite and 2 types of peracetic acid were used as disinfecting agents, and the changes in flux and the endotoxin sieving coefficient (SC) were measured. RESULTS After repeated use of high concentrations of sodium hypochlorite and peracetic acid, the PEPA and PES ETRFs did not permit passage of endotoxins, regardless of their flux. However, in the PS ETRF, the flux and endotoxin SC increased with the number of cleaning cycles. No differences were observed according to the concentration of peracetic acid disinfecting agents. CONCLUSION PEPA and PES ETRFs completely prevent endotoxin leakage and can be disinfected at concentrations higher than the conventionally recommended concentration without affecting pore expansion. Even new PS ETRFs have low levels of endotoxin leakage, which increase after disinfection cycles using sodium hypochlorite and peracetic acid.
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Affiliation(s)
- Hiroshi Nozaki
- Tokatsu-Clinic Hospital, Matsudo, Japan.,Graduate School of Health Sciences, Kyushu University of Health and Welfare, Nobeoka, Japan
| | - Yoshihiro Tange
- Graduate School of Health Sciences, Kyushu University of Health and Welfare, Nobeoka, Japan
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Verma S, Singh P, Khurana S, Ganguly NK, Kukreti R, Saso L, Rana DS, Taneja V, Bhargava V. Implications of oxidative stress in chronic kidney disease: a review on current concepts and therapies. Kidney Res Clin Pract 2021; 40:183-193. [PMID: 34078023 PMCID: PMC8237115 DOI: 10.23876/j.krcp.20.163] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 02/05/2021] [Indexed: 01/04/2023] Open
Abstract
Moderate levels of endogenous reactive oxygen species (ROS) are important for various cellular activities, but high levels lead to toxicity and are associated with various diseases. Levels of ROS are maintained as a balance between oxidants and antioxidants. Accumulating data suggest that oxidative stress is a major factor in deterioration of renal function. In this review, we highlight the possible mechanism by which oxidative stress can lead to chronic kidney disease (CKD). This review also describes therapies that counter the effect of oxidative stress in CKD patients. Numerous factors such as upregulation of genes involved in oxidative phosphorylation and ROS generation, chronic inflammation, vitamin D deficiency, and a compromised antioxidant defense mechanism system cause progressive detrimental effects on renal function that eventually lead to loss of kidney function. Patients with renal dysfunction are highly susceptible to oxidative stress, as risk factors such as diabetes, renal hypertension, dietary restrictions, hemodialysis, and old age predispose them to increased levels of ROS. Biomolecular adducts (DNA, proteins, and lipids) formed due to reaction with ROS can be used to determine oxidative stress levels. Based on the strong correlation between oxidative stress and CKD, reversal of oxidative stress is being explored as a major therapeutic option. Xanthine oxidase inhibitors, dietary antioxidants, and other agents that scavenge free radicals are gaining interest as treatment modalities in CKD patients.
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Affiliation(s)
- Sagar Verma
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Priyanka Singh
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Shiffali Khurana
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Ritushree Kukreti
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Luciano Saso
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | | | - Vibha Taneja
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
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García-Lorenzo B, Fernández-Barceló C, Maduell F, Sampietro-Colom L. Health Technology Assessment of a new water quality monitoring technology: Impact of automation, digitalization and remoteness in dialysis units. PLoS One 2021; 16:e0247450. [PMID: 33630930 PMCID: PMC7906308 DOI: 10.1371/journal.pone.0247450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Water quality monitoring at the dialysis units (DU) is essential to ensure an appropriate dialysis fluid quality and guarantee an optimal and safe dialysis treatment to patients. This paper aims to evaluate the effectiveness, economic and organizational impact of automation, digitalization and remote water quality monitoring, through a New Water Technology (NWT) at a hospital DU to produce dialysis water, compared to a Conventional Water Technology (CWT). Methods A before-and-after study was carried out at the Hospital Clínic Barcelona. Data on CWT was collected during 1-year (control) and 7-month for the NWT (case). Data on water quality, resource use and unit cost were retrospective and prospectively collected. A comparative effectiveness analysis on the compliance rate of quality water parameters with the international guidelines between the NWT and the CWT was conducted. This was followed by a cost-minimization analysis and an organizational impact from the hospital perspective. An extensive deterministic sensitivity analysis was also performed. Results The NWT compared to the CWT showed no differences on effectiveness measured as the compliance rate on international requirements on water quality (100% vs. 100%), but the NWT yielded savings of 3,599 EUR/year compared to the CWT. The NWT offered more data accuracy (daily measures: 6 vs. 1 and missing data: 0 vs. 20 days/year), optimization of the DU employees’ workload (attendance to DU: 4 vs. 19 days/month) and workflow, through the remote and continuous monitoring, reliability of data and process regarding audits for quality control. Conclusions While the compliance of international recommendations on continuous monitoring was performed with the CWT, the NWT was efficient compared to the CWT, mainly due to the travel time needed by the technical operator to attend the DU. These results were scalable to other economic contexts. Nonetheless, they should be taken with caution either when the NWT equipment/maintenance cost are largely increased, or the workforce involvement is diminished.
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Affiliation(s)
- Borja García-Lorenzo
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
- * E-mail:
| | - Carla Fernández-Barceló
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Laura Sampietro-Colom
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
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Liakopoulos V, Roumeliotis S, Zarogiannis S, Eleftheriadis T, Mertens PR. Oxidative stress in hemodialysis: Causative mechanisms, clinical implications, and possible therapeutic interventions. Semin Dial 2018; 32:58-71. [PMID: 30288786 DOI: 10.1111/sdi.12745] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Oxidative stress (OS) is the result of prooxidant molecules overwhelming the antioxidant defense mechanisms. Hemodialysis (HD) constitutes a state of elevated inflammation and OS, due to loss of antioxidants during dialysis and activation of white blood cells triggering production of reactive oxygen species. Dialysis vintage, dialysis methods, and type and condition of vascular access, biocompatibility of dialyzer membrane and dialysate, iron administration, and anemia all can play a role in aggravating OS, which in turn has been associated with increased morbidity and mortality. Oral or intravenous administration of antioxidants may detoxify the oxidative molecules and at least in part repair OS-mediated tissue damage. Lifestyle interventions and optimization of a highly biocompatible HD procedure might ameliorate OS development in dialysis.
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Affiliation(s)
- Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotirios Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Theodoros Eleftheriadis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
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Tao J, Sun Y, Li X, Li H, Liu S, Wen Y, Duan L, Li Y, Li X. Conventional versus Ultrapure Dialysate for Lowering Serum Lipoprotein(a) Levels in Patients on Long-Term Hemodialysis: A Randomized Trial. Int J Artif Organs 2018. [DOI: 10.1177/039139881003300504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose In patients on long-term hemodialysis, high lipoprotein(a) [Lp(a)] levels are difficult to lower with medications, although they remain a risk factor for cardiovascular disease. We investigated whether ultrapure dialysate (UPD) could lower Lp(a). Methods: We randomly assigned patients stabilized on long-term dialysis to either a low-flux synthetic polysulphone membrane (the UPD group; n=14) or to a conventional dialysate (the CD group; n=13). Blood samples were collected 1 week before dialysis and 1 week, 1 month, 6 months and 12 months after dialysis; Lp(a) was measured by the immunotur-bidimetry method. Hemoglobin, interleukin-6, hypersensitive C-reactive protein, β2 microglobulin and albumin were also measured. The erythropoietin dosage, Kt/V, and normalized protein catabolic rate were recorded monthly. Results At 12 months, mean (SD) serum levels of Lp(a) in the CD patients increased from 143.46 (125.11) to 283.89 (145.81) mg/L (p<0.01), whereas levels in the UPD group remained unchanged: 131.38 (201.45) to 120.90 (122.11) mg/L. Endotoxin levels in the 10 CD patients who completed the study ranged from 0.116 to 0.349 EU/mL and were undetectable in the 11 UPD patients who completed the study. The cultures were less than 200 CFU/mL in CD patients and negative all the time for all UPD patients. Changes in Lp(a) from baseline values were lower in the UPD group than in the CD group (p<0.05). However, changes in other variables did not differ between groups. Conclusions Ultrapure dialysate can prevent the rise of Lp(a), potentially decreasing the risk of cardiovascular disease in hemodialysis patients.
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Affiliation(s)
- Jianling Tao
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Yang Sun
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Xuemei Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Hang Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Shiqin Liu
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Yubing Wen
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Lin Duan
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Yan Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Xuewang Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
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8
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Cianciolo G, Colì L, La Manna G, Donati G, D'addio F, Comai G, Ricci D, Dormi A, Wratten M, Feliciangeli G, Stefoni S. Is β2-Microglobulin-Related Amyloidosis of Hemodialysis Patients a Multifactorial Disease? a New Pathogenetic Approach. Int J Artif Organs 2018; 30:864-78. [DOI: 10.1177/039139880703001003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose β2-microglobulin amyloidosis (Aβ2M) is one of the main long-term complications of dialysis treatment. The incidence and the onset of Aβ2M has been related to membrane composition and/or dialysis technique, with non-homogeneous results. This study was carried out to detect: i) the incidence of bone cysts and CTS from Aβ2M; ii) the difference in Aβ2M onset between cellulosic and synthetic membranes; iii) other risk factors besides the membrane. Methods 480 HD patients were selected between 1986 to 2005 and grouped according to the 4 types of membranes used (cellulose, synthetically modified cellulose, synthetic low-flux, synthetic high-flux). The patients were analyzed before and after 1995, when the reverse osmosis treatment for dialysis water was started at our center, and the incidence of Aβ2M was compared between the two periods. Routine plain radiography, computer tomography (CT) and nuclear magnetic resonance imaging (MRI) as well as electromyography were used to investigate the clinical symptoms. Results Bone cysts occurred in 29.2% of patients before 1995 vs. 12.2% after 1995 (p<0.0001). CTS occurred in 24% of patients before 1995 vs. 7.1% after 1995 (p<0.0001). Bone cysts and CTS occurred in older patients, who began dialysis at a late age, with high CRP, low albumin, low residual GFR, and low Hb. Cox regression analysis showed that the risk factor for bone cysts was high CRP (RR 1.3, p<0.01), while albumin (RR 0.14, p<0.0001) and residual GFR (RR 0.81, p<0.0001) were revealed to be protective factors. Cox analysis for CTS confirmed CRP as a risk factor (RR 1.2, p<0.01), and albumin (RR 0.59, p<0.0001) and residual GFR (RR 0.75, p<0.0001) as protective factors. The comparison obtained between membranes did not suggest any protective effect on Aβ2M. Conclusions The findings that the inflammatory status as well as low albumin and the residual GFR of the uremic patient are predictive of Aβ2M lesions suggests that Aβ2M has a multifactorial origin rather than being solely a membrane- or technique-related side effect.
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Affiliation(s)
- G. Cianciolo
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - L. Colì
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - G. La Manna
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
- Department of Clinical Medicine and Applied Biotechnology, University of Bologna - Italy
| | - G. Donati
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - F. D'addio
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
- Department of Clinical Medicine and Applied Biotechnology, University of Bologna - Italy
| | - G. Comai
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
- Department of Clinical Medicine and Applied Biotechnology, University of Bologna - Italy
| | - D. Ricci
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
- Department of Clinical Medicine and Applied Biotechnology, University of Bologna - Italy
| | - A. Dormi
- Department of Clinical Medicine and Applied Biotechnology, University of Bologna - Italy
| | - M. Wratten
- Sorin Group, Medical Division, Mirandola - Italy
| | - G. Feliciangeli
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - S. Stefoni
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
- Department of Clinical Medicine and Applied Biotechnology, University of Bologna - Italy
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Oxidative Stress in Hemodialysis Patients: A Review of the Literature. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:3081856. [PMID: 29138677 PMCID: PMC5613374 DOI: 10.1155/2017/3081856] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
Hemodialysis (HD) patients are at high risk for all-cause mortality and cardiovascular events. In addition to traditional risk factors, excessive oxidative stress (OS) and chronic inflammation emerge as novel and major contributors to accelerated atherosclerosis and elevated mortality. OS is defined as the imbalance between antioxidant defense mechanisms and oxidant products, the latter overwhelming the former. OS appears in early stages of chronic kidney disease (CKD), advances along with worsening of renal failure, and is further exacerbated by the HD process per se. HD patients manifest excessive OS status due to retention of a plethora of toxins, subsidized under uremia, nutrition lacking antioxidants and turn-over of antioxidants, loss of antioxidants during renal replacement therapy, and leukocyte activation that leads to accumulation of oxidative products. Duration of dialysis therapy, iron infusion, anemia, presence of central venous catheter, and bioincompatible dialyzers are several factors triggering the development of OS. Antioxidant supplementation may take an overall protective role, even at early stages of CKD, to halt the deterioration of kidney function and antagonize systemic inflammation. Unfortunately, clinical studies have not yielded unequivocal positive outcomes when antioxidants have been administered to hemodialysis patients, likely due to their heterogeneous clinical conditions and underlying risk profile.
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10
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Upadhyay A, Susantitaphong P, Jaber BL. Ultrapure versus standard dialysate: A cost-benefit analysis. Semin Dial 2017; 30:398-402. [PMID: 28608933 DOI: 10.1111/sdi.12618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Low-level bacterial and endotoxin contamination of water used to generate dialysate propagates chronic inflammation in patients with a wide-range of potential adverse consequences, including erythropoietin hyporesponsiveness. Advancements in hemodialysis systems now allow for the generation of ultrapure dialysate that has lower bacterial and endotoxin levels than the standard dialysate. The cost associated with ultrapure dialysate is thought to be a major barrier to its widespread adoption. In this report, we conduct a cost-benefit analysis examining the excess cost of generating ultrapure dialysate and the potential cost saving from a lower erythropoietin dose requirement. Our analysis suggests a potential cost saving of approximately $371 to $425 million per year with full adoption of ultrapure dialysate in the United States.
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Affiliation(s)
- Ashish Upadhyay
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Bertrand L Jaber
- Division of Nephrology, Department of Medicine, Steward St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, MA, USA
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Hyodo T, Hirawa N, Hayashi M, Than KMM, Tuyen DG, Pattanasittangkur K, Hu LW, Naramura T, Miyamoto K, Yamashita AC. Present status of renal replacement therapy at 2015 in Asian countries (Myanmar, Vietnam, Thailand, China, and Japan). RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0082-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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12
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Abstract
Patients receiving hemodialysis are exposed to a large volume of water, used to prepare dialysate for each treatment session. Technological advancements now make it possible to generate ultrapure dialysate that has substantially lower bacterial and endotoxin counts than the standard dialysate used in the United States. Low-level water contamination is thought to propagate a state of chronic inflammation seen in hemodialysis patients, and a number of studies demonstrate that the use of ultrapure dialysate has a favorable effect on laboratory parameters of inflammation, nutrition, erythropoietin responsiveness, dialysis-associated amyloidosis, and atherosclerosis. Few studies even suggest a direct clinical benefit of adopting ultrapure dialysate. As there is no proven harm with use of ultrapure dialysate and the economic implication appears to be minimal when using modern dialysis machines, it is imperative for regulatory agencies and the dialysis community to ensure that our vulnerable patients are no longer exposed to impure water during their hemodialysis treatments.
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Affiliation(s)
- Ashish Upadhyay
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Bertrand L Jaber
- Division of Nephrology, Department of Medicine, Steward St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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13
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Hasegawa T, Nakai S, Masakane I, Watanabe Y, Iseki K, Tsubakihara Y, Akizawa T. Dialysis fluid endotoxin level and mortality in maintenance hemodialysis: a nationwide cohort study. Am J Kidney Dis 2015; 65:899-904. [PMID: 25641063 DOI: 10.1053/j.ajkd.2014.12.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 12/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The quality of dialysis fluid water might play an important role in hemodialysis patient outcomes. Although targeted endotoxin levels of dialysis fluid vary among countries, evidence of the contribution of these levels to mortality in hemodialysis patients is lacking. STUDY DESIGN Retrospective cohort study using data from the Japan Renal Data Registry, a nationwide annual survey. SETTING & PARTICIPANTS 130,781 patients receiving thrice-weekly in-center hemodialysis for more than 6 months were enrolled at 2,746 facilities in Japan at the end of 2006. None of the patients changed facility or treatment modality during 2007. PREDICTOR Highest endotoxin level in dialysis fluid reported by each facility during 2006. Patients were categorized by facility endotoxin level into the following groups: <0.001, 0.001 to <0.01, 0.01 to <0.05, 0.05 to <0.1, and ≥0.1EU/mL. Age, sex, dialysis vintage, diabetes mellitus as a primary cause of end-stage renal disease, Kt/V, normalized protein catabolic rate, dialysis session duration, serum albumin, and hemoglobin were measured as potential confounders. OUTCOME All-cause mortality, censored by transplantation; withdrawal from dialysis treatment; or end of follow-up. RESULTS Of 130,781 hemodialysis patients, 91.2% had facility endotoxin levels below the limit set for dialysis fluid in Japan (<0.05EU/mL). During a 1-year follow-up, 8,978 (6.9%) patients died of all causes. The rate of all-cause mortality at 1 year was highest in the ≥0.1-EU/mL category (88.0 deaths/1,000 person-years). Patients in the ≥0.1-EU/mL group exhibited an increased risk of all-cause mortality of 28% (95% CI, 10%-48%) compared to the <0.001-EU/mL group. LIMITATIONS Endotoxin level in dialysis fluid is reported as categorical data. No information about variation in endotoxin levels in dialysis fluid over time. CONCLUSIONS Higher facility endotoxin levels in dialysis fluid may be related to increased risk for all-cause mortality among hemodialysis patients. Correcting this modifiable facility water management practice might improve the outcome of hemodialysis patients.
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Affiliation(s)
- Takeshi Hasegawa
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan; Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan; Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan.
| | - Shigeru Nakai
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Fujita Health University, Toyoake, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Yabuki Hospital, Yamagata, Japan
| | - Yuzo Watanabe
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Kasugai Municipal Hospital, Kasugai, Japan
| | - Kunitoshi Iseki
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Faculty of Medicine, University of Ryukyus, Okinawa, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Abstract
Over 383,900 individuals in the U.S. undergo maintenance hemodialysis that exposes them to water, primarily in the form of dialysate. The quality of water and associated dialysis solutions have been implicated in adverse patient outcomes and is therefore critical. The Association for the Advancement of Medical Instrumentation has published both standards and recommended practices that address both water and the dialyzing solutions. Some of these recommendations have been adopted into Federal Regulations by the Centers for Medicare and Medicaid Services as part of the Conditions for Coverage, which includes limits on specific contaminants within water used for dialysis, dialysate, and substitution fluids. Chemical, bacterial, and endotoxin contaminants are health threats to dialysis patients, as shown by the continued episodic nature of outbreaks since the 1960s causing at least 592 cases and 16 deaths in the U.S. The importance of the dialysis water distribution system, current standards and recommendations, acceptable monitoring methods, a review of chemical, bacterial, and endotoxin outbreaks, and infection control programs are discussed.
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Masakane I, Kawanishi H, Mineshima M, Takemoto Y, Uchino J, Hoshino T, Igoshi T, Hirakata H, Akizawa T. 2011 JSDT Standard on the Management of Endotoxin Retentive Filter for Dialysis and Related Therapies. Ther Apher Dial 2013; 17:229-40. [DOI: 10.1111/1744-9987.12031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Ikuto Masakane
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Hideki Kawanishi
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Michio Mineshima
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Yoshiaki Takemoto
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Junji Uchino
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Taketoshi Hoshino
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Tadaaki Igoshi
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Hideki Hirakata
- Chairperson of the Committee of Scientific Academy; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Tadao Akizawa
- President of the Japanese Society for Dialysis Therapy; The Japanese Society for Dialysis Therapy; Tokyo; Japan
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Susantitaphong P, Riella C, Jaber BL. Effect of ultrapure dialysate on markers of inflammation, oxidative stress, nutrition and anemia parameters: a meta-analysis. Nephrol Dial Transplant 2013; 28:438-46. [PMID: 23291370 DOI: 10.1093/ndt/gfs514] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Markers of inflammation are linked to malnutrition and confer an increased mortality risk in hemodialysis patients. Ultrapure dialysate might have a beneficial effect on markers of inflammation. We conducted a meta-analysis that examined the effect of ultrapure versus standard dialysate on markers of inflammation, oxidative stress, nutrition and anemia parameters. METHODS We performed a literature search using MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and scientific abstracts. Single-arm studies, nonrandomized and randomized controlled trials were included. We conducted random effects model meta-analyses to assess changes in the aforementioned outcomes. RESULTS We identified 16 single-arm studies, 2 crossover and 3 parallel-arm nonrandomized controlled trials and 5 crossover and 5 parallel-arm randomized controlled trials. In an analysis of 23 study arms or cohorts (n = 2221), ultrapure dialysate resulted in a significant decrease in C-reactive protein (-3.2 mg/L; 95% CI -4.6, -1.8; P < 0.001). Other markers of inflammation and oxidative stress displayed similar significant improvements. Ultrapure dialysate also resulted in a significant increase in serum albumin (0.11 g/dL; 95% CI 0.02, 0.19; P = 0.011) and hemoglobin (0.40 g/dL; 95% CI 0.06, 0.75; P = 0.022), and a decrease in the weekly erythropoietin dose (-273 units; 95% CI -420, -126; P < 0.001). The results remained significant in analyses restricted to controlled trials. CONCLUSIONS Use of ultrapure dialysate in hemodialysis patients results in a decrease in markers of inflammation and oxidative stress, an increase in serum albumin and hemoglobin and a decrease in erythropoietin requirement. Although improvement in these surrogate endpoints might confer a cardiovascular benefit, a large trial with hard clinical endpoints is required.
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Affiliation(s)
- Paweena Susantitaphong
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St Elizabeth's Medical Center, Boston, MA, USA
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Gong D, Ji D, Zhang K, Huang X, Huang G, Xu B, Liu Z. Endotoxemia after high cutoff hemodialysis for treatment of patient with multiple myeloma can be prevented by using ultrapure dialysate: a case report. Hemodial Int 2012; 17:618-23. [PMID: 23113894 DOI: 10.1111/j.1542-4758.2012.00757.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To report endotoxemia presented in a case with multiple myeloma (MM) treated by high cutoff hemodialysis (HCO-HD) being prevented by using ultrapure dialysate. A female inpatient with MM received six times HCO-HD (HCO 2100 dialyzer) within 3 weeks after initiation of a chemotherapy based on vincristine+epirubicin+dexamethasone protocol. Conventional dialysate was used in the first three times and then changed to ultrapure dialysate due to elevation of body temperature after HCO-HD. Free light chains (FLC) and endotoxin levels in blood and dialysate were monitored. After six times HCO-HD, her serum FLC λ decreased from 4689 mg/L to 492.7 mg/L, with a trend of decline of serum creatinine. The clearance, reduction ratio, and removal amount of FLC λ was 38.4 mL/min, 71.0-85.2%, and 9.06-18.02 g, respectively, in the setting of dialysate flow rate 500 mL/min, while in the setting of dialysate flow rate 200 mL/min, the removal efficacy of FLC λ was lower than the former. A rise of body temperature up to 38.5°C after treatment and endotoxemia (endotoxin levels 0.122 EU/mL) was found when using conventional dialysate (endotoxin levels 0.112-0.145 EU/mL), but not seen after changing to ultrapure dialysate. Combined with appropriate chemotherapy, HCO-HD can effectively remove and reduce blood FLC. Attention should be paid to the endotoxemia and the rise of temperature after treatment when conventional dialysate is used, which can be prevented by using ultrapure dialysate.
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Affiliation(s)
- Dehua Gong
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Praditpornsilpa K, Tiranathanagul K, Susantitaphong P, Katavetin P, Trakarnvanich T, Townamchai N, Kanjanabuch T, Avihingsanon Y, Tungsanga K, Eiam-Ong S. Effects of Different Levels of Endotoxin Contamination on Inflammatory Cytokine Production by Peripheral Blood Mononuclear Cells after High-Flux Hemodialysis. Blood Purif 2011; 32:112-6. [DOI: 10.1159/000324394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 01/14/2011] [Indexed: 11/19/2022]
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Fleming GM. Renal replacement therapy review: past, present and future. Organogenesis 2011; 7:2-12. [PMID: 21289478 PMCID: PMC3082028 DOI: 10.4161/org.7.1.13997] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 10/21/2010] [Indexed: 11/19/2022] Open
Abstract
Support of renal function in modern times encompasses a wide array of methods and clinical scenarios, from the ambulatory patient to the critically ill. The ability to safely and routinely deliver ongoing organ support in the outpatient setting has until recently separated renal replacement therapy from other organ support. Renal replacement therapy (RRT) can be applied intermittently or continuously using extracorporeal (hemodialysis) or paracorporeal (peritoneal dialysis) methods. The purpose of this article is to familiarize the reader with the history, physiology, mode, dose, equipment and future of renal replacement therapy and not to detail the technical methods employed for blood purification.
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Affiliation(s)
- Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.
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Tsubakihara Y, Nishi S, Akiba T, Hirakata H, Iseki K, Kubota M, Kuriyama S, Komatsu Y, Suzuki M, Nakai S, Hattori M, Babazono T, Hiramatsu M, Yamamoto H, Bessho M, Akizawa T. 2008 Japanese Society for Dialysis Therapy: guidelines for renal anemia in chronic kidney disease. Ther Apher Dial 2010; 14:240-75. [PMID: 20609178 DOI: 10.1111/j.1744-9987.2010.00836.x] [Citation(s) in RCA: 183] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The Japanese Society for Dialysis Therapy (JSDT) guideline committee, chaired by Dr Y. Tsubakihara, presents the Japanese guidelines entitled "Guidelines for Renal Anemia in Chronic Kidney Disease." These guidelines replace the "2004 JSDT Guidelines for Renal Anemia in Chronic Hemodialysis Patients," and contain new, additional guidelines for peritoneal dialysis (PD), non-dialysis (ND), and pediatric chronic kidney disease (CKD) patients. Chapter 1 presents reference values for diagnosing anemia that are based on the most recent epidemiological data from the general Japanese population. In both men and women, hemoglobin (Hb) levels decrease along with an increase in age and the level for diagnosing anemia has been set at <13.5 g/dL in males and <11.5 g/dL in females. However, the guidelines explicitly state that the target Hb level in erythropoiesis stimulating agent (ESA) therapy is different to the anemia reference level. In addition, in defining renal anemia, the guidelines emphasize that the reduced production of erythropoietin (EPO) that is associated with renal disorders is the primary cause of renal anemia, and that renal anemia refers to a condition in which there is no increased production of EPO and serum EPO levels remain within the reference range for healthy individuals without anemia, irrespective of the glomerular filtration rate (GFR). In other words, renal anemia is clearly identified as an "endocrine disease." It is believed that defining renal anemia in this way will be extremely beneficial for ND patients exhibiting renal anemia despite having a high GFR. We have also emphasized that renal anemia may be treated not only with ESA therapy but also with appropriate iron supplementation and the improvement of anemia associated with chronic disease, which is associated with inflammation, and inadequate dialysis, another major cause of renal anemia. In Chapter 2, which discusses the target Hb levels in ESA therapy, the guidelines establish different target levels for hemodialysis (HD) patients than for PD and ND patients, for two reasons: (i) In Japanese HD patients, Hb levels following hemodialysis rise considerably above their previous levels because of ultrafiltration-induced hemoconcentration; and (ii) as noted in the 2004 guidelines, although 10 to 11 g/dL was optimal for long-term prognosis if the Hb level prior to the hemodialysis session in an HD patient had been established at the target level, it has been reported that, based on data accumulated on Japanese PD and ND patients, in patients without serious cardiovascular disease, higher levels have a cardiac or renal function protective effect, without any safety issues. Accordingly, the guidelines establish a target Hb level in PD and ND patients of 11 g/dL or more, and recommend 13 g/dL as the criterion for dose reduction/withdrawal. However, with the results of, for example, the CHOIR (Correction of Hemoglobin and Outcomes in Renal Insufficiency) study in mind, the guidelines establish an upper limit of 12 g/dL for patients with serious cardiovascular disease or patients for whom the attending physician determines high Hb levels would not be appropriate. Chapter 3 discusses the criteria for iron supplementation. The guidelines establish reference levels for iron supplementation in Japan that are lower than those established in the Western guidelines. This is because of concerns about long-term toxicity if the results of short-term studies conducted by Western manufacturers, in which an ESA cost-savings effect has been positioned as a primary endpoint, are too readily accepted. In other words, if the serum ferritin is <100 ng/mL and the transferrin saturation rate (TSAT) is <20%, then the criteria for iron supplementation will be met; if only one of these criteria is met, then iron supplementation should be considered unnecessary. Although there is a dearth of supporting evidence for these criteria, there are patients that have been surviving on hemodialysis in Japan for more than 40 years, and since there are approximately 20 000 patients who have been receiving hemodialysis for more than 20 years, which is a situation that is different from that in many other countries. As there are concerns about adverse reactions due to the overuse of iron preparations as well, we therefore adopted the expert opinion that evidence obtained from studies in which an ESA cost-savings effect had been positioned as the primary endpoint should not be accepted unquestioningly. In Chapter 4, which discusses ESA dosing regimens, and Chapter 5, which discusses poor response to ESAs, we gave priority to the usual doses that are listed in the package inserts of the ESAs that can be used in Japan. However, if the maximum dose of darbepoetin alfa that can currently be used in HD and PD patients were to be used, then the majority of poor responders would be rescued. Blood transfusions are discussed in Chapter 6. Blood transfusions are attributed to the difficulty of managing renal anemia not only in HD patients, but also in end-stage ND patients who respond poorly to ESAs. It is believed that the number of patients requiring transfusions could be reduced further if there were novel long-acting ESAs that could be used for ND patients. Chapter 7 discusses adverse reactions to ESA therapy. Of particular concern is the emergence and exacerbation of hypertension associated with rapid hematopoiesis due to ESA therapy. The treatment of renal anemia in pediatric CKD patients is discussed in Chapter 8; it is fundamentally the same as that in adults.
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Affiliation(s)
- Yoshiharu Tsubakihara
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan.
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Masakane I. High-quality dialysis: a lesson from the Japanese experience: Effects of membrane material on nutritional status and dialysis-related symptoms. NDT Plus 2010; 3:i28-i35. [PMID: 27046011 PMCID: PMC4813821 DOI: 10.1093/ndtplus/sfq034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
High-quality dialysis does not always mean high efficiency; dialysis should maintain nutritional balance and full biocompatibility. In undergoing treatment with polymethylmethacrylate (PMMA) and/or ethylene vinyl alcohol copolymer (EVAL) membrane dialysers, the body weight decrease caused by polysulfone membrane has been dramatically improved for those receiving predilution online haemodiafiltration (HDF) as well. These membranes are assumed to somewhat suppress the clearance of small molecular weight substances to maintain an exquisite balance of broadly removing low molecular weight proteins. This removal process is assumed to be extremely close to the balance maintained by the clearing characteristics of the kidneys. On the other hand, fluid purification is also one of the important factors in high-quality dialysis. Bacteriological contamination of dialysis fluid is one of the serious factors that deteriorate the biocompatibility of dialysis therapy. From this therapeutic concept, the patient survival rate is excellent in our facilities: the 1-year survival rate is 91.1% and the 5-year survival rate is 76.6%, although the mean age of our patients is 69 years. We usually adjust the therapeutic modality based on patient complaints, and we call this concept ‘patient-oriented dialysis’ (POD). In the POD system, the prevalence of uraemic pruritus or sleep disturbances was lower than that of the DOPPS. The protein-leaking dialysis modalities with PMMA, EVAL or predilution online HDF form the key concept in the POD system.
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Ledebo I, Blankestijn PJ. Haemodiafiltration-optimal efficiency and safety. NDT Plus 2009; 3:8-16. [PMID: 20090878 PMCID: PMC2808132 DOI: 10.1093/ndtplus/sfp149] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 09/25/2009] [Indexed: 11/13/2022] Open
Abstract
Haemodiafiltration (HDF) is the blood purification therapy of choice for those who want significant removal of uraemic solutes beyond the traditional range of small molecules. Combining diffusive and convective solute transport, a HDF treatment comprises the largest number of variables among blood purification therapies, and it is important to understand how they interact in order to optimize the therapy. This review discusses the parameters that determine the efficiency of HDF and how they can be controlled in the different forms of HDF and ‘HDF-like’ therapies practised today. The key to safe and effective HDF therapy is to have access to large volumes of high-quality fluids. Starting with ultrapure dialysis fluid, on-line preparation of a sterile, non-pyrogenic substitution solution can be made an integral part of the treatment, and we describe the necessary conditions for this. On-line HDF can provide the largest removal of the widest range of solutes among available dialysis therapies, and the potential clinical benefits of this are within practical reach for the increasing number of patients dialysed with high-flux membranes and ultrapure dialysis fluid.
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Changing paradigms of renal replacement therapy in chronic kidney disease patients: ultrapure dialysis fluid and high-efficiency hemodiafiltration for all? Kidney Int 2009; 76:591-3. [DOI: 10.1038/ki.2009.249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Masakane I, Tsubakihara Y, Akiba T, Watanabe Y, Iseki K. Bacteriological Qualities of Dialysis Fluid in Japan as of 31 December 2006. Ther Apher Dial 2008; 12:457-63. [DOI: 10.1111/j.1744-9987.2008.00635.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
In hemodialysis, huge amounts of water are used for diluting the concentrates to produce dialysis fluid. The water is produced on site by reverse osmosis units. The chemical and microbiological quality of the water is essential for dialysis patients. Reverse osmosis units produce water of acceptable chemical quality that can be kept throughout the water system. The microbiological water quality, on the other hand, does not depend on the reverse osmosis unit but on the maintenance of the whole water system. All over the world, dialysis units take water samples and send them to laboratories for cultivation and endotoxin tests. Depending on the method of microbiological analysis, the water may be judged to be very good even if in reality it is much worse and outside of standard recommendations. When standardizing the methods with adequate cultivation of water samples, the accuracy of the tests will be better, and as a result, dialysis units can use their resources for keeping the water systems in good shape, i.e. disinfect preventively and frequently and use less effort in collecting samples. This will benefit patients, who will receive a high-quality dialysis fluid, thus eliminating the effects of microbiological impacts such as increased levels of inflammation markers (e.g. C-reactive protein). In the situation of performing hemodiafiltration by producing the substitution fluid "on-line", it is even more important to have a sensitive method of microbiological verification to follow-up the hygienic quality.
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Affiliation(s)
- Rolf Nystrand
- Bio-TeQ Nystrand Consulting, gullbackengatan, Malmö, Sweden.
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Hoenich N, Thijssen S, Kitzler T, Levin R, Ronco C. Impact of water quality and dialysis fluid composition on dialysis practice. Blood Purif 2008; 26:6-11. [PMID: 18182788 DOI: 10.1159/000110556] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
An essential but frequently neglected aspect of dialysis treatment is the dialysis fluid produced by blending treated tap water with concentrated solutions containing electrolytes and buffer. Chemical and microbiological contaminants as well as the electrolyte and buffer composition of the dialysis fluid play major roles in the induction or modulation of morbidity associated with regular dialysis therapy.
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Affiliation(s)
- Nicholas Hoenich
- School of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
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