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Stuard S, Ridel C, Cioffi M, Trost-Rupnik A, Gurevich K, Bojic M, Karibayev Y, Mohebbi N, Marcinkowski W, Kupres V, Maslovaric J, Antebi A, Ponce P, Nada M, Salvador MEB, Rosenberger J, Jirka T, Enden K, Novakivskyy V, Voiculescu D, Pachmann M, Arkossy O. Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance. J Clin Med 2024; 13:3211. [PMID: 38892922 PMCID: PMC11173331 DOI: 10.3390/jcm13113211] [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: 04/13/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.
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Affiliation(s)
- Stefano Stuard
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | | | | | | | | | - Marija Bojic
- FME Global Medical Office, 75400 Zvornik, Bosnia and Herzegovina;
| | | | | | | | | | | | - Alon Antebi
- FME Global Medical Office, Ra’anana 4366411, Israel;
| | - Pedro Ponce
- FME Global Medical Office, 1750-233 Lisboa, Portugal;
| | - Mamdouh Nada
- FME Global Medical Office, Riyadh 12472, Saudi Arabia;
| | | | | | - Tomas Jirka
- FME Global Medical Office, 16000 Praha, Czech Republic;
| | - Kira Enden
- FME Global Medical Office, 00380 Helsinki, Finland;
| | | | | | - Martin Pachmann
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | - Otto Arkossy
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
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Al-Azzam N, Khassawneh B, Al-Azzam S, Karasneh RA, Aldeyab MA. Acid-base imbalance as a risk factor for mortality among COVID-19 hospitalized patients. Biosci Rep 2023; 43:232681. [PMID: 36876487 PMCID: PMC10037419 DOI: 10.1042/bsr20222362] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Severe coronavirus disease 2019 (COVID-19) infection can lead to extensive lung infiltrate, a significant increase in the respiratory rate, and respiratory failure, which can affect the acid-base balance. No research in the Middle East has previously examined acid-base imbalance in COVID-19 patients. The present study aimed to describe the acid-base imbalance in hospitalized COVID-19 patients, determine its causes, and assess its impact on mortality in a Jordanian hospital. The study divided patients into 11 groups based on arterial blood gas data. Patients in normal group were defined as having a pH of 7.35-7.45, PaCO2 of 35-45 mmHg, and HCO3- of 21-27 mEq/L. Other patients were divided into 10 additional groups: mixed acidosis and alkalosis, respiratory and metabolic acidosis with or without compensation, and respiratory and metabolic alkalosis with or without compensation. This is the first study to categorize patients in this way. The results showed that acid-base imbalance was a significant risk factor for mortality (P<0.0001). Mixed acidosis nearly quadruples the risk of death when compared with those with normal levels (OR = 3.61, P=0.05). Furthermore, the risk of death was twice as high (OR = 2) for metabolic acidosis with respiratory compensation (P=0.002), respiratory alkalosis with metabolic compensation (P=0.002), or respiratory acidosis with no compensation (P=0.002). In conclusion, acid-base abnormalities, particularly mixed metabolic and respiratory acidosis, were associated with increased mortality in hospitalized COVID-19 patients. Clinicians should be aware of the significance of these abnormalities and address their underlying causes.
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Affiliation(s)
- Nosayba Al-Azzam
- Department of Physiology and Biochemistry, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Basheer Khassawneh
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sayer Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Reema A Karasneh
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Mamoon A Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, U.K
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Moghari L, Taghizadeh M, Soleimani A, Akbari H, Sharifi N. Dietary Acid Load and Predialysis Serum Bicarbonate Levels in Patients With End-Stage Renal Disease. J Ren Nutr 2023; 33:172-180. [PMID: 35597317 DOI: 10.1053/j.jrn.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 03/08/2022] [Accepted: 05/01/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Maintaining the predialysis serum bicarbonate at a recommended level is critical in patients undergoing hemodialysis. Therefore, the present study investigated the association between dietary acid load (DAL) and serum predialysis bicarbonate levels in patients with end-stage renal disease. METHODS Adult patients undergoing hemodialysis were enrolled in this cross-sectional study. Diet was assessed using a semiquantitative food frequency questionnaire. DAL was calculated with 2 validated indices: potential renal acid load (PRAL) and net endogenous acid production (NEAP). Values regarding predialysis serum bicarbonate level and serum electrolytes were obtained from the participant's medical records. The multiple linear regression analysis was used to determine the association between DAL indices and predialysis serum bicarbonate level. RESULTS The number of hemodialysis patients eligible for this study was 122. The participants' mean age and body mass index was 57.14 ± 3.8 years and 25.2 ± 4.9 kg/m2, respectively. About 65.6% of participants were male. The mean serum levels of predialysis bicarbonate were 21.59 ± 3.1 mEq/L. Also, 47.5% of patients had predialysis serum bicarbonate levels below the recommended value. The mean values of PRAL and NEAP were -2.8 ± 7.48 and 42.7 ± 10.1 mEq/day, respectively. PRAL significantly and inversely predicted predialysis serum bicarbonate level independent of covariates (standardized β = -0.38; P < .001). Also, NEAP was independently and inversely associated with predialysis bicarbonate level (standardized β = -0.40; P < .001). Consuming vegetables such as lettuce, tomato, cucumber, spinach, and dried fruits as well as low-fat milk, plain yogurt, and cream cheese were positively correlated to predialysis serum bicarbonate level. However, the canned tuna had a negative correlation with the predialysis serum bicarbonate. CONCLUSIONS The study's findings showed that the lower DAL was associated with higher predialysis serum bicarbonate levels in patients with end-stage renal disease. Due to the cross-sectional nature of the present study, prospective cohorts or well-controlled clinical trials are needed to confirm our result.
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Affiliation(s)
- Leila Moghari
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohsen Taghizadeh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran
| | - Alireza Soleimani
- Department of Internal Medicine, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Akbari
- Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Nasrin Sharifi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran.
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Abstract
Introduction Abnormalities in blood bicarbonates (HCO3–) concentration are a common finding in patients with chronic kidney disease, especially at the end-stage renal failure. Initiating of hemodialysis does not completely solve this problem. The recommendations only formulate the target concentration of ≥22 mmol/L before hemodialysis but do not guide how to achieve it. The aim of the study was to assess the acid–base balance in everyday practice, the effect of hemodialysis session and possible correlations with clinical and biochemical parameters in stable hemodialysis patients. Material and methods We enrolled 75 stable hemodialysis patients (mean age 65.5 years, 34 women), from a single Department of Nephrology. We assessed blood pressure, and acid–base balance parameters before and after mid-week hemodialysis session. Results We found significant differences in pH, HCO3– pCO2, lactate before and after HD session in whole group (p < 0.001; p < 0.001; p < 0.001; p = 0.001, respectively). Buffer bicarbonate concentration had only statistically significant effect on the bicarbonate concentration after dialysis (p < 0.001). Both pre-HD acid–base parameters and post-HD pH were independent from buffer bicarbonate content. We observed significant inverse correlations between change in the serum bicarbonates and only two parameters: pH and HCO3– before hemodialysis (p = 0.013; p < 0.001, respectively). Conclusions Despite the improvement in hemodialysis techniques, acid–base balance still remains a challenge. The individual selection of bicarbonate in bath, based on previous single tests, does not improve permanently the acid–base balance in the population of hemodialysis patients. New guidelines how to correct acid–base disorders in hemodialysis patients are needed to have less ‘acidotic’ patients before hemodialysis and less ‘alkalotic’ patients after the session.
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Affiliation(s)
- Monika Wieliczko
- Department of Nephrology, Dialysis and Internal Disease, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Disease, Medical University of Warsaw, Warsaw, Poland
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6
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Vanderlinden JA, Holden RM, Scott SH, Boyd JG. Cerebral Perfusion in Hemodialysis Patients: A Feasibility Study. Can J Kidney Health Dis 2021; 8:20543581211010654. [PMID: 34017595 PMCID: PMC8114747 DOI: 10.1177/20543581211010654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/21/2021] [Indexed: 11/15/2022] Open
Abstract
Background Patients on hemodialysis (HD) are known to exhibit low values of regional cerebral oxygenation (rSO2) and impaired cognitive functioning. The etiology of both is currently unknown. Objective To determine the feasibility of serially monitoring rSO2 in patients initiating HD. In addition, we sought to investigate how rSO2 is related to hemodynamic and dialysis parameters. Design Prospective observational study. Setting Single-center tertiary academic teaching hospital in Ontario, Canada. Participants Six patients initiating HD were enrolled in the study. Methods Feasibility was defined as successful study enrollment (>1 patient/month), successful consent rate (>70%), high data capture rates (>90%), and assessment tolerability. Regional cerebral oxygenation monitoring was performed 1 time/wk for the first year of dialysis. A neuropsychological battery was performed 3 times during the study: before dialysis initiation, 3 months, and 1 year after dialysis initiation. The neuropsychological battery included a traditional screening tool: the Repeatable Battery for the Assessment of Neuropsychological Status, and a robot-based assessment: Kinarm. Results Our overall consent rate was 33%, and our enrollment rate was 0.4 patients/mo. In total 243 rSO2 sessions were recorded, with a data capture rate of 91.4% (222/243) across the 6 patients. Throughout the study, no adverse interactions were reported. Correlations between rSO2 with hemodynamic and dialysis parameters showed individual patient variability. However, at the individual level, all patients demonstrated positive correlations between mean arterial pressure and rSO2. Patients who had more than 3 liters of fluid showed significant negative correlations with rSO2. Less cognitive impairment was detected after initiating dialysis. Limitation This small cohort limits conclusions that can be made between rSO2 and hemodynamic and dialysis parameters. Conclusions Prospectively monitoring rSO2 in patients was unfeasible in a single dialysis unit, due to low consent and enrollment rates. However, rSO2 monitoring may provide unique insights into the effects of HD on cerebral oxygenation that should be further investigated. Trial Registration Due to the feasibility nature of this study, no trial registration was performed.
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Affiliation(s)
| | - Rachel Mary Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Stephen Harold Scott
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - John Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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Sprick JD, Nocera JR, Hajjar I, O'Neill WC, Bailey J, Park J. Cerebral blood flow regulation in end-stage kidney disease. Am J Physiol Renal Physiol 2020; 319:F782-F791. [PMID: 32985235 DOI: 10.1152/ajprenal.00438.2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) experience an increased risk of cerebrovascular disease and cognitive dysfunction. Hemodialysis (HD), a major modality of renal replacement therapy in ESKD, can cause rapid changes in blood pressure, osmolality, and acid-base balance that collectively present a unique stress to the cerebral vasculature. This review presents an update regarding cerebral blood flow (CBF) regulation in CKD and ESKD and how the maintenance of cerebral oxygenation may be compromised during HD. Patients with ESKD exhibit decreased cerebral oxygen delivery due to anemia, despite cerebral hyperperfusion at rest. Cerebral oxygenation further declines during HD due to reductions in CBF, and this may induce cerebral ischemia or "stunning." Intradialytic reductions in CBF are driven by decreases in cerebral perfusion pressure that may be partially opposed by bicarbonate shifts during dialysis. Intradialytic reductions in CBF have been related to several variables that are routinely measured in clinical practice including ultrafiltration rate and blood pressure. However, the role of compensatory cerebrovascular regulatory mechanisms during HD remains relatively unexplored. In particular, cerebral autoregulation can oppose reductions in CBF driven by reductions in systemic blood pressure, while cerebrovascular reactivity to CO2 may attenuate intradialytic reductions in CBF through promoting cerebral vasodilation. However, whether these mechanisms are effective in ESKD and during HD remain relatively unexplored. Important areas for future work include investigating potential alterations in cerebrovascular regulation in CKD and ESKD and how key regulatory mechanisms are engaged and integrated during HD to modulate intradialytic declines in CBF.
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Affiliation(s)
- Justin D Sprick
- Division of Renal Medicine, Department of Medicine, Emory University Department of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Joe R Nocera
- Department of Veterans Affairs Health Care System, Decatur, Georgia.,Center for Visual and Neurocognitive Rehabilitation, Department of Veterans Affairs Health Care System, Decatur, Georgia.,Departments of Neurology and Rehabilitation Medicine, Emory University Department of Medicine, Atlanta, Georgia
| | - Ihab Hajjar
- Department of Neurology, Emory University Department of Medicine, Atlanta, Georgia
| | - W Charles O'Neill
- Division of Renal Medicine, Department of Medicine, Emory University Department of Medicine, Atlanta, Georgia
| | - James Bailey
- Division of Renal Medicine, Department of Medicine, Emory University Department of Medicine, Atlanta, Georgia
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University Department of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia.,Center for Visual and Neurocognitive Rehabilitation, Department of Veterans Affairs Health Care System, Decatur, Georgia
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8
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Coşkun Yavuz Y, Altun E, Sevinc C, Guney I, Korez MK, Biyik Z, Altintepe L. Does altitude affect blood gases in hemodialysis patients? Hemodial Int 2020; 24:323-329. [PMID: 32537882 DOI: 10.1111/hdi.12844] [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: 02/03/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION This study aimed to determine whether predialysis blood gases is affected by altitude differences in hemodialysis patients with arteriovenous fistulas living in Turkey at three different altitudes. METHODS Patients' predialysis blood gases were compared by standardizing both arterial blood gases collections and working methods for patients undergoing hemodialysis using a dialysate with the same properties at altitudes of 30 m (sea level), 1020 m (moderate altitude), and 1951 m (high altitude). FINDINGS Blood gases disorders were detected in 32 (82.1%) high altitude group patients, whereas 49 (74.2%) sea level group patients had no blood gases disorders (P < 0.001). pH values in the high altitude group were significantly lower than those in the other groups, and the pH increased as altitude decreased (P < 0.001). The partial pressure of carbon dioxide (PaCO2 ) values was higher in the sea level group than in the other groups and increased at lower sea levels (P < 0.001). Bicarbonate values were significantly higher in the sea level group than in the other groups and increased at lower sea levels, similar to PaCO2 values (P < 0.001). The partial pressure of oxygen (PaO2 ) values in the high altitude and sea level groups were significantly higher and increased at lower sea levels (P < 0.001). The oxygen saturation (SaO2 ) values were significantly lower in the high altitude group than in the other groups and increased gradually at lower sea levels (P < 0.001). DISCUSSION Predialysis metabolic acidosis was more pronounced in patients undergoing hemodialysis at high altitudes, whereas PaCO2 , PaO2 , and SaO2 values were lower.
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Affiliation(s)
| | - Eda Altun
- Nephrology Depatment, Golcuk Necati Celik State Hospital, Kocaeli, Turkey
| | - Can Sevinc
- Nephrology Department, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Ibrahim Guney
- Nephrology Department, Konya Training and Research Hospital, Health Sciences University, Konya, Turkey
| | - Muslu Kazim Korez
- Statistics Department, Faculty of Science, Selcuk University, Konya, Turkey
| | - Zeynep Biyik
- Nephrology Department, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Lutfullah Altintepe
- Nephrology Department, Faculty of Medicine, Selcuk University, Konya, Turkey
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9
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Durkalec-Michalski K, Nowaczyk PM, Adrian J, Kamińska J, Podgórski T. The influence of progressive-chronic and acute sodium bicarbonate supplementation on anaerobic power and specific performance in team sports: a randomized, double-blind, placebo-controlled crossover study. Nutr Metab (Lond) 2020; 17:38. [PMID: 32489393 PMCID: PMC7245907 DOI: 10.1186/s12986-020-00457-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background The aims of this study were to verify the effect of progressive-chronic and acute sodium bicarbonate (SB) supplementation on the anaerobic capacity, blood acid-base balance, and discipline-specific performance in team sports disciplines. Methods Twenty-four trained male field hockey players completed a randomized, placebo-controlled, crossover trial of either progressive-chronic (increments from 0.05 up to 0.2 g/kg) or an acute one-off dose (0.2 g/kg) supplementation protocol. Before and after treatments, athletes completed an exercise protocol that comprised of a discipline-specific field performance test conducted between two separate Wingate anaerobic tests (WAnTs). Results Progressive-chronic SB supplementation improved anaerobic capacity in the first bout of WAnTs, as observed based on an increase in mean power (MP: 575 ± 71 vs. 602 ± 67 W, p = 0.005, ~ + 4.7%), peak power (PP: 749 ± 94 vs. 777 ± 96 W, p = 0.002, ~ + 3.7%), power carry threshold (PCT) at 97%PP (727 ± 91 vs. 753 ± 93 W, p = 0.002, ~ + 3.6%) and average power over PCT (739 ± 94 vs. 765 ± 95 W, p = 0.001, ~ + 3.5%). Acute SB supplementation had no effect on anaerobic capacity. However, an improvement in time during discipline-specific field performance test was observed after progressive-chronic (919 ± 42 vs. 912 ± 27 s, p = 0.05; ~ - 0.8%) and acute (939 ± 26 vs. 914 ± 22 s, p = 0.006, ~ 2.7%) SB supplementation. Acute SB supplementation also improved post-exercise parameters of acid-base balance (based on blood pH, bicarbonate concentration and base excess) compared to no supplementation or placebo. Conclusions Our study indicates that both chronic and acute SB supplementation positively supports discipline-specific performance among field hockey athletes. Moreover, the chronic protocol supported anaerobic power indices before the inset of exercise-induced fatigue but had no significant impact afterwards. However, only the acute protocol significantly affected the buffering capacity, which can be used to determine athlete's performance during high-intensity sporting events. This study design therefore highlighted that future studies focusing on sodium bicarbonate supplementation in team sports should concentrate on the efficiency of chronic and acute supplementation in varying time frames.
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Affiliation(s)
- Krzysztof Durkalec-Michalski
- Institute of Human Nutrition and Dietetics, Poznań University of Life Sciences, Wojska Polskiego 31, 60-624 Poznań, Poland.,Department of Food and Nutrition, Poznań University of Physical Education, Królowej Jadwigi 27/39, 61-871 Poznań, Poland
| | - Paulina M Nowaczyk
- Institute of Human Nutrition and Dietetics, Poznań University of Life Sciences, Wojska Polskiego 31, 60-624 Poznań, Poland
| | - Jacek Adrian
- Department of Theory and Methodology of Team Sport Games, Poznań University of Physical Education, Królowej Jadwigi 27/39, 61-871 Poznań, Poland
| | - Joanna Kamińska
- Department od Physiology and Biochemistry, Poznań University of Physical Education, Królowej Jadwigi 27/39, 61-871 Poznań, Poland
| | - Tomasz Podgórski
- Department od Physiology and Biochemistry, Poznań University of Physical Education, Królowej Jadwigi 27/39, 61-871 Poznań, Poland
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Palmer BF. Potassium Binders for Hyperkalemia in Chronic Kidney Disease-Diet, Renin-Angiotensin-Aldosterone System Inhibitor Therapy, and Hemodialysis. Mayo Clin Proc 2020; 95:339-354. [PMID: 31668450 DOI: 10.1016/j.mayocp.2019.05.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
Hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD). The management of CKD requires balancing the benefits of specific treatments, which may exacerbate the potential for hyperkalemia, with the risks of hyperkalemia itself. Renin-angiotensin-aldosterone system (RAAS) inhibitors, which slow CKD progression and improve cardiovascular outcomes, are often discontinued if hyperkalemia develops. Patients with hyperkalemia are frequently advised to restrict dietary potassium (K+), depriving these patients of many heart-healthy foods. Patients receiving hemodialysis are particularly susceptible to hyperkalemia during long interdialytic intervals, and managing this risk without causing hypokalemia can be challenging. Recently, 2 K+-binding agents were approved for the treatment of hyperkalemia: sodium zirconium cyclosilicate and patiromer. These agents offer alternatives to sodium polystyrene sulfonate, which is associated with serious gastrointestinal adverse effects. For this review, PubMed was searched for English-language articles published in 2014-2018 using the terms patiromer, sodium zirconium cyclosilicate, sodium polystyrene sulfonate, hyperkalemia, renin-angiotensin-aldosterone, diet, and dialysis. In randomized controlled studies of patients with hyperkalemia, sodium zirconium cyclosilicate and patiromer effectively reduced serum K+ and were generally well tolerated. Furthermore, patients in these studies could maintain RAAS inhibitor therapy and, in some studies, were not required to limit dietary K+. There may also be a role for these agents in preventing hyperkalemia in patients receiving hemodialysis. Thus, K+-binding agents may allow patients with CKD at risk for hyperkalemia to optimize RAAS inhibitor therapy, receive benefits of a K+-rich diet, and experience improved hemodialysis outcomes. Additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
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11
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Polinder-Bos HA, Elting JWJ, Aries MJ, García DV, Willemsen AT, van Laar PJ, Kuipers J, Krijnen WP, Slart RH, Luurtsema G, Westerhuis R, Gansevoort RT, Gaillard CA, Franssen CF. Changes in cerebral oxygenation and cerebral blood flow during hemodialysis - A simultaneous near-infrared spectroscopy and positron emission tomography study. J Cereb Blood Flow Metab 2020; 40:328-340. [PMID: 30540219 PMCID: PMC7370620 DOI: 10.1177/0271678x18818652] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Near-infrared spectroscopy (NIRS) is used to monitor cerebral tissue oxygenation (rSO2) depending on cerebral blood flow (CBF), cerebral blood volume and blood oxygen content. We explored whether NIRS might be a more easy applicable proxy to [15O]H2O positron emission tomography (PET) for detecting CBF changes during hemodialysis. Furthermore, we compared potential determinants of rSO2 and CBF. In 12 patients aged ≥ 65 years, NIRS and PET were performed simultaneously: before (T1), early after start (T2), and at the end of hemodialysis (T3). Between T1 and T3, the relative change in frontal rSO2 (ΔrSO2) was -8 ± 9% (P = 0.001) and -5 ± 11% (P = 0.08), whereas the relative change in frontal gray matter CBF (ΔCBF) was -11 ± 18% (P = 0.009) and -12 ± 16% (P = 0.007) for the left and right hemisphere, respectively. ΔrSO2 and ΔCBF were weakly correlated for the left (ρ 0.31, P = 0.4), and moderately correlated for the right (ρ 0.69, P = 0.03) hemisphere. The Bland-Altman plot suggested underestimation of ΔCBF by NIRS. Divergent associations of pH, pCO2 and arterial oxygen content with rSO2 were found compared to corresponding associations with CBF. In conclusion, NIRS could be a proxy to PET to detect intradialytic CBF changes, although NIRS and PET capture different physiological parameters of the brain.
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Affiliation(s)
- Harmke A Polinder-Bos
- Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Willem J Elting
- Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marcel Jh Aries
- Department of Intensive Care, University of Maastricht, University Medical Center Maastricht, Maastricht, The Netherlands
| | - David Vállez García
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Antoon Tm Willemsen
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J van Laar
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Wim P Krijnen
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands.,Johann Bernoulli Institute for Mathematics and Computer Science, University of Groningen, Groningen, The Netherlands
| | - Riemer Hja Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Gert Luurtsema
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Ron T Gansevoort
- Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlo Ajm Gaillard
- Division of Internal Medicine and Dermatology, Department of Nephrology, University Medical Center Utrecht, University of Utrecht, The Netherlands
| | - Casper Fm Franssen
- Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Acid-Base Status Disturbances in Patients on Chronic Hemodialysis at High Altitudes. Int J Nephrol 2018; 2018:2872381. [PMID: 30581623 PMCID: PMC6276435 DOI: 10.1155/2018/2872381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022] Open
Abstract
Background Acid-base disorders have been previously described in patients with chronic hemodialysis, with metabolic acidosis being the most important of them; however, little is known about the potential changes in acid-base status of patients on dialysis living at high altitudes. Methods Cross-sectional study including 93 patients receiving chronic hemodialysis on alternate days and living in Bogotá, Colombia, at an elevation of 2,640 meters (8,661 feet) over sea level (m.o.s.l.). Measurements of pH, PaCO2, HCO3, PO2, and base excess were made on blood samples taken from the arteriovenous fistula (AVF) during the pre- and postdialysis periods in the midweek hemodialysis session. Normal values for the altitude of Bogotá were taken into consideration for the interpretation of the arterial blood gases. Results 43% (n= 40) of patients showed predialysis normal acid-base status. The most common acid-base disorder in predialysis period was metabolic alkalosis with chronic hydrogen ion deficiency in 19,3% (n=18). Only 9,7% (n=9) had predialysis metabolic acidosis. When comparing pre- and postdialysis blood gas analysis, higher postdialysis levels of pH (7,41 versus 7,50, p<0,01), bicarbonate (21,7mmol/L versus 25,4mmol/L, p<0,01), and base excess (-2,8 versus 2,4, p<0,01) were reported, with lower levels of partial pressure of carbon dioxide (34,9 mmHg versus 32,5 mmHg, p<0,01). Conclusion At an elevation of 2,640 m.o.s.l., a large percentage of patients are in normal acid-base status prior to the dialysis session (“predialysis period”). Metabolic alkalosis is more common than metabolic acidosis in the predialysis period when compared to previous studies. Paradoxically, despite postdialysis metabolic alkalosis, PaCO2 levels are lower than those found in the predialysis period.
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Murea M, Tucker BM. The physiology of uric acid and the impact of end-stage kidney disease and dialysis. Semin Dial 2018; 32:47-57. [DOI: 10.1111/sdi.12735] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine; Section on Nephrology; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Bryan M. Tucker
- Department of Internal Medicine; Section on Nephrology; Wake Forest School of Medicine; Winston-Salem NC USA
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Basile C, Rossi L, Lomonte C. Dialysate bicarbonate concentration: Too much of a good thing? Semin Dial 2018; 31:576-582. [PMID: 29885083 DOI: 10.1111/sdi.12716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acid-base equilibrium is a complex and vital system whose regulation is impaired in chronic kidney disease (CKD). Metabolic acidosis is a common complication of CKD. It is typically due to the accumulation of sulfate, phosphorus, and organic anions. Metabolic acidosis is correlated with several adverse outcomes, such as morbidity, hospitalization and mortality. In patients undergoing hemodialysis, acid-base homeostasis depends on many factors: net acid production, amount of alkali given by the dialysate bath, duration of interdialytic period, as well as residual diuresis, if any. Recent literature data suggest that the development of postdialysis metabolic alkalosis may contribute to adverse clinical outcomes. Unfortunately, no randomized studies exist about the effect of different dialysate bicarbonate concentrations on hard outcomes, such as mortality. Like everything else in dialysis, the quest for the "ideal" dialysate bicarbonate concentration is far from over. The Latin aphorism "ne quid nimis" ie "nothing in excess" (excess of neither acid nor base) probably best summarizes our current state of knowledge in this field. For the present, the clinician should understand that target values for predialysis serum bicarbonate concentrations have been established primarily based on observational studies and expert opinion. On the basis of this information, we should keep predialysis serum bicarbonate concentrations at least at 22 mEq/L. Furthermore, a specific focus should be addressed to the clinical and nutritional status of the major outliers on both the acid and alkaline sides of the curve.
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Affiliation(s)
- Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
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