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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment. Korean J Intern Med 2022; 37:701-718. [PMID: 35811360 PMCID: PMC9271711 DOI: 10.3904/kjim.2021.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 12/05/2022] Open
Abstract
The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).
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Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan,
Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul,
Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul,
Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul,
Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul,
Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
| | | | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu,
Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul,
Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
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2
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:578-595. [PMID: 34922430 PMCID: PMC8685366 DOI: 10.23876/j.krcp.21.700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/17/2022] Open
Abstract
The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There is also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).
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Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:S1-S37. [PMID: 34923803 PMCID: PMC8694695 DOI: 10.23876/j.krcp.21.600] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Roumeliotis A, Roumeliotis S, Chan C, Pierratos A. Cardiovascular Benefits of Extended-Time Nocturnal Hemodialysis. Curr Vasc Pharmacol 2021; 19:21-33. [PMID: 32234001 DOI: 10.2174/1570161118666200401112106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/09/2023]
Abstract
Hemodialysis (HD) remains the most utilized treatment for End-Stage Kidney Disease (ESKD) globally, mainly as conventional HD administered in 4 h sessions thrice weekly. Despite advances in HD delivery, patients with ESKD carry a heavy cardiovascular morbidity and mortality burden. This is associated with cardiac remodeling, left ventricular hypertrophy (LVH), myocardial stunning, hypertension, decreased heart rate variability, sleep apnea, coronary calcification and endothelial dysfunction. Therefore, intensive HD regimens closer to renal physiology were developed. They include longer, more frequent dialysis or both. Among them, Nocturnal Hemodialysis (NHD), carried out at night while asleep, provides efficient dialysis without excessive interference with daily activities. This regimen is closer to the physiology of the native kidneys. By providing increased clearance of small and middle molecular weight molecules, NHD can ameliorate uremic symptoms, control hyperphosphatemia and improve quality of life by allowing a liberal diet and free time during the day. Lastly, it improves reproductive biology leading to successful pregnancies. Conversion from conventional to NHD is followed by improved blood pressure control with fewer medications, regression of LVH, improved LV function, improved sleep apnea, and stabilization of coronary calcifications. These beneficial effects have been associated, among others, with better extracellular fluid volume control, improved endothelial- dependent vasodilation, decreased total peripheral resistance, decreased plasma norepinephrine levels and restoration of heart rate variability. Some of these effects represent improvements in outcomes used as surrogates of hard outcomes related to cardiovascular morbidity and mortality. In this review, we consider the cardiovascular effects of NHD.
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Affiliation(s)
- Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christopher Chan
- University Health Network, Toronto General Hospital, Toronto, Canada
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5
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Schachter ME, Saunders MJ, Akbari A, Caryk JM, Bugeja A, Clark EG, Tennankore KK, Martinusen DJ. Technique Survival and Determinants of Technique Failure in In-Center Nocturnal Hemodialysis: A Retrospective Observational Study. Can J Kidney Health Dis 2020; 7:2054358120975305. [PMID: 33335741 PMCID: PMC7724416 DOI: 10.1177/2054358120975305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022] Open
Abstract
Background Long-duration (7-8 hours) hemodialysis provides benefits compared with conventional thrice-weekly, 4-hour sessions. Nurse-administered, in-center nocturnal hemodialysis (INHD) may expand the population to whom an intensive dialysis schedule can be offered. Objective The primary objective of this study was to determine predictors of INHD technique failure, disruptions, and technique survival. Design This study used retrospective chart and database review methodology. Setting This study was conducted at a single Canadian INHD program operating in Victoria, British Columbia, within a tertiary care hospital. Our program serves a catchment population of approximately 450 000 people. Patients/Sample/Participants Forty-three consecutive incident INHD patients took part in the INHD program of whom 42 provided informed consent to participate in this study. Methods We conducted a retrospective observational study including incident INHD patients from 2015 to 2017. The primary outcome was technique failure ≤6 months (TF ≤6). Secondary outcomes included technique survival and reasons for/predictors of INHD discontinuation or temporary disruption. Predictors of each outcome included demographics, comorbidities, and Clinical Frailty Scale (CFS) scoring. Results Among 42 patients, mean (SD) age, dialysis vintage, CFS score, and follow-up were 63 (16) years, 46 (55) months, 4 (1), and 11 (9) months, respectively. 52% were aged ≥65 years. TF ≤6 occurred in 12 (29%) patients. One-year technique survival censored for transplants and home dialysis transitions was 60%. Discontinuation related to insomnia (32%), medical status change (27%), and vascular access (23%). In unadjusted Cox survival analysis, 1-point increases in CFS score associated with a higher risk of technique failure (hazard ratio: 2.04, 95% confidence interval [CI]: 1.26-3.31). In an adjusted analysis, higher frailty severity also associated with temporary INHD disruptions (incidence rate ratio: 2.64, 95% CI: 1.55-4.50, comparing CFS of ≥4 to 1-3). Limitations The retrospective, observational design of this study resulted in limited ability to control for confounding factors. In addition, the relatively small number of events observed owing to a small sample size diminished statistical power to inform study conclusions. Use of a single physician to determine the clinical frailty score is another limitation. Finally, the use of a single center for this study limits generalizability to other programs and clinic settings. Conclusions INHD is a sustainable modality, even among older patients. Higher frailty associates with INHD technique failure and greater missed treatments. Inclusion of a CFS threshold of ≤4 into INHD inclusion criteria may help to identify individuals most likely to realize the long-term benefits of INHD. Trial Registration Due to the retrospective and observational design of this study, trial registration was not necessary.
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Affiliation(s)
- Michael E Schachter
- Division of Nephrology, Vancouver Island Health Authority, Victoria, BC, Canada
| | - Marc J Saunders
- Master of Biomedical Technology Program, University of Calgary, AB, Canada
| | - Ayub Akbari
- Division of Nephrology, The Ottawa Hospital and University of Ottawa, ON, Canada
| | - Julia M Caryk
- Division of Nephrology, Vancouver Island Health Authority, Victoria, BC, Canada
| | - Ann Bugeja
- Division of Nephrology, The Ottawa Hospital and University of Ottawa, ON, Canada
| | - Edward G Clark
- Division of Nephrology, The Ottawa Hospital and University of Ottawa, ON, Canada
| | | | - Dan J Martinusen
- Division of Nephrology, Vancouver Island Health Authority, Victoria, BC, Canada
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Balbino KP, Juvanhol LL, Wendling AL, Marota LD, Costa JBS, Bressan J, Hermsdorff HHM. Dietary intake, clinical-nutritional status, and homocysteine in hemodialysis subjects: the mediating role of inflammation (NUGE-HD study). Appl Physiol Nutr Metab 2020; 45:845-850. [PMID: 32680432 DOI: 10.1139/apnm-2019-0800] [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] [Indexed: 12/28/2022]
Abstract
The aim of the present study was to test the hypothesis that inflammation mediates the associations among food intake, clinical-nutritional status, and plasma homocysteine (Hcys) in hemodialysis (HD) subjects. This was a cross-sectional analysis of data on 129 subjects undergoing HD (58.9% male, 61.8 ± 15.5 years of age) from the cohort Nutrition and Genetics on HD outcomes (NUGE-HD study). Sociodemographic, anthropometric, and metabolic data were collected, and food intake was assessed using a quantitative food frequency questionnaire. Plasma C-reactive protein (CRP) was used as an inflammatory marker. Data were analyzed by structural equation modeling. Regarding the direct effects, complex B vitamin intake was negatively associated with body mass index, and diabetes mellitus was positively associated with CRP. Plasma CRP also showed a negative association with Hcys, and the ratio of saturated and polyunsaturated fatty acids intake showed a positive association with Hcys. Regarding indirect effects, the results showed that the relationship between the presence of diabetes mellitus and Hcys is mediated by plasma CRP. In conclusion, the ratio of saturated and polyunsaturated fatty acids had a direct effect on plasma Hcys, whereas inflammation had a direct and mediating effect on the relationship between Hcys and diabetes mellitus in HD subjects. Novelty In end-stage renal disease, CRP influences plasma Hcys directly and also indirectly through its mediating effect. The quantity and quality of dietary fatty acids influence plasma Hcys concentrations in HD subjects.
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Affiliation(s)
- Karla Pereira Balbino
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
| | - Leidjaira Lopes Juvanhol
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
| | - Aline Lage Wendling
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
| | | | | | - Josefina Bressan
- Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, MG 36570-900, Brazil
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7
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Girsberger M, Trinh E, Chan CT. Ventricular ejection fraction over time in patients on intensive home hemodialysis: A retrospective cohort study. Hemodial Int 2020; 24:290-298. [DOI: 10.1111/hdi.12838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Emilie Trinh
- Divison of Nephrology McGill University Health Center Montréal Quebec Canada
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8
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Karur GR, Wald R, Goldstein MB, Wald R, Jimenez-Juan L, Kiaii M, Leipsic J, Kirpalani A, Bello O, Barthur A, Ng MY, Deva DP, Yan AT. Association between conversion to in-center nocturnal hemodialysis and right ventricular remodeling. Nephrol Dial Transplant 2019; 33:1010-1016. [PMID: 28992094 DOI: 10.1093/ndt/gfx232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/07/2017] [Indexed: 11/12/2022] Open
Abstract
Background In-center nocturnal hemodialysis (INHD) is associated with favorable left ventricular (LV) remodeling. Although right ventricular (RV) structure and function carry prognostic significance, the impact of dialysis intensification on RV is unknown. Our objectives were to evaluate changes in RV mass index (MI), end-diastolic volume index (EDVI), end-systolic volume index (ESVI) and ejection fraction (EF) after conversion to INHD and their relationship with LV remodeling. Methods Of 67 conventional hemodialysis (CHD, 4 h/session, three times/week) patients, 30 continued on CHD and 37 converted to INHD (7-8 h/session, three times/week). Cardiac magnetic resonance imaging was performed at baseline and 1 year using a standardized protocol; an experienced and blinded reader performed RV measurements. Results At 1 year there were significant reductions in RVMI {-2.1 g/m2 [95% confidence interval (CI) -3.8 to - 0.4], P = 0.017}, RVEDVI [-9.5 mL/m2 (95% CI - 16.3 to - 2.6), P = 0.008] and RVESVI [-6.2 mL/m2 (95% CI - 10.9 to - 1.6), P = 0.011] in the INHD group; no significant changes were observed in the CHD group. Between-group comparisons showed significantly greater reduction of RVESVI [-7.9 mL/m2 (95% CI - 14.9 to - 0.9), P = 0.03] in the INHD group, a nonsignificant trend toward greater reduction in RVEDVI and no significant difference in RVMI and RVEF changes. There was significant correlation between LV and RV in terms of changes in mass index (MI) (r = 0.46), EDVI (r = 0.73), ESVI (r = 0.7) and EF (r = 0.38) over 1 year (all P < 0.01). Conclusions Conversion to INHD was associated with a significant reduction of RVESVI. Temporal changes in RV mass, volume and function paralleled those of LV. Our findings support the need for larger, longer-term studies to confirm favorable RV remodeling and determine its impact on clinical outcomes.
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Affiliation(s)
- Gauri R Karur
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ron Wald
- Division of Nephrology, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Marc B Goldstein
- Division of Nephrology, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rachel Wald
- University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Jimenez-Juan
- University of Toronto, Toronto, Ontario, Canada.,Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Department of Radiology and Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anish Kirpalani
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Olugbenga Bello
- Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ashita Barthur
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ming-Yen Ng
- University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Djeven P Deva
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- University of Toronto, Toronto, Ontario, Canada.,Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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9
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Ong JP, Wald R, Goldstein MB, Leipsic J, Kiaii M, Deva DP, Kirpalani A, Jimenez‐Juan L, Bello O, Azizi PM, Wald RM, Wright GA, Harel Z, Connelly KA, Yan AT. Left ventricular strain analysis using cardiac magnetic resonance imaging in patients undergoing in‐centre nocturnal haemodialysis. Nephrology (Carlton) 2019; 24:557-563. [DOI: 10.1111/nep.13404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Jann P Ong
- Division of CardiologySt. Michael’s Hospital Toronto Ontario Canada
- University of Toronto Toronto Ontario Canada
| | - Ron Wald
- University of Toronto Toronto Ontario Canada
- Division of NephrologySt Michael’s Hospital, and Li Ka Shing Knowledge Institute of St. Michael’s Hospital Toronto Ontario Canada
| | - Marc B Goldstein
- University of Toronto Toronto Ontario Canada
- Division of NephrologySt Michael’s Hospital, and Li Ka Shing Knowledge Institute of St. Michael’s Hospital Toronto Ontario Canada
| | - Jonathon Leipsic
- Department of Radiology and Division of CardiologySt. Paul’s Hospital, University of British Columbia Vancouver British Columbia Canada
| | - Mercedeh Kiaii
- Division of NephrologySt. Paul’s Hospital, University of British Columbia Vancouver British Columbia Canada
| | - Djeven P Deva
- University of Toronto Toronto Ontario Canada
- Department of Medical ImagingSt. Michael’s Hospital, Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital Toronto Ontario Canada
| | - Anish Kirpalani
- University of Toronto Toronto Ontario Canada
- Department of Medical ImagingSt. Michael’s Hospital, Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital Toronto Ontario Canada
| | - Laura Jimenez‐Juan
- University of Toronto Toronto Ontario Canada
- Department of Medical ImagingSunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Olugbenga Bello
- Division of CardiologySt. Michael’s Hospital Toronto Ontario Canada
| | | | - Rachel M Wald
- University of Toronto Toronto Ontario Canada
- Division of CardiologyToronto General Hospital Toronto Ontario Canada
| | - Graham A Wright
- University of Toronto Toronto Ontario Canada
- Schulich Heart Program and the Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Ziv Harel
- University of Toronto Toronto Ontario Canada
- Division of NephrologySt Michael’s Hospital, and Li Ka Shing Knowledge Institute of St. Michael’s Hospital Toronto Ontario Canada
| | - Kim A Connelly
- Division of CardiologySt. Michael’s Hospital Toronto Ontario Canada
- University of Toronto Toronto Ontario Canada
| | - Andrew T Yan
- Division of CardiologySt. Michael’s Hospital Toronto Ontario Canada
- University of Toronto Toronto Ontario Canada
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10
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Abstract
Conventional hemodialysis is associated with high morbidity and mortality rates, as well as a reduced quality of life. There is a growing interest in the provision of more intensive hemodialysis, due to associated benefits in terms of reduced cardiovascular morbidity, better regulation of mineral metabolism, as well as its impact on quality of life measures, fertility, and sleep. Nocturnal hemodialysis, both in center and at home, allows the delivery of more intensive hemodialysis. This review discusses the benefits of nocturnal hemodialysis and evaluates the evidence based on available literature.
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11
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Gong IY, Al-Amro B, Prasad GVR, Connelly PW, Wald RM, Wald R, Deva DP, Leong-Poi H, Nash MM, Yuan W, Gunaratnam L, Kim SJ, Lok CE, Connelly KA, Yan AT. Cardiovascular magnetic resonance left ventricular strain in end-stage renal disease patients after kidney transplantation. J Cardiovasc Magn Reson 2018; 20:83. [PMID: 30554567 PMCID: PMC6296102 DOI: 10.1186/s12968-018-0504-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/09/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cardiovascular disease is a significant cause of morbidity and mortality in patients with end-stage renal disease (ESRD) and kidney transplant (KT) patients. Compared with left ventricular (LV) ejection fraction (LVEF), LV strain has emerged as an important marker of LV function as it is less load dependent. We sought to evaluate changes in LV strain using cardiovascular magnetic resonance imaging (CMR) in ESRD patients who received KT, to determine whether KT may improve LV function. METHODS We conducted a prospective multi-centre longitudinal study of 79 ESRD patients (40 on dialysis, 39 underwent KT). CMR was performed at baseline and at 12 months after KT. RESULTS Among 79 participants (mean age 55 years; 30% women), KT patients had significant improvement in global circumferential strain (GCS) (p = 0.007) and global radial strain (GRS) (p = 0.003), but a decline in global longitudinal strain (GLS) over 12 months (p = 0.026), while no significant change in any LV strain was observed in the ongoing dialysis group. For KT patients, the improvement in LV strain paralleled improvement in LVEF (57.4 ± 6.4% at baseline, 60.6% ± 6.9% at 12 months; p = 0.001). For entire cohort, over 12 months, change in LVEF was significantly correlated with change in GCS (Spearman's r = - 0.42, p < 0.001), GRS (Spearman's r = 0.64, p < 0.001), and GLS (Spearman's r = - 0.34, p = 0.002). Improvements in GCS and GRS over 12 months were significantly correlated with reductions in LV end-diastolic volume index and LV end-systolic volume index (all p < 0.05), but not with change in blood pressure (all p > 0.10). CONCLUSIONS Compared with continuation of dialysis, KT was associated with significant improvements in LV strain metrics of GCS and GRS after 12 months, which did not correlate with blood pressure change. This supports the notion that KT has favorable effects on LV function beyond volume and blood pessure control. Larger studies with longer follow-up are needed to confirm these findings.
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Affiliation(s)
| | - Bandar Al-Amro
- Terrence Donnelly Heart Centre, St. Michael’s Hospital, Toronto, Canada
| | - G. V. Ramesh Prasad
- University of Toronto, Toronto, Canada
- Division of Nephrology, St Michael’s Hospital, Toronto, ON Canada
| | - Philip W. Connelly
- University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
| | - Rachel M. Wald
- University of Toronto, Toronto, Canada
- Division of Cardiology, Toronto General Hospital, Toronto, Canada
| | - Ron Wald
- University of Toronto, Toronto, Canada
- Division of Nephrology, St Michael’s Hospital, Toronto, ON Canada
| | - Djeven P. Deva
- University of Toronto, Toronto, Canada
- Department of Medical Imaging, St Michael’s Hospital, Toronto, Canada
| | - Howard Leong-Poi
- University of Toronto, Toronto, Canada
- Terrence Donnelly Heart Centre, St. Michael’s Hospital, Toronto, Canada
| | - Michelle M. Nash
- Division of Nephrology, St Michael’s Hospital, Toronto, ON Canada
| | - Weiqiu Yuan
- Division of Nephrology, St Michael’s Hospital, Toronto, ON Canada
| | - Lakshman Gunaratnam
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - S. Joseph Kim
- University of Toronto, Toronto, Canada
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Charmaine E. Lok
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Kim A. Connelly
- University of Toronto, Toronto, Canada
- Terrence Donnelly Heart Centre, St. Michael’s Hospital, Toronto, Canada
| | - Andrew T. Yan
- University of Toronto, Toronto, Canada
- Terrence Donnelly Heart Centre, St. Michael’s Hospital, Toronto, Canada
- Division of Cardiology, St. Michael’s Hospital, 30 Bond Street, Rm 6-030 Donnelly, Toronto, M5B 1W8 Canada
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12
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Prasad GVR, Yan AT, Nash MM, Kim SJ, Wald R, Wald R, Lok C, Gunaratnam L, Karur GR, Kirpalani A, Connelly PW. Determinants of Left Ventricular Characteristics Assessed by Cardiac Magnetic Resonance Imaging and Cardiovascular Biomarkers Related to Kidney Transplantation. Can J Kidney Health Dis 2018; 5:2054358118809974. [PMID: 30542623 PMCID: PMC6236646 DOI: 10.1177/2054358118809974] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/10/2018] [Indexed: 01/03/2023] Open
Abstract
Background: Cardiac magnetic resonance (CMR) imaging accurately and precisely measures
left ventricular (LV) mass and function. Identifying mechanisms by which LV
mass change and functional improvement occur in some end-stage kidney
disease (ESKD) patients may help to appropriately target kidney transplant
(KT) recipients for further investigation and intervention. The
concentration of serum adiponectin, a cardiovascular biomarker, increases in
cardiac failure, its production being enhanced by B-type natriuretic peptide
(BNP), and both serum adiponectin and BNP concentrations decline
posttransplantation. Objective: We tested the hypothesis that kidney transplantation alters LV
characteristics that relate to serum adiponectin concentrations. Design: Prospective and observational cohort study. Setting: The study was performed at 3 adult kidney transplant and dialysis centers in
Ontario, Canada. Patients: A total of 82 KT candidate subjects were recruited (39 to the KT group and 43
to the dialysis group). Predialysis patients were excluded. Measurements: Subjects underwent CMR with a 1.5-tesla whole-body magnetic resonance scanner
using a phased-array cardiac coil and retrospective vectorographic gating.
LV mass, LV ejection fraction (LVEF), LV end-systolic volume (LVESV), and LV
end-diastolic volume (LVEDV) were measured by CMR pre-KT and again 12 months
post-KT (N = 39), or 12 months later if still receiving dialysis (N = 43).
LV mass, LVESV, and LVEDV were indexed for height (m2.7) to
calculate left ventricular mass index (LVMI), left ventricular end-systolic
volume index (LVESVI), and left ventricular end-diastolic volume index
(LVEDVI), respectively. Serum total adiponectin and N-terminal proBNP
(NT-proBNP) concentrations were measured at baseline, 3 months, and 12
months. Methods: We performed a prospective 1:1 observational study comparing KT candidates
with ESKD either receiving a living donor organ (KT group) or waiting for a
deceased donor organ (dialysis group). Results: Left ventricular mass index change was −1.98 ± 5.5 and −0.36 ± 5.7
g/m2.7 for KT versus dialysis subjects (P =
.44). Left ventricular mass change was associated with systolic blood
pressure (SBP) (P = .0008) and average LV mass
(P = .0001). Left ventricular ejection fraction did not
improve (2.9 ± 6.6 vs 0.7 ± 4.9 %, P = .09), while LVESVI
and LVEDVI decreased more post-KT than with continued dialysis (−3.36 ± 5.6
vs −0.22 ± 4.4 mL/m2.7, P < .01 and −4.9 ±
8.5 vs −0.3 ± 9.2 mL/m2.7, P = .02). Both
adiponectin (−7.1 ± 11.3 vs −0.11 ± 7.9 µg/mL, P <
.0001) and NT-proBNP (−3811 ± 8130 vs 1665 ± 20013 pg/mL, P
< .0001) declined post-KT. Post-KT adiponectin correlated with NT-proBNP
(P = .001), but not estimated glomerular filtration
rate (eGFR) (P = .13). Change in adiponectin did not
correlate with change in LVEF in the KT group (Spearman ρ = 0.16,
P = .31) or dialysis group (Spearman ρ = 0.19,
P = .21). Limitations: Few biomarkers of cardiac function were measured to fully contextualize their
role during changing kidney function. Limited intrapatient biomarker
sampling and CMR measurements precluded constructing dose-response curves of
biomarkers to LV mass and function. The CMR timing in relation to dialysis
was not standardized. Conclusions: The LVESVI and LVEDVI but not LVMI or LVEF improve post-KT. LVMI and LVEF
change is independent of renal function and adiponectin. As adiponectin
correlates with NT-proBNP post-KT, improved renal function through KT
restores the normal heart-endocrine axis.
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Affiliation(s)
- G V Ramesh Prasad
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Andrew T Yan
- Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Michelle M Nash
- Renal Transplant Program, St. Michael's Hospital, Toronto, ON, Canada
| | - S Joseph Kim
- Division of Nephrology, Toronto General Hospital, University of Toronto, ON, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Rachel Wald
- Division of Cardiology, Toronto General Hospital, University of Toronto, ON, Canada
| | - Charmaine Lok
- Division of Nephrology, Toronto General Hospital, University of Toronto, ON, Canada
| | - Lakshman Gunaratnam
- Division of Nephrology, London Health Sciences Centre, Western University, ON, Canada
| | - Gauri R Karur
- Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Anish Kirpalani
- Department of Medical Imaging, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Philip W Connelly
- Division of Endocrinology and Metabolism, St. Michael's Hospital, University of Toronto, ON, Canada
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13
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Zupančič T, Ponikvar R, Gubenšek J, Buturović-Ponikvar J. Phosphate Removal During Long Nocturnal Hemodialysis/Hemodiafiltration: A Study With Total Dialysate Collection. Ther Apher Dial 2017; 20:267-71. [PMID: 27312913 DOI: 10.1111/1744-9987.12435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 11/28/2022]
Abstract
The aim of our prospective study was to quantify phosphate removal during long nocturnal high-flux hemodialysis or hemodiafiltration (HD) with total dialysate collection. Eight patients (two women) were studied for the first-in-the-week HD session that lasted 7-8 h. Total dialysate was collected. Serum and collected dialysate phosphate concentrations were measured every hour. Phosphate removal as assessed from the serum concentration was most important during the first 2 h of HD, and then a plateau was reached. The highest average phosphate concentration in the total dialysate was in the 1(st) hour, thereafter the concentration decreased but remained stable. The average total removed mass of phosphate quantified from hourly collected dialysate was 5195.7 ± 1898 mg. Phosphate had been removed in a consistent manner during the whole duration of nocturnal HD as assessed through dialysate (despite stable serum phosphate concentration). This could indicate phosphate transfer from intracellular space. The total removed phosphate quantified from the total dialysate collection was higher than previously reported and exceeded the normal phosphate food intake.
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Affiliation(s)
- Tina Zupančič
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
| | - Rafael Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jakob Gubenšek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
| | - Jadranka Buturović-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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14
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Hutagaol S, Lubis HR, Zein LH, Aman A, Koh SCL, Hariman H. Status of interleukin-6 and hepcidin levels in first-time haemodialysis patients. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2017. [DOI: 10.4103/ejim.ejim_27_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Wong B, Collister D, Muneer M, Storie D, Courtney M, Lloyd A, Campbell S, Pauly RP. In-Center Nocturnal Hemodialysis Versus Conventional Hemodialysis: A Systematic Review of the Evidence. Am J Kidney Dis 2017; 70:218-234. [PMID: 28359656 DOI: 10.1053/j.ajkd.2017.01.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/03/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Owing to its longer treatment duration-up to 8 hours per dialysis treatment-in-center thrice-weekly nocturnal hemodialysis (HD) is receiving greater attention. To better understand the evidence for in-center nocturnal HD, we sought to systematically review the literature to determine the effects of in-center nocturnal HD versus conventional HD on clinically relevant outcomes. STUDY DESIGN We searched MEDLINE, Embase, Evidence-Based Medicine Reviews (EBMR), Web of Science, and Scopus from the earliest date in the database to November 2016. SETTING & POPULATION Adults receiving in-center nocturnal HD compared with those receiving conventional HD. SELECTION CRITERIA FOR STUDIES All quasi-experimental and observational studies were considered; randomized trials were sought but not found. PREDICTOR Nocturnal vs conventional in-center HD. OUTCOMES Indexes of blood pressure and left ventricular hypertrophy, markers of anemia, measures of bone mineral metabolism, nutrition, quality of life, sleep quality, episodes of intradialytic hypotension, hospitalization, and mortality. RESULTS Of 2,086 identified citations, 21 met the inclusion criteria, comprising a total of 1,165 in-center nocturnal HD patients and 15,865 conventional HD patients. Although there was substantial heterogeneity in reporting of outcomes, we pooled data for measures of blood pressure, anemia, and mineral metabolism. Though heterogeneity was generally high, in-center nocturnal HD was associated with improved systolic blood pressure (-3.18 [95% CI, -5.58 to -0.78) mm Hg, increased hemoglobin levels (0.53 [95% CI, 0.11-0.94] g/dL), and lower serum phosphate levels (-0.97 [95% CI, -1.48 to -0.46] mg/dL). LIMITATIONS No randomized trials have been conducted to address the clinical effects of in-center nocturnal HD. The quality of the observational literature contributing to the results of this review was generally poor to moderate. Confounded outcomes are a significant concern. Publication bias and outcome reporting bias remain possibilities. CONCLUSIONS Relative to conventional HD, in-center nocturnal HD was associated with improvements in several clinically relevant outcomes. Other benefits may not have been detected due to small sample sizes of included studies; no prespecified outcome was worse with in-center nocturnal HD.
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Affiliation(s)
- Ben Wong
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada; Headwaters Health Care Centre, Orangeville, ON, Canada.
| | | | - Maliha Muneer
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
| | - Dale Storie
- University of Alberta Libraries, Edmonton, AB, Canada
| | - Mark Courtney
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
| | - Anita Lloyd
- Alberta Kidney Disease Network, Edmonton, AB, Canada
| | | | - Robert P Pauly
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
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16
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Rivara MB, Adams SV, Kuttykrishnan S, Kalantar-Zadeh K, Arah OA, Cheung AK, Katz R, Molnar MZ, Ravel V, Soohoo M, Streja E, Himmelfarb J, Mehrotra R. Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal disease. Kidney Int 2016; 90:1312-1320. [PMID: 27555118 PMCID: PMC5123950 DOI: 10.1016/j.kint.2016.06.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/19/2016] [Accepted: 06/23/2016] [Indexed: 01/16/2023]
Abstract
Extended-hours hemodialysis offers substantially longer treatment time compared to conventional hemodialysis schedules and is associated with improved fluid and electrolyte control and favorable cardiac remodeling. However, whether extended-hours hemodialysis improves survival remains unclear. Therefore, we determined the association between extended-hours compared to conventional hemodialysis and the risk of all-cause mortality in a nationally representative cohort of patients initiating maintenance dialysis in the United States from 2007 to 2011. Survival analyses using causal inference modeling with marginal structural models were performed to compare mortality risk among 1206 individuals undergoing thrice weekly extended-hours hemodialysis or 111,707 patients receiving conventional hemodialysis treatments. The average treatment time per session for extended-hours hemodialysis was 399 minutes compared to 211 minutes for conventional therapy. The crude mortality rate with extended-hours hemodialysis was 6.4 deaths per 100 patient-years compared with 14.7 deaths per 100 patient-years for conventional hemodialysis. In the primary analysis, patients treated with extended-hours hemodialysis had a 33% lower adjusted risk of death compared to those who were treated with a conventional regimen (95% confidence interval: 7% to 51%). Additional analyses accounting for analytical assumptions regarding exposure and outcome, facility-level confounders, and prior modality history were similar. Thus, in this large nationally representative cohort, treatment with extended-hours hemodialysis was associated with a lower risk for mortality compared to treatment with conventional in-center therapy. Adequately powered randomized clinical trials comparing extended-hours to conventional hemodialysis are required to confirm these findings.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.
| | - Scott V Adams
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sooraj Kuttykrishnan
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Onyebuchi A Arah
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA; UCLA Center for Health Policy Research, Los Angeles, California, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Ronit Katz
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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Churchward DR, Graham-Brown MPM, Preston R, Pickering W, McCann GP, Burton JO. Investigating the effects of 6 months extended duration, in-centre nocturnal versus conventional haemodialysis treatment: a non-randomised, controlled feasibility study. BMJ Open 2016; 6:e012583. [PMID: 27609856 PMCID: PMC5020664 DOI: 10.1136/bmjopen-2016-012583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/28/2016] [Accepted: 08/12/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION In-centre nocturnal haemodialysis (INHD) is an underutilised dialysis regimen that can potentially provide patients with better clinical outcomes due to extended treatment times. We have established an INHD programme within our clinical network, fulfilling a previously unmet patient need. This feasibility study aims to gather sufficient data on numerous outcome measures to inform the design of a multicentre randomised controlled trial that will establish the potential benefits of INHD and increase the availability of this service nationally and internationally. METHODS AND ANALYSIS This will be a non-randomised controlled study. Prevalent patients on haemodialysis (HD) will electively change from a conventional in-centre HD regimen of 4 hours thrice weekly to a regimen of extended treatment times (5-8 hours) delivered in-centre overnight thrice weekly. After recruitment of the INHD cohort, a group of patients matched for age, gender and dialysis vintage will be selected from patients remaining on a conventional daytime dialysis programme. Outcome measures will include left ventricular mass as measured by MRI, physical performance measured by the short physical performance battery and physical activity measured by accelerometry. Additionally we will measure quality of life using validated questionnaires, nutritional status by bioimpedance spectroscopy and food diaries, and blood sampling for markers of cardiovascular disease, systemic inflammation. Suitable statistical tests shall be used to analyse the data. We will use omnibus tests to observe changes over the duration of the intervention and between groups. We will also look for associations between outcome measures that may warrant further investigation. These data will be used to inform the power calculation for future studies. ETHICS AND DISSEMINATION A favourable opinion was granted by Northampton Research Ethics Committee (15/EM/0268). It is anticipated that results of this study will be presented at national and international meetings, with reports being published in journals during 2017. TRIAL REGISTRATION NUMBER ISRCTN16672784.
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Affiliation(s)
- Darren R Churchward
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Matthew P M Graham-Brown
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Robert Preston
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Warren Pickering
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiology, NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - James O Burton
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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18
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Perl J, Kalim S, Wald R, Goldstein MB, Yan AT, Noori N, Kiaii M, Wenger J, Chan C, Thadhani RI, Karumanchi SA, Berg AH. Reduction of carbamylated albumin by extended hemodialysis. Hemodial Int 2016; 20:510-521. [PMID: 27329430 DOI: 10.1111/hdi.12435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction Among conventional hemodialysis (CHD) patients, carbamylated serum albumin (C-Alb) correlates with urea and amino acid deficiencies and is associated with mortality. We postulated that reduction of C-Alb by intensive HD may correlate with improvements in protein metabolism and cardiac function. Methods One-year observational study of in-center nocturnal extended hemodialysis (EHD) patients and CHD control subjects. Thirty-three patients receiving 4-hour CHD who converted to 8-hour EHD were enrolled, along with 20 controls on CHD. Serum C-Alb, biochemistries, and cardiac MRI parameters were measured before and after 12 months of EHD. Findings EHD was associated with reduction of C-Alb (average EHD change -3.20 mmol/mol [95% CI -4.23, -2.17] compared to +0.21 [95% CI -1.11, 1.54] change in CHD controls, P < 0.001). EHD was also associated with increases in average essential amino acids (in standardized units) compared to CHD (+0.38 [0.08, 0.68 95%CI]) vs. -0.12 [-0.50, 0.27, 95% CI], P = 0.047). Subjects who reduced C-Alb more than 25% were found to have reduced left ventricular mass, increased urea reduction ratio, and increased serum albumin compared to nonresponders, and % change in C-Alb significantly correlated with % change in left ventricular mass. Discussion EHD was associated with reduction of C-Alb as compared to CHD, and reduction of C-Alb by EHD correlates with reduction of urea. Additional studies are needed to test whether reduction of C-Alb by EHD also correlates with improved clinical outcomes.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Sahir Kalim
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ron Wald
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc B Goldstein
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- Division of Cardiology, Department of Medicine, Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Nazanin Noori
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julia Wenger
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Chan
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - S Ananth Karumanchi
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anders H Berg
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School.
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19
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Graham-Brown MPM, Churchward DR, Smith AC, Baines RJ, Burton JO. A 4-month programme of in-centre nocturnal haemodialysis was associated with improvements in patient outcomes. Clin Kidney J 2015; 8:789-95. [PMID: 26613041 PMCID: PMC4655800 DOI: 10.1093/ckj/sfv096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/03/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Extended periods of haemodialysis (HD) can improve patient outcomes. In-centre nocturnal haemodialysis (INHD) should be explored as a method of offering extended periods of HD to patients unsuitable for or unable to perform home therapy. METHODS Ten self-selecting, prevalent HD patients started an INHD programme to assess feasibility and patient satisfaction. Quality-of-life (QOL) measures were evaluated at enrolment and after 4 months of INHD using the EQ-5D, the Hospital Anxiety and Depression Scale (HADS) and the SF-12 questionnaires. Demographic, biochemical and haematological data and data on dialysis adequacy were collected before starting INHD and after 4 months. RESULTS Three of the 10 patients failed to complete the 2-week run-in period. Seven patients completed the 4-month programme, with mean dialysis time of 355 ± 43.92 min throughout the period. The EQ-5D visual analogue score improved from 48 ± 16.89 to 72 ± 13.2 (P = 0.003) and the HADS anxiety score decreased from 9 ± 5.83 to 3.57 ± 3.04 (P = 0.029). The urea reduction ratio improved from 71.57 ± 2.29% to 80.43 ± 3.101% (P < 0.001), with improvements in phosphate control, reducing to within the target range from 1.73 ± 0.6 to 1.2 ± 0.2 (P = 0.08). Ultrafiltration (UF) volumes increased during the study from 2000 ± 510 to 2606 ± 343 mL (P = 0.015); there was a significant reduction in mean UF rate adjusted for body weight from 6.47 ± 1.71 to 4.61 ± 1.59 mL/kg/h (P = 0.032). Sensitivity analyses confirmed the significance of these results. CONCLUSIONS This single-centre study showed a 4-month programme of extended hours INHD is safe and associated with improvements in QOL measures, decreased UF rates and measures of dialysis adequacy. These data have been used to expand our service and inform the design of future randomized controlled trials to examine medical endpoints.
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Affiliation(s)
- Matthew P M Graham-Brown
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - Darren R Churchward
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - Alice C Smith
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - Richard J Baines
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK
| | - James O Burton
- John Walls Renal Unit , Leicester General Hospital , Leicester , UK ; Department of Infection, Immunity and Inflammation , University of Leicester , Leicester , UK ; Department of Cardiovascular Science , NIHR Leicester Cardiovascular Biomedical Research Unit , Leicester , UK
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Abstract
Dialysis intensification from conventional regimens (typically thrice weekly, 4 hours per session) is increasingly utilized with the intent of improving the cardiovascular health and quality of life of chronic dialysis recipients. While home nocturnal hemodialysis offers the opportunity for maximal intensification of dialysis, it is inaccessible to the majority of dialysis recipients who are unable to self-administer hemodialysis in their own homes. In-center nocturnal hemodialysis (INHD) permits the intensification of conventional hemodialysis with the benefits of nursing support and supervision in addition to freedom from dialysis during productive daytime hours. Although no randomized trials have evaluated the relative merits of INHD, preliminary data indicate that INHD is a viable option that may confer a variety of benefits for chronic dialysis recipients.
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21
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Wong B, Courtney M, Pauly RP, Jindal K, Klarenbach S. Cost analysis of in-centre nocturnal compared with conventional hemodialysis. Can J Kidney Health Dis 2014; 1:14. [PMID: 25780609 PMCID: PMC4349597 DOI: 10.1186/2054-3581-1-14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 06/05/2014] [Indexed: 11/30/2022] Open
Abstract
Background Provision of in-centre nocturnal hemodialysis (ICNHD; 6–8 hours thrice weekly) is associated with health benefits, but the economic implications of providing this treatment are unclear. Objective We conducted a health care costing study comparing ICNHD to in-centre thrice-weekly conventional hemodialysis (CvHD). Design Micro-costing of both ICNHD and CvHD as practiced at our centre. Setting Hemodialysis unit at a tertiary-care hospital in Edmonton. Participants An informal survey of 2 other Canadian ICNHD programs was conducted to inform practices that may deviate from ours to guide sensitivity analysis. Measurements Resources consumed for each strategy were determined, and the cost of each unit (CAN $2012) was used to calculate incremental costs of ICNHD and CvHD. Methods We focused on resources that differ between strategies (staffing, dialysis materials, and utilities). The reference case considered 1:3 staff to patient ratio; alternate scenarios explored nursing pay grade and ratio, full care vs. self-care dialysis (including training costs), and medication costs. Results In the reference case, ICNHD was $61 more costly per dialysis treatment compared with CvHD ($9,538 per patient per year). Incremental annual costs for staffing, dialysis materials, and utilities were $8,201, $1,193, and $144, respectively. If ICNHD reduces medication use (anti-hypertensives, bone mineral metabolism medications), the incremental cost of ICNHD decreases to $8,620 per patient per year. In a scenario of self-care ICNHD utilizing a staff-to-patient ratio of 1:10, ICNHD is more costly in year 1 ($15,196), but results in cost savings of $2,625 in subsequent years compared with CvHD. Limitations The findings of this cost analysis may not be generalizable to other health care systems, including other parts of Canada. Conclusions Compared to CvHD, provision of ICNHD is more expensive, largely driven by increased staffing costs as patients dialyze longer. Alternate staffing models, including self-care ICNHD with minimal staff, may lead to net cost savings. The incremental cost of treatment should be considered in the context of impact on patient health outcomes, staffing model, and pragmatic factors, such as current capacity for daytime CvHD and the capital costs of new dialysis stations. Electronic supplementary material The online version of this article (doi:10.1186/2054-3581-1-14) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ben Wong
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada ; Department of Community Health Sciences, University of Calgary, Calgary, Alberta Canada
| | - Mark Courtney
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Robert P Pauly
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada ; Institute of Health Economics, Edmonton, Alberta Canada ; Alberta Kidney Disease Network, Edmonton, Alberta Canada
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22
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Knap B, Večerić-Haler Ž, Benedik M, Buturović-Ponikvar J, Ponikvar R, Bren AF. Fibroblast growth factor 23 and left ventricular mass index in maintenance hemodialysis patients: standard versus long nocturnal hemodialysis. Ther Apher Dial 2014; 17:407-11. [PMID: 23931880 DOI: 10.1111/1744-9987.12087] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Elevated levels of fibroblast growth factor 23 (FGF23) and phosphorus (P) have been linked to greater risks of left ventricular hypertrophy (LVH) in patients with end stage renal disease (ESRD). The aim of this study was to test if differences exist in a long nocturnal HD group in comparison with a group treated with standard daily thrice weekly dialysis. The attempt was to evaluate if elevated FGF-23 levels, intact parathyroid hormone and P might be associated with left ventricular mass index (LVMI). Quantitative echocardiographic analyses were performed at baseline in 50 maintenance HD patients (17 women and 33 men, mean age: 56.4 ± 15.35 years, mean HD vintage: 9.06 ± 8.86 years, all patients are on HD thrice a week-median duration 15 h/week, 10 of them on long nocturnal HD, median duration 24 h/week). LVMIs were calculated. FGF23 was measured in duplicate using a second generation C-terminal enzyme-linked immunosorbent assay and log of FGF-23 values were computed. Mean LVMI was 136.44 ± 44.44 g/m(2) . Serum FGF-23 levels were elevated when compared to population data with preserved kidney function (median 1388.5 RU/mL, range 252 to 24 336 RU/mL). There were no correlations recorded between log FGF-23 levels and LVMI (r = 0.2, P = 0.66). LVMI was significantly lower in HD patients on long nocturnal dialysis procedure (r = -0.31, P = 0.05). Patients treated with long nocturnal HD showed lower LV mass, lower P-values and higher 25-OH-D3 supply. Plasma FGF-23 concentration was comparable between the groups and was not associated with LVMI in our maintenance HD patients.
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Affiliation(s)
- Bojan Knap
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.
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23
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Dunlop JL, Vandal AC, de Zoysa JR, Gabriel RS, Haloob IA, Hood CJ, Matheson PJ, McGregor DOR, Rabindranath KS, Semple DJ, Marshall MR. Rationale and design of the Sodium Lowering In Dialysate (SoLID) trial: a randomised controlled trial of low versus standard dialysate sodium concentration during hemodialysis for regression of left ventricular mass. BMC Nephrol 2013; 14:149. [PMID: 23855560 PMCID: PMC3720185 DOI: 10.1186/1471-2369-14-149] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/08/2013] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The current literature recognises that left ventricular hypertrophy makes a key contribution to the high rate of premature cardiovascular mortality in dialysis patients. Determining how we might intervene to ameliorate left ventricular hypertrophy in dialysis populations has become a research priority. Reducing sodium exposure through lower dialysate sodium may be a promising intervention in this regard. However there is clinical equipoise around this intervention because the benefit has not yet been demonstrated in a robust prospective clinical trial, and several observational studies have suggested sodium lowering interventions may be deleterious in some dialysis patients. METHODS/DESIGN The Sodium Lowering in Dialysate (SoLID) study is funded by the Health Research Council of New Zealand. It is a multi-centre, prospective, randomised, single-blind (outcomes assessor), controlled parallel assignment 3-year clinical trial. The SoLID study is designed to study what impact low dialysate sodium has upon cardiovascular risk in dialysis patients. The study intends to enrol 118 home hemodialysis patients from 6 sites in New Zealand over 24 months and follow up each participant over 12 months. Key exclusion criteria are: patients who dialyse more frequently than 3.5 times per week, pre-dialysis serum sodium of <135 mM, and maintenance hemodiafiltration. In addition, some medical conditions, treatments or participation in other dialysis trials, which contraindicate the SoLID study intervention or confound its effects, will be exclusion criteria. The intervention and control groups will be dialysed using dialysate sodium 135 mM and 140 mM respectively, for 12 months. The primary outcome measure is left ventricular mass index, as measured by cardiac magnetic resonance imaging, after 12 months of intervention. Eleven or more secondary outcomes will be studied in an attempt to better understand the physiologic and clinical mechanisms by which lower dialysate sodium alters the primary end point. DISCUSSION The SoLID study is designed to clarify the effect of low dialysate sodium upon the cardiovascular outcomes of dialysis patients. The study results will provide much needed information about the efficacy of a cost effective, economically sustainable solution to a condition which is curtailing the lives of so many dialysis patients. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry number: ACTRN12611000975998.
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Affiliation(s)
- Joanna Leigh Dunlop
- South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
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24
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Schachter ME, Chan CT. Current state of intensive hemodialysis: a comparative review of benefits and barriers. Nephrol Dial Transplant 2013; 27:4307-13. [PMID: 23235954 DOI: 10.1093/ndt/gfs506] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The current interest in intensive hemodialysis (HD) was born out of the impasse in an effort to improve survival and quality of life (QOL) in patients with end-stage renal disease. In this review, we have summarized the emerging data of intensive HD on (i) survival, (ii) cardiovascular outcomes, (iii) phosphate balance and (iv) QOL. Although there is a consistent and compelling signal favoring intensive HD, it is important to balance the enthusiasm with the significant amount of perceived and actual barriers for our patients to overcome to receive or perform intensive HD. For an individual patient, the answer to the question 'What is the best form of intensive hemodialysis?' should be a consideration between the benefits sought and the obstacles in attaining intensive HD. In the future, changes in dialysis technology, healthcare delivery and education strategy are needed to allow the majority of patients to receive optimal renal replacement therapy.
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Affiliation(s)
- Michael E Schachter
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Canada
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