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Corbu A, Terrec F, Malvezzi P, Jouzier A, Jouve T, Rostaing L, Naciri Bennani H. Calcium-Free Dialysate Hemodialysis: A Simplified Approach. J Pers Med 2024; 14:660. [PMID: 38929882 PMCID: PMC11204440 DOI: 10.3390/jpm14060660] [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: 05/22/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Intermittent hemodialysis (HD) in high-bleeding-risk patients presents a challenge as circuit anticoagulation using heparin is contraindicated in such cases. Recently, the use of calcium-free citrate-containing dialysate with calcium supplementation emerged as a viable alternative to heparin-circuit anticoagulation. This is a retrospective, monocentric study to evaluate dialysis efficacy using calcium-free citrate-containing dialysate with calcium reinjection into the venous line in hemodialysis patients at risk of bleeding. A total of 53 patients were analyzed: 52 had a temporary contraindication to systemic anticoagulation (active bleeding or surgical intervention), and 1 chronic HD patient had prolonged bleeding time due to inoperable arteriovenous fistula stenosis. Only 7 out of 79 dialysis sessions performed were prematurely terminated (vascular access dysfunction). The median dialysis time was 240 min (range: 150-300). The chronic dialysis patient had 108 sessions with no premature termination. Frequent monitoring of ionized calcium was performed throughout the dialysis sessions: levels remained stable at T0 and T + 60 min (1.08 ± 0.08 mmol/L) and slightly increased at the end of the dialysis session (1.19 ± 0.13 mmol/L), remaining within normal limits. Target postfilter ionized calcium <0.4 mmol/L was achieved in all sessions (0.31 ± 0.07 mmol/L). There were no cases of symptomatic hypo-/hypercalcemia and no need for calcium infusion rate adjustment throughout the sessions. Hemodialysis with calcium-free citrate-containing dialysate and calcium reinjection into the venous line is efficient and safe in HD patients with contraindications to systemic anticoagulation.
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Affiliation(s)
- Alexandra Corbu
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Florian Terrec
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Paolo Malvezzi
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Arnaud Jouzier
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Thomas Jouve
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
- Univ. Grenoble Alpes Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences, 38000 Grenoble, France
| | - Lionel Rostaing
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
- Univ. Grenoble Alpes Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences, 38000 Grenoble, France
| | - Hamza Naciri Bennani
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
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Liu H, Zhou Y, Guo P, Zheng X, Chen W, Zhang S, Fu Y, Zhou X, Wan Z, Zhao B, Zhao Y. Hemodialysis bilayer bionic blood vessels developed by the mechanical stimulation of hepatitis B viral X( HBX) gene- transfected hepatic stellate cells. J Zhejiang Univ Sci B 2024; 25:499-512. [PMID: 38910495 PMCID: PMC11199092 DOI: 10.1631/jzus.b2300479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/23/2023] [Indexed: 06/25/2024]
Abstract
Artificial vascular graft (AVG) fistula is widely used for hemodialysis treatment in patients with renal failure. However, it has poor elasticity and compliance, leading to stenosis and thrombosis. The ideal artificial blood vessel for dialysis should replicate the structure and components of a real artery, which is primarily maintained by collagen in the extracellular matrix (ECM) of arterial cells. Studies have revealed that in hepatitis B virus (HBV)-induced liver fibrosis, hepatic stellate cells (HSCs) become hyperactive and produce excessive ECM fibers. Furthermore, mechanical stimulation can encourage ECM secretion and remodeling of a fiber structure. Based on the above factors, we transfected HSCs with the hepatitis B viral X (HBX) gene for simulating the process of HBV infection. Subsequently, these HBX-HSCs were implanted into a polycaprolactone-polyurethane (PCL-PU) bilayer scaffold in which the inner layer is dense and the outer layer consists of pores, which was mechanically stimulated to promote the secretion of collagen nanofiber from the HBX-HSCs and to facilitate crosslinking with the scaffold. We obtained an ECM-PCL-PU composite bionic blood vessel that could act as access for dialysis after decellularization. Then, the vessel scaffold was implanted into a rabbit's neck arteriovenous fistula model. It exhibited strong tensile strength and smooth blood flow and formed autologous blood vessels in the rabbit's body. Our study demonstrates the use of human cells to create biomimetic dialysis blood vessels, providing a novel approach for creating clinical vascular access for dialysis.
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Affiliation(s)
- Hongyi Liu
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- School of Medicine, Xiamen University, Xiamen 361102, China
| | - Yuanyuan Zhou
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China.
- School of Medicine, Xiamen University, Xiamen 361102, China.
| | - Peng Guo
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Xiongwei Zheng
- School of Medicine, Xiamen University, Xiamen 361102, China
| | - Weibin Chen
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- School of Medicine, Xiamen University, Xiamen 361102, China
| | - Shichao Zhang
- School of Medicine, Xiamen University, Xiamen 361102, China
| | - Yu Fu
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- School of Medicine, Xiamen University, Xiamen 361102, China
| | - Xu Zhou
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Zheng Wan
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Bin Zhao
- Xiamen Health and Medical Big Data Center, Xiamen 361008, China
| | - Yilin Zhao
- Department of Oncology and Vascular Interventional Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China.
- School of Medicine, Xiamen University, Xiamen 361102, China.
- Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma (Zhongshan Hospital Affiliated to Xiamen University), Xiamen 361004, China.
- Xiamen Key Laboratory of Cellular Intervention and Interventional Medical Materials, Xiamen 361004, China.
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Natale P, Palmer SC, Ruospo M, Longmuir H, Dodds B, Prasad R, Batt TJ, Jose MD, Strippoli GF. Anticoagulation for people receiving long-term haemodialysis. Cochrane Database Syst Rev 2024; 1:CD011858. [PMID: 38189593 PMCID: PMC10772979 DOI: 10.1002/14651858.cd011858.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. OBJECTIVES To assess the efficacy and safety of anticoagulation strategies (including both heparin and non-heparin drugs) for long-term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin-coated dialysers, pre-dilution haemodiafiltration (HDF), and saline flushes were also included. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-randomised controlled studies (quasi-RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta-analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). MAIN RESULTS We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin-grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non-fatal myocardial infarction, non-fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. AUTHORS' CONCLUSIONS Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision-making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes.
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Affiliation(s)
- Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, Universityof Foggia, Foggia, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Benjamin Dodds
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Ritam Prasad
- Department of Haematology/Pathology, Royal Hobart Hospital, Hobart, Australia
| | - Tracey J Batt
- Department of Haematology, Westmead Hospital, Westmead, Australia
| | - Matthew D Jose
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Demuynck T, Grooteman M, Ter Wee P, Cozzolino M, Meijers B. Regional Citrate Anticoagulation: A Tale of More Than Two Stories. Semin Nephrol 2023; 43:151481. [PMID: 38212212 DOI: 10.1016/j.semnephrol.2023.151481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Calcium is a key clotting factor, and several inorganic molecules that bind to calcium have been found to reduce the clotting propensity of blood. Citrate, a calcium chelator, is used as inhibitor of the coagulation cascade in blood transfusion. Also, it is used as an anaticoagulant during dialysis to maintain patency of the extracorporeal circuit, known as regional citrate anticoagulation (RCA). The amount of citrate should be chosen such that ionized calcium concentrations in the extracorporeal circuit are reduced enough to minimize propagation of the coagulation cascade. The dialytic removal of the calcium-citrate complexes combined with reduced ionized calcium concentrations makes necessary calcium supplementation of the blood returning to the patient. This can be achieved in different ways. In classical RCA, citrate and calcium are infused in the afferent and efferent tubing, respectively, whereas the dialysate does not contain calcium. This setup has been shown to be highly efficacious with a very low clotting propensity. Strict monitoring of blood electrolytes is required. Alternatively, the use of a high-calcium dialysate leads to calcium loading, obviating the need for a separate calcium infusion pump. The main advantages are simplified delivery of RCA and less fluctuation of systemic calcium concentrations. Currently, citric acid is sometimes added to the acid concentrate as a replacement for acetic acid. Differences and similarities between RCA and citrate-containing dialysate are discussed. RCA is an excellent alternative to heparin for patients at high risk of bleeding.
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Affiliation(s)
- Thomas Demuynck
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Muriel Grooteman
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Piet Ter Wee
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| | - Björn Meijers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
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Liu J, Liu Z, Zhao T, Su T, Jin Q. Thromboelastography and Traditional Coagulation Testing in Non-ICU-Admitted Patients with Acute Kidney Injury: An Observational Cohort Study. Am J Nephrol 2023; 54:208-218. [PMID: 37364534 DOI: 10.1159/000530777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION This study aimed to elucidate the coagulation disorders in non-ICU patients with acute kidney injury (AKI) and their contribution to clotting-related outcomes of intermittent kidney replacement therapy (KRT). METHODS We included non-ICU-admitted patients with AKI requiring intermittent KRT, clinically having a risk of bleeding and against systemic anticoagulant use during KRT between April and December 2018. The premature termination of treatment due to circuit clotting was considered a poor outcome. We analyzed the characteristics of thromboelastography (TEG)-derived and traditional coagulation parameters and explored the potential-affecting factors. RESULTS In total, 64 patients were enrolled. Hypocoagulability was detected in 4.7%-15.6% of patients by a combination of the traditional parameters, i.e., prothrombin time (PT)/international normalized ratio, activated partial PT, and fibrinogen. No patient had hypocoagulability observed on TEG-derived reaction time; only 2.1%, 3.1%, and 10.9% of patients had hypocoagulability on TEG-derived kinetic time (K-time), α-angle, and maximum amplitude (MA), respectively, which were also platelet-related coagulation parameters, despite 37.5% of the cohort having thrombocytopenia. In contrast, hypercoagulability was more prevalent, involving 12.5%, 43.8%, 21.9%, and 48.4% of patients on TEG K-time, α-angle, MA, and coagulation index (CI), respectively, although thrombocytosis was only in 1.5% of the cohort. Patients with thrombocytopenia showed lower fibrinogen level (2.6 vs. 4.0 g/L, p = 0.00), α-angle (63.5° vs. 73.3°, p = 0.00), MA (53.5 vs. 66.1 mm, p = 0.00), and CI (1.8 vs. 3.6, p = 0.00) but higher thrombin time (17.8 vs. 16.2 s, p = 0.00) and K-time (2.0 vs. 1.2 min, p = 0.00) than those with a platelet count over 100 × 109/L. 41 patients were treated with heparin-free protocol, and 23 were treated with regional citrate anticoagulation (RCA). The premature termination rate was 41.5% on heparin-free patients, while 8.7% of patients underwent an RCA protocol (p = 0.006). Heparin-free protocol was the strongest adverse factor to poor outcomes. A heparin-free subgroup analysis found that the circuit clotting risk was increased by 61.7% with a 10 × 109/L elevation in platelet count (odds ratio [OR] = 1.617, p = 0.049) and decreased by 67.5% following a second increase of PT (OR = 0.325, p = 0.041). No significant correlation was found between TEG parameters and premature circuit clotting. CONCLUSIONS Most non-ICU-admitted patients with AKI had normal-to-enhanced hemostasis and activated platelet function based on TEG results, as well as a high rate of premature circuit clotting when receiving heparin-free protocol despite thrombocytopenia. Further studies are needed to better determine the use of TEG in respect to management of anticoagulation and bleeding complications in AKI patients with KRT.
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Affiliation(s)
- Jiajia Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Zhongyuan Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Tao Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
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Yu-Huan S, Guang-Yan C, Yue-Fei X. Risk factors for intracerebral hemorrhage in patients undergoing maintenance hemodialysis. Front Neurol 2023; 14:1111865. [PMID: 37034079 PMCID: PMC10073690 DOI: 10.3389/fneur.2023.1111865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023] Open
Abstract
Background In patients undergoing hemodialysis, intracerebral hemorrhage (ICH) is the main cause of mortality among stroke subtypes. It is unclear whether, along with traditional cardiovascular risk factors, the risk factors unique to the uraemic environment, such as the abnormal metabolism of intact parathyroid hormone (iPTH), can contribute to the risk of ICH in these patients. Methods This retrospective case-control study included 25 patients undergoing hemodialysis with ICH at a single center between 30 June 2015 and 10 October 2022. The controls were 95 patients undergoing maintenance hemodialysis treated at the same dialysis center in July 2020. We compared the characteristics of patients with ICH with those of the control group to identify factors that contributed to the development of ICH. Results Intracerebral hemorrhage (ICH) was located in the basal ganglia (14/25), cerebellum (6/25), and brainstem (6/25) in 25 patients. A total of 17 patients died in the first 16 days due to neurological complications. Univariate analysis showed significant differences in systolic BP, diastolic BP, iPTH, and alkaline phosphatase between the two groups (p < 0.05). Multivariate logistic regression analysis showed that higher systolic BP (OR, 1.053; 95% CI, 1.018-1.090; p = 0.003) and higher iPTH (OR, 1.007; 95% CI, 1.003-1.012; p = 0.001) were associated with the onset of ICH. ICH was predicted by systolic BP and iPTH by receiver operating characteristic (ROC) curve analysis, with areas under the curve (AUCs) of 0.732 and 0.624, respectively. The optimal cutoffs for systolic BP and iPTH were 151.9 mmHg and 295.4 pg./ml, respectively. Restricted cubic spline showed that the shape of the association of iPTH with the risk of ICH was approximately J-shaped (P for non-linearity <0.05). Conclusion Higher systolic BP and abnormal iPTH metabolism might be associated with ICH in patients undergoing hemodialysis. Comprehensive control of hypertension and iPTH may be a fundamental preventive strategy for ICH in these patients.
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Affiliation(s)
- Song Yu-Huan
- Department of Nephrology, Aerospace Center Hospital, Beijing, China
| | - Cai Guang-Yan
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
- *Correspondence: Cai Guang-Yan,
| | - Xiao Yue-Fei
- Department of Nephrology, Aerospace Center Hospital, Beijing, China
- Xiao Yue-Fei,
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