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Wang P, Wang Z, Li ZX, Ma SH, Li Y, Li H, Yang C, Yu M, Wang J, An YC, Li M. Efficacy and safety of Tongdutiaoshen acupuncture on insomnia in maintenance hemodialysis patients: A randomized clinical trial protocol. Contemp Clin Trials Commun 2023; 35:101196. [PMID: 37583470 PMCID: PMC10423895 DOI: 10.1016/j.conctc.2023.101196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/23/2023] [Accepted: 07/30/2023] [Indexed: 08/17/2023] Open
Abstract
Background Patients undergoing maintenance hemodialysis (MHD) experience insomnia frequently. Poor sleep quality impairs the quality of life and adversely affects long-term outcomes. Currently, the treatment of insomnia in patients undergoing MHD is mainly based on medication, although it has severe side effects and poor compliance in patients. Therefore, developing complementary and alternative therapies with higher efficacies is important. This study explores the clinical efficacy and safety of Tongdutiaoshen acupuncture in treating insomnia in patients with MHD. Methods This randomized controlled trial (RCT) will be performed at Beijing Luhe Hospital, affiliated with Capital Medical University in China. We will strictly adhere to the Standards for Reporting Interventions in Clinical Trials of Acupuncture (2010). A total of 110 MHD patients with insomnia will be randomly allocated in a 1:1 ratio to the drug control (DC) or Tongdutiaoshen acupuncture (TA) group. Patients in the control group will be administered estazolam tablets (1 mg/day) for four weeks, followed by a 4-week follow-up period. Based on the background therapy provided for the DC group, the TA group will be administered the interventional cohort three times a week for four weeks in a row, followed by a 4-week follow-up period. The primary endpoints will include the Pittsburgh Sleep Quality Index (PSQI), Hamilton Anxiety Scale (HAM-A), TCM Insomnia Syndrome Score, and clinical response rate, which will be evaluated on days 0, 14, 28, and 56. Secondary endpoints will include sleep data monitoring and related laboratory indices, which will be evaluated on days 0, 28, and 56, respectively. Discussion This study is designed based on a rigorous methodology to evaluate the efficacy and safety of Tongdutiaoshen acupuncture for insomnia in patients undergoing hemodialysis. The findings of this trial will be published in peer-reviewed journals as reliable evidence. Trial registration Chinese Clinical Trial Registry ChiCTR2200061967. Registered on July 07, 2022.
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Affiliation(s)
- Pei Wang
- Center of Traditional Chinese Medicine, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Zheng Wang
- Center of Traditional Chinese Medicine, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Zhong-xin Li
- Kidney Center, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Si-hui Ma
- Kidney Center, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Yan Li
- Kidney Center, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Huan Li
- Department of Psychiatry, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Chao Yang
- Department of Psychiatry, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Man Yu
- Center of Traditional Chinese Medicine, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Jiao Wang
- Center of Traditional Chinese Medicine, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Yan-chen An
- Center of Traditional Chinese Medicine, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
| | - Min Li
- Center of Traditional Chinese Medicine, Beijing Luhe Hospital Affiliated to Capital Medical University, No.82, Xinhua South Street, Tongzhou Distract, Beijing, 101149, China
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Hull KL, Bramham K, Brookes CL, Cluley V, Conefrey C, Cooper NJ, Eborall H, Fotheringham J, Graham-Brown MPM, Gray LJ, Mark PB, Mitra S, Murphy GJ, Quann N, Rooshenas L, Warren M, Burton JO. The NightLife study - the clinical and cost-effectiveness of thrice-weekly, extended, in-centre nocturnal haemodialysis versus daytime haemodialysis using a mixed methods approach: study protocol for a randomised controlled trial. Trials 2023; 24:522. [PMID: 37573352 PMCID: PMC10422763 DOI: 10.1186/s13063-023-07565-w] [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: 05/18/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND In-centre nocturnal haemodialysis (INHD) offers extended-hours haemodialysis, 6 to 8 h thrice-weekly overnight, with the support of dialysis specialist nurses. There is increasing observational data demonstrating potential benefits of INHD on health-related quality of life (HRQoL). There is a lack of randomised controlled trial (RCT) data to confirm these benefits and assess safety. METHODS The NightLife study is a pragmatic, two-arm, multicentre RCT comparing the impact of 6 months INHD to conventional haemodialysis (thrice-weekly daytime in-centre haemodialysis, 3.5-5 h per session). The primary outcome is the total score from the Kidney Disease Quality of Life tool at 6 months. Secondary outcomes include sleep and cognitive function, measures of safety, adherence to dialysis and impact on clinical parameters. There is an embedded Process Evaluation to assess implementation, health economic modelling and a QuinteT Recruitment Intervention to understand factors that influence recruitment and retention. Adults (≥ 18 years old) who have been established on haemodialysis for > 3 months are eligible to participate. DISCUSSION There are 68,000 adults in the UK that need kidney replacement therapy (KRT), with in-centre haemodialysis the treatment modality for over a third of cases. HRQoL is an independent predictor of hospitalisation and mortality in individuals on maintenance dialysis. Haemodialysis is associated with poor HRQoL in comparison to the general population. INHD has the potential to improve HRQoL. Vigorous RCT evidence of effectiveness is lacking. The NightLife study is an essential step in the understanding of dialysis therapies and will guide patient-centred decisions regarding KRT in the future. TRIAL REGISTRATION Trial registration number: ISRCTN87042063. Registered: 14/07/2020.
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Affiliation(s)
- Katherine L Hull
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Kate Bramham
- King's Kidney Care, King's College Hospital, London, UK
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Victoria Cluley
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Carmel Conefrey
- Bristol Population Health Science Institute, University of Bristol Medical School, Bristol, UK
| | - Nicola J Cooper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Helen Eborall
- College of Medicine and Veterinary Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - James Fotheringham
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Laura J Gray
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sandip Mitra
- Manchester Institute of Nephrology and Transplantation, Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gavin J Murphy
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
- Cardiovascular Research Centre, University of Leicester, Leicester, UK
| | - Niamh Quann
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Leila Rooshenas
- Bristol Population Health Science Institute, University of Bristol Medical School, Bristol, UK
| | | | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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Kang M, Chen J, Liu L, Xue C, Tang X, Lv J, Fu L, Mei C, Mao Z, Liu Y, Dai B. In-center Nocturnal Hemodialysis Reduced the Circulating FGF23, Left Ventricular Hypertrophy, and All-Cause Mortality: A Retrospective Cohort Study. Front Med (Lausanne) 2022; 9:912764. [PMID: 35801203 PMCID: PMC9253468 DOI: 10.3389/fmed.2022.912764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Fibroblast growth factor 23(FGF23) is the most important biomarker and pathogenic factor in Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD). In the moderate and severe stages of chronic renal failure, abnormally elevated circulating FGF23 can lead to some complications, including myocardial hypertrophy, which is positively correlated with all-cause mortality. However, the circulating FGF23 level of different hemodialysis modalities, the underlying essential regulatory factors, and potential clinical benefits remain to be elucidated. In this retrospective cohort study, 90 in-center nocturnal hemodialysis (INHD) and 90 matched conventional hemodialysis (CHD) patients were enrolled. The complete blood count, intact FGF23(iFGF23), calcium, phosphorus, PTH, and other biochemical and echocardiographic parameters of INHD and CHD patients were collected and analyzed at 1-year follow-up. The all-cause mortality was recorded during the 7-year follow-up. Furthermore, the regulatory factors of iFGF23 and its association with echocardiographic parameters and mortality were investigated by multivariate regression. The levels of iFGF23 and serum phosphate in patients undergoing INHD were significantly lower than those in patients undergoing CHD. The left ventricular volume index (LVMI) in patients with INHD was significantly attenuated and positively correlated with the drop of serum iFGF23. The INHD group had reduced all-cause mortality compared to the CHD group. Multivariate analysis showed that iFGF23 was positively correlated with serum calcium, serum phosphorus, and calcium-phosphate product. The calcium-phosphate product is an independent determining factor of serum iFGF23. Compared with the CHD group, the INHD group presented with a significantly reduced circulating iFGF23 level, which was closely associated with attenuation of left ventricular hypertrophy, but INHD reduced all-cause mortality in an FGF23 independent manner.
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Affiliation(s)
- Meizi Kang
- Division of Nephrology, The Second Affiliated Hospital of Nantong University, Nantong, China
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jing Chen
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Lingling Liu
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Cheng Xue
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xiaojing Tang
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jiayi Lv
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Lili Fu
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Changlin Mei
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhiguo Mao
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yawei Liu
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
- Department of Internal Medicine, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Bing Dai
| | - Bing Dai
- Division of Nephrology, Kidney Institute of People's Liberation Army of China, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
- Yawei Liu
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Gong Y, Xie L, Yu S. Long-Term In-Center Nocturnal Hemodialysis Improves Renal Anemia and Malnutrition and Life Quality of Older Patients with Chronic Renal Failure. Clin Interv Aging 2022; 17:915-923. [PMID: 35686029 PMCID: PMC9172732 DOI: 10.2147/cia.s358472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022] Open
Abstract
Background Older patients with chronic renal failure (CRF) which currently is referred to as end-stage renal disease (ESRD) are associated with higher mortality. In-center nocturnal dialysis (INHD) is a new blood purification model, which is characterized by longer sessions and nighttime administration. However, no data for the efficacy of INHD in older patients with ESRD are available. This study is to analyze the effect of INHD in the treatment of older patients with ESRD. Methods A retrospective, observational study was conducted in a university teaching hospital. Seventy-two patients with ESRD receiving INHD were enrolled. They were divided into the older ESRD patients (age ≥60) group (n = 22) and the non-older ESRD patients (age <60) group (n = 50). The causes of older ESRD patients and non-older ESRD patients receiving INHD were analyzed. Differences of laboratory test indicators of older patients with ESRD before INHD and after INHD were compared. Quality of life for older ESRD patients receiving INHD was assessed by using the Kidney Disease Quality of Life-36 Instrument (KDQOL-36). Results Serum concentration of hemoglobin and serum concentration of albumin of older patients with ESRD increased significantly after INHD (p < 0.05). There were similar results in the non-older cohort (p ≤ 0.05). Scores of five KDQOL-36 subscales increased significantly after INHD (p ≤ 0.001) indicated that the quality of life for old patients with ESRD was significantly improved after INHD. Conclusion INHD is an effective blood purification therapy that can improve the condition of renal anemia, and it may provide a potential positive impact in the malnutrition of older and non-older patients with ESRD. INHD can improve the quality of life of older patients with ESRD. The results will provide a basis for formulating new policies of blood purification therapy for older patients.
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Affiliation(s)
- Yu Gong
- Department of Internal Medicine, Division of Nephrology, Telemedicine Center, Shanghai Municipal Eighth People's Hospital, Shanghai, People's Republic of China
| | - Liangyu Xie
- Department of Internal Medicine, Division of Nephrology, Shanghai Changzheng Hospital, Shanghai, People's Republic of China
| | - Shengqiang Yu
- Department of Internal Medicine, Division of Nephrology, Shanghai Changzheng Hospital, Shanghai, People's Republic of China
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Tennankore KK, Nadeau-Fredette AC, Matheson K, Chan CT, Trinh E, Perl J. Home versus In-Center Dialysis and Day of the Week Hospitalization: A Cohort Study. KIDNEY360 2021; 3:103-112. [PMID: 35368556 PMCID: PMC8967598 DOI: 10.34067/kid.0003552021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/21/2021] [Indexed: 01/10/2023]
Abstract
Background The dialysis treatment day after the 2-day interdialytic interval (Monday/Tuesday) is associated with a heightened risk of hospitalization for patients on in-center hemodialysis (ICHD). In this national cohort study, we sought to characterize hospitalizations by day of the week for patients receiving ICHD, home HD (HHD), and peritoneal dialysis (PD) and to identify whether there were differences in the probability of a Monday/Tuesday admission for each modality type. Methods Patients on maintenance dialysis in Canada were analyzed from 2005 to 2014 using the Canadian Organ Replacement Register. Patients on hemodialysis were categorized as those receiving ICHD, HHD, frequent ICHD, or frequent HHD (the latter two included short daily and nocturnal HD). Hospitalizations were attributed to the previous treatment if they occurred within 30 days of a treatment change. Differences in the proportion of patients experiencing a Monday/Tuesday admission with all other days of the week were compared using a generalized linear model with binomial distribution and reported using adjusted odds ratios (OR) with 95% CIs. Results Overall, 27,430 individuals experienced 111,748 hospitalization episodes. Rates per 1000 patient days were 3.76, 2.98, 2.71, 2.16, and 2.13 for each of frequent ICHD, ICHD, PD, HHD, and frequent HHD, respectively. Compared with those on ICHD, only patients receiving frequent HHD (OR, 0.89; 95% CI, 0.81 to 0.97) and PD (OR, 0.95; 95% CI, 0.93 to 0.97) had a lower odds of experiencing a Monday/Tuesday admission. The OR was lower when restricted to hospitalization episodes for cardiovascular reasons comparing frequent HHD with ICHD (OR, 0.68; 95% CI, 0.48 to 0.96). Conclusion In this nationally representative cohort, we identified that the probability of a Monday/Tuesday admission was lower for frequent HHD and PD compared with ICHD, most notably for hospitalizations due to cardiovascular causes. Gaining a better understanding of the reasons behind this observation may help to develop future strategies to reduce overall and cause-specific hospitalization for patients receiving dialysis.
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Affiliation(s)
| | | | - Kara Matheson
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Christopher T. Chan
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Jeffrey Perl
- St. Michael’s Hospital, Toronto, Ontario, Canada
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Hull KL, Quann N, Glover S, Wimbury C, Churchward DR, Pickering WP, Preston R, Baines R, Graham-Brown MPM, Burton JO. Evaluating the clinical experience of a regional in-center nocturnal hemodialysis program: The patient and staff perspective. Hemodial Int 2021; 25:447-456. [PMID: 34133061 DOI: 10.1111/hdi.12953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/10/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION End-stage kidney disease causes significant morbidity, mortality, and reduced quality of life. Despite improvements in conventional hemodialysis, these problems persist. In-center nocturnal hemodialysis (INHD) has been shown to be beneficial in observational studies. This report outlines a 4-year renal network experience of INHD from the patient and frontline staff perspective. METHODS Staff and patients' experiences of INHD were evaluated through two work streams. Work stream one: 12 patients who chose to stop INHD and 24 patients who chose to continue with INHD completed an anonymous survey. Work stream two: one-to-one interviews with 20 patients receiving INHD and seven staff working INHD shifts were conducted. Clinical incident reporting for conventional hemodialysis and INHD from April 2014 to December 2018 was reviewed. FINDINGS Work stream one: Five themes were identified; facilities, time, health and well-being, sleep, and transport. A patient "starter pack" was developed and improvements to the dialysis unit were completed. Work stream two: Patient interviews demonstrated starter packs to aid sleep were well received; sleep itself was not a single reason to discontinue INHD. Staff indicated that their greatest concern was staffing levels; although staff-to-patient ratio remains unchanged, total numbers on INHD shifts were fewer, causing concern around less colleague availability for support during an emergency. SAFETY 363 clinical incidents were reported across all dialysis shifts; for conventional hemodialysis, a larger proportion were due to medical interventions, infection control, and transport; for INHD, most incidents centered around communication with patients and relatives, delays in patient transfer, and issues with medical equipment or facilities. DISCUSSION Patients continue with INHD due to increased social time and perceived health benefits. Patient starter packs and adjustments to the dialysis unit may enhance sleep. This experience has optimized the design of the NightLife study; a randomized controlled trial evaluated the effect of INHD on quality of life.
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Affiliation(s)
- Katherine L Hull
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Niamh Quann
- Leicester Clinical Trials Unit, College of Life Sciences, University of Leicester, Leicester, UK
| | - Suzanne Glover
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Coral Wimbury
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | | | - Rob Preston
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Richard Baines
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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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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Dumaine CS, Ravani P, Parmar MK, Leung KCW, MacRae JM. In-center nocturnal hemodialysis improves health-related quality of life for patients with end-stage renal disease. J Nephrol 2021; 35:245-253. [PMID: 34050903 DOI: 10.1007/s40620-021-01066-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Conventional in-center hemodialysis (HD) is associated with significant symptom burden and reduced health-related quality of life (HRQOL). The HRQOL effects of conversion to in-center nocturnal hemodialysis (INHD) remain unclear, especially amongst those with poor HRQOL. METHODS Prospective cohort study of HD patients converting to INHD. Linear regression models summarized the mean score at baseline and at 12 months for the cohort. To assess whether patients with low baseline HRQOL derive greater benefit, we compared values before and after by levels of baseline score for each domain (below vs equal to or above the median) using a formal interaction test (t test). RESULTS 36 patients started INHD, 7 withdrew (5 transplanted, 1 death, 1 moved) and 5 declined follow-up. After 12 months the mental component score (MCS) increased by 7.1 points to a value of 51.0 (95% CI + 1.5 to 10.9, p = 0.01). Amongst patients with baseline scores below the median, improvements were seen in: Symptoms/Problems of Kidney Disease (+ 15.2, 95% CI + 5.5 to + 24.9, p = 0.003), Effects of Kidney Disease (+ 16.9, 95% CI + 2.2 to + 31.7, p = 0.026), Physical Component Score (+ 9.4, 95% CI + 1.69 to + 17.2, p = 0.018), MCS (+ 10.7, 95% CI + 2.4 to + 19.1, p = 0.013). Burden of Kidney Disease domain change was not significant (+ 15.1, 95% CI - 2.1 to + 32.3, p = 0.083). DISCUSSION INHD is a potential intervention for HD patients who struggle with reduced HRQOL, especially for those who struggle with poor mental health. Medical benefits of reduced pill burden and improved phosphate control occur with transition to INHD.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine, University of Calgary, HRIC Building, 3230 Hospital Dr NW, Calgary, AB, T2N4Z6, Canada
| | | | - Kelvin C W Leung
- Division of Nephrology, Cumming School of Medicine, University of Calgary, HRIC Building, 3230 Hospital Dr NW, Calgary, AB, T2N4Z6, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, HRIC Building, 3230 Hospital Dr NW, Calgary, AB, T2N4Z6, Canada. .,Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada.
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Rastogi A, Lerma EV. Anemia management for home dialysis including the new US public policy initiative. Kidney Int Suppl (2011) 2021; 11:59-69. [PMID: 33777496 PMCID: PMC7983021 DOI: 10.1016/j.kisu.2020.12.005] [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: 10/02/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/28/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.
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Affiliation(s)
- Anjay Rastogi
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Edgar V. Lerma
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Section of Nephrology, Oak Lawn, Illinois, USA
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10
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Laruelle É, Corlu L, Pladys A, Dolley Hitze T, Couchoud C, Vigneau C. [Prolonged hemodialysis: Rationale, practical organization, results]. Nephrol Ther 2021; 17S:S71-S77. [PMID: 33910702 DOI: 10.1016/j.nephro.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/07/2020] [Indexed: 11/15/2022]
Abstract
In France, long nocturnal dialyses, eight hours three-times a week, are sparsely proposed. However, numerous studies reported that this specific type of dialysis is associated to better blood pressure control, better cardiac remodeling, better mineral and nutritional balance as well as better life quality and survival rate. MATERIAL AND METHODS: In this study, we aimed at quantifying the benefits, risks and obstacles of developing night dialysis and at describing the results of a program that took place in Rennes from 2002 to 2019. Data were collected between 2008 and 2014 for eighteen case-patients and were compared to thirty-six controls that underwent conventional dialysis. Patients were paired according sex, age and year of dialysis start. RESULTS: The median age for dialysis start was 47.5 years [27-60] with a male prevalence (5/1). After six months, a significant difference was reported for postdialytic, systolic and diastolic pressure (respectively 126±15 vs 139±21 [P=0.04] and 72±9 vs 81±14 [P=0.02]) despite an antihypertensive reduction ranging from 2.4±1.4 to 1.3±0.9 per day at six months and 0.7±0.9 at one year (P=0.02). An increase of nPCR was evidenced at 6 and 9 months (P=0.02). At the end of the study, the phosphate level was maintained for both cohorts at the expense of an increased consumption of phosphate binder for the long nocturnal dialysis group (P=0.025). As a whole, 61% of the patients that pursued long night dialysis maintained a professional activity compared to only 30% for the controls (P=0.04). This highlights the advantages of night dialysis for maintaining employment but also the bias that represents the employment status in observational study on this specific topic.
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Affiliation(s)
- Éric Laruelle
- AUB Santé, 28, rue Henri-Le-Guilloux, 35033 Rennes, France.
| | - Léa Corlu
- Service de néphrologie, groupe hospitalier Bretagne-Sud, Lorient, France
| | | | | | | | - Cécile Vigneau
- EHESP, 35033 Rennes, France; Inserm, EHESP, IRSET (institut de recherche en santé, environnement et travail)-UMR S1805, université de Rennes, CHU de Rennes, 35000 Rennes, France
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11
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Malavade TS, Dey A, Chan CT. Nocturnal Hemodialysis: Why Aren't More People Doing It? Adv Chronic Kidney Dis 2021; 28:184-189. [PMID: 34717866 DOI: 10.1053/j.ackd.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/13/2021] [Indexed: 11/11/2022]
Abstract
Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.
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12
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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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13
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Girsberger M, Chan CT. Retrospective single center cohort study: effect of intensive home hemodialysis on right ventricular systolic pressure and clinical outcomes. BMC Nephrol 2020; 21:508. [PMID: 33238914 PMCID: PMC7687753 DOI: 10.1186/s12882-020-02159-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Increased right ventricular systolic pressure (RVSP), a surrogate marker for pulmonary hypertension, is common in patients with end-stage kidney disease. Limited data suggest improvement of RVSP with intensive dialysis, but it is unknown whether these improvements translate to better clinical outcomes. METHODS We conducted a retrospective single center cohort study at the Toronto General Hospital. All patients who performed intensive home hemodialysis (IHHD) for at least a year between 1999 and 2017, and who had a baseline as well as a follow-up echocardiogram more than a year after IHHD, were included. Patients were categorized into two groups based on the RVSP at follow-up: elevated (≥ 35 mmHg) and normal RVSP. Multivariate and cox regression analyses were done to identify risk factors for elevated RVSP at follow-up and reaching the composite endpoint (death, cardiovascular hospitalization, treatment failure), respectively. RESULTS One hundred eight patients were included in the study. At baseline, 63% (68/108) of patients had normal RVSP and 37% (40/108) having elevated RVSP. After a follow-up of 4 years, 70% (76/108) patient had normal RVSP while 30% (32/108) had elevated RVSP. 8 (10%) out of the 76 patients with normal RVSP and 15 (47%) out of the 32 patients with elevated RVSP reached the composite endpoint of death, cardiovascular hospitalization or technique failure. In a multivariate analysis, age, diabetes and smoking were not associated with elevated RVSP at follow-up. Elevated RVSP at baseline was not associated with a higher likelihood in reaching the composite endpoint or mortality. CONCLUSION Mean RVSP did not increase in patients on IHHD over time, and maintenance of normal RVSP was associated with better clinical outcomes.
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Affiliation(s)
- Michael Girsberger
- Division of Nephrology, University Health Network, 200 Elizabeth Street, 8N room 846, Toronto, ON, M5G 2C4, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, 200 Elizabeth Street, 8N room 846, Toronto, ON, M5G 2C4, Canada.
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14
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Budhram B, Sinclair A, Komenda P, Severn M, Sood MM. A Comparison of Patient-Reported Outcome Measures of Quality of Life By Dialysis Modality in the Treatment of Kidney Failure: A Systematic Review. Can J Kidney Health Dis 2020; 7:2054358120957431. [PMID: 33149924 PMCID: PMC7580133 DOI: 10.1177/2054358120957431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/15/2020] [Indexed: 12/19/2022] Open
Abstract
Background: There is an increasing demand to incorporate patient-reported outcome measures (PROMs) such as quality of life (QOL) in decision-making when selecting a chronic dialysis modality. Objective: To compare the change in QOL over time among similar patients on different dialysis modalities to provide unique and novel insights on the impact of dialysis modality on PROMs. Design: Systematic reviews, randomized controlled trials, and nonrandomized controlled trials were examined via a comprehensive search strategy incorporating multiple bibliographic databases. Setting: Data were extracted from relevant studies from January 1, 2000 to December 31, 2019 without limitations on country of study conduction. Patients: Eligible studies included adults (≥18 years) with end-stage kidney disease of any cause who were prescribed dialysis treatment (either as lifetime treatment or bridge to transplant). Measurements: The 5 comparisons were peritoneal dialysis (PD) vs in-center hemodialysis (ICHD), home hemodialysis (HHD) vs ICHD, HHD modalities compared with one another, HHD vs PD, and self-care ICHD vs traditional nurse-based ICHD. Methods: Included studies compared adults on different dialysis modalities with repeat measures within individuals to determine changes in QOL between dialysis modalities (in-center or home dialysis). Methodological quality was assessed by the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. A narrative synthesis was conducted, synthesizing the direction and size of any observed effects across studies. Results: Two randomized controlled trials and 9 prospective cohort studies involving a combined total of 3711 participants were included. Comparing PD and ICHD, 5 out of 9 studies found significant differences (P < .05) favoring PD in the change of multiple QOL domains, including “physical component score,” “role of social component score,” “cognitive status,” “role limitation due to emotional function,” “role limitation due to physical function,” “bodily pain,” “burden of kidney disease,” “effects of kidney disease on daily life,” “symptoms/problems,” “sexual function,” “finance,” and “patient satisfaction.” Conversely, 3 of these studies demonstrated statistically significant differences (P < .05) favoring ICHD in the domains of “role limitation due to physical function,” “general health,” “support from staff,” “sleep quality,” “social support,” “health status,” “social interaction,” “body image,” and “overall health.” Comparing HHD and ICHD, significant differences (P < .05) favoring HHD for the QOL domains of “general health,” “burden of kidney disease,” and the visual analogue scale were reported. Limitations: Our study is constrained by the small sample sizes of included studies, as well as heterogeneity among both study populations and validated QOL scales, limiting inter-study comparison. Conclusions: We identified differences in specific QOL domains between dialysis modalities that may aid in patient decision-making based on individual priorities. Trial registration: PROSPERO Registration Number: CRD42016046980. Primary funding source: The original research for this study was derived from the Canadian Agency for Drugs and Technologies in Health (CADTH) 2017 optimal use report, titled “Dialysis Modalities for the Treatment of End-Stage Kidney Disease: A Health Technology Assessment.” The CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
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Affiliation(s)
- Brandon Budhram
- The Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | - Alison Sinclair
- Canadian Agency for Drugs and Technologies in Health, Ottawa, ON, Canada
| | - Paul Komenda
- Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Melissa Severn
- Canadian Agency for Drugs and Technologies in Health, Ottawa, ON, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
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15
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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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16
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Wilk AS, Tang Z, Hoge C, Plantinga LC, Lea JP. Association between patient psychosocial characteristics and receipt of in‐center nocturnal hemodialysis among prevalent dialysis patients. Hemodial Int 2019; 23:479-485. [DOI: 10.1111/hdi.12782] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 07/25/2019] [Accepted: 08/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public HealthEmory University Atlanta Georgia USA
| | - Zhaoli Tang
- Department of Health Policy and Management, Rollins School of Public HealthEmory University Atlanta Georgia USA
| | - Courtney Hoge
- Department of Epidemiology, Rollins School of Public HealthEmory University Atlanta Georgia USA
| | - Laura C. Plantinga
- Department of Epidemiology, Rollins School of Public HealthEmory University Atlanta Georgia USA
- Division of Renal Medicine, Department of MedicineEmory University School of Medicine Atlanta Georgia USA
| | - Janice P. Lea
- Division of Renal Medicine, Department of MedicineEmory University School of Medicine Atlanta Georgia USA
- Emory Dialysis CentersEmory Healthcare Atlanta Georgia USA
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17
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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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18
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Wong CKH, Chen JY, Fung SKS, Lo WK, Lui SL, Chan TM, Cheng YL, Kong I, Wan EYF, Lam CLK. Health-related quality of life and health utility of Chinese patients undergoing nocturnal home haemodialysis in comparison with other modes of dialysis. Nephrology (Carlton) 2019; 24:630-637. [PMID: 29926521 DOI: 10.1111/nep.13429] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND To compare the health-related quality of life (HRQOL) and health utility of Chinese patients with end-stage renal disease (ESRD) undergoing nocturnal home haemodialysis (Home HD) against those patients undergoing other modes of dialysis. METHODS Chinese ESRD patients undergoing Home HD were recruited in renal specialist outpatient clinics at three public hospitals in Hong Kong. SF-12 Health Survey (SF-12) was used to measure HRQOL and generate the SF-6D heath utility score. Mean scores of SF-12 domains, physical and mental component summary and SF-6D health utility of 41 patients undergoing Home HD were compared with available scores of patients receiving other forms of dialysis, namely, peritoneal dialysis (PD) (n = 103), hospital in-centre HD (n = 135) or community in-centre HD (n = 118). Adjusted linear regression models were used to examine the impact of mode of dialysis on the HRQOL and health utility scores, accounting for the sociodemographic and clinical characteristics. RESULTS ESRD patients undergoing PD and community in-centre HD had better health utility, physical and mental component summary scores than the hospital in-centre HD. Adjusted analysis showed that hospital in-centre HD reported worse physical component summary and health utility scores when compared with PD and community in-centre HD. CONCLUSION HRQOL and health utility scores of patients undergoing Home HD were similar to those undergoing PD and community in-centre HD. Better physical aspects of HRQOL and health utility was observed in PD and community-based HD than hospital in-centre HD, providing evidence for the increase in capacity of non-hospital-based HD, which provided flexibility as well as patient centredness and empowerment in Hong Kong.
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Affiliation(s)
- Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Julie Y Chen
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China.,Bau Institute of Medical and Health Sciences Education, The University of Hong Kong, Hong Kong SAR, China
| | - Samuel K S Fung
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
| | - Sing Leung Lui
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
| | - Tak Mao Chan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yuk Lun Cheng
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Irene Kong
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Eric Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
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19
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20
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Li L, Tang X, Kim S, Zhang Y, Li Y, Fu P. Effect of nocturnal hemodialysis on sleep parameters in patients with end-stage renal disease: a systematic review and meta-analysis. PLoS One 2018; 13:e0203710. [PMID: 30204790 PMCID: PMC6133364 DOI: 10.1371/journal.pone.0203710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/24/2018] [Indexed: 02/05/2023] Open
Abstract
Introduction Recently, a small but growing literature has depicted the beneficial effects of nocturnal hemodialysis (NHD) over conventional hemodialysis (CHD) in the fields of sleep disorders such as sleep apnea. The impact of various dialysis models on sleep disorders, however, has not been determined. The objective of our meta-analysis is to examine the potential effects of NHD, compared with CHD, on sleep disorders in HD patients. Methods Several electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and CNKI were searched, using the search terms “nocturnal” (or “nightly”) and “dialysis” (or “hemodialysis” or “renal dialysis”) from the earliest available date of indexing to March 2018. Two authors independently extracted data, evaluated the study quality, and conducted random-effects meta-analyses using STATA 12.0. Results Of 1789 potentially relevant citations, 9 fulfilled eligibility criteria, consisting of 6 single-arm studies (comparing pre- and post-intervention outcomes), 1 observational study, and 2 randomized controlled trials (a total of 286 participants). Regarding objective sleep assessments, conversion from CHD to NHD resulted in a significant reduction in the AHI (Mean difference was -14.90; 95% CI, -20.12 to -9.68), a significant increase of SaO2 (Mean difference was 1.38%; 95% CI, 0.35% to 2.42%), and a significant decrease of TST (Mean difference was -0.31; 95% CI, -0.47 to -0.15). The trends were even stronger in the HD patients with sleep disorders. However, regarding subjective sleep assessments, improved sleep quality was found in the prospective pre-post intervention studies and cohort studies, while no significant improvements were found in the randomized controlled trials. Conclusion Although a significant improvement of sleep apnea was observed by switching from CHD to NHD, it may not yield a net benefit in overall subjective sleep quality.
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Affiliation(s)
- Lingzhi Li
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Xi Tang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Ye Zhang
- Sleep Medicine Center, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Li
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
- West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, China
- * E-mail:
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21
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Left Atrial Remodeling Assessed by Cardiac MRI after Conversion from Conventional Hemodialysis to In-Centre Nocturnal Hemodialysis. J Nephrol 2018; 32:273-281. [PMID: 30168083 DOI: 10.1007/s40620-018-0522-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/08/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Left atrial (LA) volume is a well-established cardiovascular prognosticator in patients with end-stage renal disease. Although dialysis intensification is associated with left ventricular mass regression, there are limited data regarding LA remodeling. Using cardiac magnetic resonance imaging (CMR), we examined changes in LA size and function relative to ventricular remodeling and cardiac biomarkers after dialysis intensification. METHODS In this prospective 2-centre cohort study, 37 patients receiving conventional hemodialysis (CHD, 4 h/session, 3×/week) were converted to in-centre nocturnal hemodialysis (INHD 7-8 h/session, 3×/week); 30 patients remained on CHD. CMR and biomarkers were performed at baseline and repeated at 52 weeks. RESULTS After 52 weeks, there were no significant changes in the LA volumes or LA ejection fraction (EF) within either the CHD or INHD group, and no significant differences between the two groups. Correlations existed between changes in LA and LV end-diastolic volume index (EDVi, Spearman's r = 0.69, p < 0.001), LA and LV end-systolic volume index (ESVi, r = 0.44, p = 0.001), LAEF and LVEF (r = 0.28, p = 0.04), LA and RV EDVi (r = 0.51, p < 0.001), LA and RV ESVi (r = 0.29, p = 0.039), and LA ESVi and LV mass index (r = 0.31, p = 0.02). At baseline, indexed LA volumes positively correlated with NT-proBNP, whereas LAEF negatively correlated with NT-proBNP and Troponin I. After 52 weeks, changes in biomarker levels did not correlate with changes in LA volume or EF. CONCLUSION There was no significant change in LA size or systolic function after conversion to INHD. The significant correlations between LA and ventricular remodeling and cardiac biomarkers suggest common underlying pathophysiologic mechanisms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00718848.
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Dai H, Zhou J, Zhu B. Gene co-expression network analysis identifies the hub genes associated with immune functions for nocturnal hemodialysis in patients with end-stage renal disease. Medicine (Baltimore) 2018; 97:e12018. [PMID: 30212930 PMCID: PMC6156040 DOI: 10.1097/md.0000000000012018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/28/2018] [Indexed: 01/14/2023] Open
Abstract
End-stage renal disease (ESRD) is the final stage of chronic kidney disease in which the kidney is not sufficient to meet the needs of daily life. It is necessary to understand the role of genes expression involved in ESRD patient responses to nocturnal hemodialysis (NHD) and to improve the immunity responsiveness. The aim of this study was to investigate novel immune-associated genes that may play important roles in patients with ESRD.The microarray expression profiles of peripheral blood in patients with ESRD before and after NHD were analyzed by network-based approaches, and then using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes pathway analysis to explore the biological process and molecular functions of differentially expressed genes. Subsequently, a transcriptional regulatory network of the core genes and the connected transcriptional regulators was constructed. We found that NHD had a significant effect on neutrophil activation and immune response in patients with ESRD.In addition, Our findings suggest that MAPKAPK3, RHOA, ARRB2, FLOT1, MYH9, PRKCD, RHOG, PTPN6, MAPK3, CNPY3, PI3KCG, and PYGL genes maybe potential targets regulated by core transcriptional factors, including ARNT, C/EBPalpha, CEBPA, CREB1, PSG1, DAND5, SP1, GATA1, MYC, EGR2, and EGR3.
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Jansz TT, Özyilmaz A, Grooteman MPC, Hoekstra T, Romijn M, Blankestijn PJ, Bots ML, van Jaarsveld BC. Long-term clinical parameters after switching to nocturnal haemodialysis: a Dutch propensity-score-matched cohort study comparing patients on nocturnal haemodialysis with patients on three-times-a-week haemodialysis/haemodiafiltration. BMJ Open 2018. [PMID: 29523566 PMCID: PMC5855195 DOI: 10.1136/bmjopen-2017-019900] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Nocturnal haemodialysis (NHD), characterised by 8-hour sessions ≥3 times a week, is known to improve clinical parameters in the short term compared with conventional-schedule haemodialysis (HD), generally 3×3.5-4 hours a week. We studied long-term effects of NHD and used patients on conventional HD/haemodiafiltration (HDF) as controls. DESIGN Four-year prospective follow-up of patients who switched to NHD; we compared patients with patients on HD/HDF using propensity score matching. SETTING 28 Dutch dialysis centres. PARTICIPANTS We included 159 patients starting with NHD any time since 2004, aged 56.7±12.9 years, with median dialysis vintage 2.3 (0.9-5.1) years. We propensity-score matched 100 patients on NHD to 100 on HD/HDF. PRIMARY AND SECONDARY OUTCOME MEASURES Control of hypertension (predialysis blood pressure, number of antihypertensives), phosphate (phosphate, number of phosphate binders), nutritional status and inflammation (albumin, C reactive protein and postdialysis weight) and anaemia (erythropoiesis-stimulating agent (ESA) resistance). RESULTS Switching to NHD was associated with a non-significant reduction of antihypertensives compared with HD/HDF (OR <2 types 2.17, 95% CI 0.86 to 5.50, P=0.11); and a prolonged lower need for phosphate binders (OR <2 types 1.83, 95% CI 1.10 to 3.03, P=0.02). NHD was not associated with significant changes in blood pressure or phosphate. NHD was associated with significantly higher albumin over time compared with HD/HDF (0.70 g/L/year, 95% CI 0.10 to 1.30, P=0.02). ESA resistance decreased significantly in NHD compared with HD/HDF, resulting in a 33% lower ESA dose in the long term. CONCLUSIONS After switching to NHD, the lower need for antihypertensives, phosphate binders and ESA persists for at least 4 years. These sustained improvements in NHD contrast significantly with the course of these parameters during continued treatment with conventional-schedule HD and HDF. NHD provides an optimal form of dialysis, also suitable for patients expected to have a long waiting time for transplantation or those convicted to indefinite dialysis.
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Affiliation(s)
- Thijs Thomas Jansz
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Akin Özyilmaz
- Dialysis Centre Groningen, Groningen, The Netherlands
- Division of Nephrology, Department of Internal Medicine, University Medical Centre, Groningen, The Netherlands
| | - Muriel P C Grooteman
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Tiny Hoekstra
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Marieke Romijn
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michael L Bots
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Brigit C van Jaarsveld
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
- Diapriva Dialysis Centre, Amsterdam, The Netherlands
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Ju A, Unruh ML, Davison SN, Dapueto J, Dew MA, Fluck R, Germain M, Jassal SV, Obrador G, O’Donoghue D, Tugwell P, Craig JC, Ralph AF, Howell M, Tong A. Patient-Reported Outcome Measures for Fatigue in Patients on Hemodialysis: A Systematic Review. Am J Kidney Dis 2018; 71:327-343. [DOI: 10.1053/j.ajkd.2017.08.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 08/01/2017] [Indexed: 11/12/2022]
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Leypoldt JK, Agar BU, Akonur A, Gellens ME, Culleton BF. Steady State Phosphorus Mass Balance Model during Hemodialysis Based on a Pseudo One-Compartment Kinetic Model. Int J Artif Organs 2018. [DOI: 10.1177/039139881203501102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John K. Leypoldt
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Baris U. Agar
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Alp Akonur
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Mary E. Gellens
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Bruce F. Culleton
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
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Graham-Brown MPM, Churchward DR, Hull KL, Preston R, Pickering WP, Eborall HC, McCann GP, Burton JO. Cardiac Remodelling in Patients Undergoing in-Centre Nocturnal Haemodialysis: Results from the MIDNIGHT Study, a Non-Randomized Controlled Trial. Blood Purif 2017; 44:301-310. [PMID: 29084397 DOI: 10.1159/000481248] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 09/04/2017] [Indexed: 01/01/2023]
Abstract
Evidence suggests extended-hours haemodialysis (HD) may improve cardiovascular, medical and quality-of-life outcomes. In-centre nocturnal haemodialysis (INHD) is an established but underutilized method of providing extended-hours treatment. This 6-month, non-randomized controlled trial (ISRCTN16672784) recruited 13 INHD patients and 12 control patients on conventional HD. The effects of treatment on left ventricular (LV) structure, function and myocardial fibrosis were assessed using cardiac magnetic resonance imaging and native T1 mapping. Quality-of-life and clinical measures were also collected. INHD led to significant reductions in LV mass (-14.75 vs. +6.54 g; p = 0.02), global T1 (-30.62 vs. 0.4 ms; p = 0.05) and non-septal native T1 values (-30.93 vs. 8.96 ms; p = 0.02) over time. There were also significant improvements in serum phosphate (-0.39 vs. +0.02 mmol/L; p = 0.03) and reductions in ultrafiltration rates (-2.32 vs. +0.70 mL/h/kg p = 0.05) between INHD and controls. Six-months of INHD was associated with favourable LV remodelling and reduced myocardial fibrosis compared to patients on conventional haemodialysis.
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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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Kraus MA, Fluck RJ, Weinhandl ED, Kansal S, Copland M, Komenda P, Finkelstein FO. Intensive Hemodialysis and Health-Related Quality of Life. Am J Kidney Dis 2016; 68:S33-S42. [DOI: 10.1053/j.ajkd.2016.05.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 02/08/2023]
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O'Brien FJ, Fong KD, Sirich TL, Meyer TW. More Dialysis Has Not Proven Much Better. Semin Dial 2016; 29:481-490. [PMID: 27556575 DOI: 10.1111/sdi.12533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients maintained on standard three times weekly hemodialysis have a high mortality rate and a limited quality of life. Some of this illness is due to systemic diseases that have caused kidney failure, and thus may be irreversible. But we presume that imperfect replacement of normal kidney function by dialysis contributes importantly. Patients on hemodialysis are subject to fluctuations in extracellular fluid volume and inorganic ion concentrations and their plasma levels of many organic waste solutes remain very high. It is thus natural to suppose that their health could be improved by increasing the intensity of dialysis treatment. But despite a great deal of work over the past 20 years, evidence that such improvement can be obtained is generally lacking. Specific benefits can indeed be achieved. Patients who cannot control their intradialytic weight gains or plasma phosphate levels with standard therapy can benefit from extending treatment time. But we cannot promise the average patient that longer or more frequent treatment will reduce mortality or improve the quality of life.
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Affiliation(s)
- Frank J O'Brien
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California.
| | - Kara D Fong
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
| | - Tammy L Sirich
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
| | - Timothy W Meyer
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
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Maduell F, Ojeda R, Arias-Guillen M, Rossi F, Fontseré N, Vera M, Rico N, Gonzalez LN, Piñeiro G, Jiménez-Hernández M, Rodas L, Bedini JL. Eight-Year Experience with Nocturnal, Every-Other-Day, Online Haemodiafiltration. Nephron Clin Pract 2016; 133:98-110. [DOI: 10.1159/000446970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/19/2016] [Indexed: 12/15/2022] Open
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31
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Marshall MR, Polkinghorne KR, Kerr PG, Hawley CM, Agar JW, McDonald SP. Intensive Hemodialysis and Mortality Risk in Australian and New Zealand Populations. Am J Kidney Dis 2016; 67:617-28. [DOI: 10.1053/j.ajkd.2015.09.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/21/2015] [Indexed: 11/11/2022]
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32
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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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Thumfart J, Müller D. Nocturnal intermittent hemodialysis. Pediatr Nephrol 2015; 30:749-57. [PMID: 25103600 DOI: 10.1007/s00467-014-2869-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 10/24/2022]
Abstract
Preemptive renal transplantation is the method of choice for end stage renal disease in childhood and adolescence. However, without preemptive transplantation, waiting time for kidney transplantation might exceed several years. The poor quality of life and the extremely high morbidity and mortality rates of dialysis patients have led to the development of intensified hemodialysis programs in which the modes of dialysis (short daily, nocturnal intermittent or daily nocturnal) are different. Such programs have been shown to significantly improve several uremia-associated parameters, such as blood pressure, phosphate control, anemia and growth retardation, in both adult and pediatric (children and adolescents) patients and lead to a reduction in medications, including phosphate binders, erythropoietin and antihypertensive agents. Fluid limitations and dietary restrictions can also be lifted. With respect to psychosocial rehabilitation and quality of life, nocturnal intermittent dialysis programs provide a reasonable compromise of all forms of intensified programs. Experiences and practical approaches of our own in-center nocturnal intermittent hemodialysis program in the light of the recent publications are described in this review.
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Affiliation(s)
- Julia Thumfart
- Department of Pediatric Nephrology, Charité, Augustenburger Platz 1, 13353, Berlin, Germany
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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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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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Thumfart J, Pommer W, Querfeld U, Müller D. Intensified hemodialysis in adults, and in children and adolescents. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:237-43. [PMID: 24766711 PMCID: PMC4003444 DOI: 10.3238/arztebl.2014.0237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/20/2014] [Accepted: 01/20/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are now almost 70 000 dialysis patients in Germany. Conventional hemodialysis does not adequately compensate for malnutrition, arterial hypertension, renal osteopathy, and diminished performance ability. Various strategies for intensified hemodialysis have been implemented in an attempt to lower the considerable morbidity and mortality of end-stage renal failure. METHOD We selectively review the literature on intensified dialysis in adults, children, and adolescents. RESULTS In a randomized, controlled trial (RCT), a group of patients undergoing conventional dialysis was compared to a group undergoing brief, daily dialysis. Daily dialysis significantly improved the combined endpoint of left-ventricular hypertrophy or death (hazard ratio [HR] 0.61). In contrast, another, retrospective study found daily dialysis to be associated with higher mortality (15.6 vs. 10.9 deaths, HR 1.6). A prospective case-control study found nocturnal intermittent hemodialysis to be associated with lower mortality than conventional dialysis (1.77 vs. 6.23 per 100 patient-years); this result was confirmed in a further, retrospective study. An RCT on nocturnal dialysis performed every night revealed a significant regression of left-ventricular mass, yet the patients' quality of life improved only in individual domains specifically related to renal function. Small-scale studies of intensified hemodialysis in children and adolescents have found that it leads to a higher growth rate and weight gain. CONCLUSION Intensified hemodialysis techniques improve arterial blood pressure, uremia-associated variables, and psychosocial variables. They also lower the necessary doses of antihypertensive drugs and phosphate binders. Dietary restrictions need not be as stringent. Further prospective trials are needed for a reliable assessment of the effect of intensified hemodialysis on mortality and quality of life.
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Affiliation(s)
- Julia Thumfart
- Department of Pediatrics, Division of Nephrology, Charité-University Medicine Berlin
| | - Wolfgang Pommer
- Department of Internal Medicine—Division of Nephrology, Vivantes Humboldt-Klinikum, Berlin
| | - Uwe Querfeld
- Department of Pediatrics, Division of Nephrology, Charité-University Medicine Berlin
| | - Dominik Müller
- Department of Pediatrics, Division of Nephrology, Charité-University Medicine Berlin
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Nesrallah GE, Mustafa RA, MacRae J, Pauly RP, Perkins DN, Gangji A, Rioux JP, Steele A, Suri RS, Chan CT, Copland M, Komenda P, McFarlane PA, Pierratos A, Lindsay R, Zimmerman DL. Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis. Am J Kidney Dis 2013; 62:187-98. [DOI: 10.1053/j.ajkd.2013.02.351] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/14/2013] [Indexed: 11/11/2022]
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38
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Zimmerman DL, Nesrallah GE, Chan CT, Copland M, Komenda P, McFarlane PA, Gangji A, Lindsay R, MacRae J, Pauly RP, Perkins DN, Pierratos A, Rioux JP, Steele A, Suri RS, Mustafa RA. Dialysate calcium concentration and mineral metabolism in long and long-frequent hemodialysis: a systematic review and meta-analysis for a Canadian Society of Nephrology clinical practice guideline. Am J Kidney Dis 2013; 62:97-111. [PMID: 23591289 DOI: 10.1053/j.ajkd.2013.02.357] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/01/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
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Affiliation(s)
- Deborah L Zimmerman
- Division of Nephrology, Kidney Research Centre of the Ottawa Hospital Research Institute, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada.
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Abstract
Patients receiving conventional hemodialysis have high hospitalisation rates, poor quality of life and survival compared to the general population. Many centres around the world are providing longer hours of hemodialysis - short daily hemodialysis and nocturnal hemodialysis - with a view to improving patient survival and quality of life. Studies have shown that nocturnal haemodiaysis is more effective than conventional hemodialysis in clearing most small, middle and larger molecule toxins and suggest nocturnal dialysis enhances patient survival and quality of life. Concerns include patient acceptance, vascular access related complications and increased cost. The purpose of this review is to examine the advantages and drawbacks of nocturnal dialysis, with a focus on applicability to India where the renal physician has to face cultural and economic barriers, erratic power supply and poor water quality.
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Affiliation(s)
- D Ranganathan
- Department of Renal Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Leypoldt JK, Akonur A, Agar BU, Culleton BF. Physiologic volume of phosphorus during hemodialysis: Predictions from a pseudo one-compartment model. Hemodial Int 2012; 16 Suppl 1:S15-9. [DOI: 10.1111/j.1542-4758.2012.00742.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- John K. Leypoldt
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
| | - Alp Akonur
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
| | - Baris U. Agar
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
| | - Bruce F. Culleton
- Medical Products (Renal); Baxter Healthcare Corporation; McGaw Park; Illinois; USA
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Susantitaphong P, Tiranathanagul K, Katavetin P, Hanwiwatwong O, Wittayalertpanya S, Praditpornsilpa K, Tungsanga K, Eiam-Ong S. Efficacy Comparison Between Simple Mixed-Dilution and Simple Mid-Dilution On-Line Hemodiafiltration Techniques: A Crossover Study. Artif Organs 2012; 36:1059-65. [DOI: 10.1111/j.1525-1594.2012.01508.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Jin X, Rong S, Mei C, Ye C, Chen J, Chen X. Effects of In-Center Nocturnal Versus Conventional Hemodialysis on Endothelial Dysfunction. Ther Apher Dial 2012; 16:334-40. [DOI: 10.1111/j.1744-9987.2012.01070.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Guest S, Akonur A, Ghaffari A, Sloand J, Leypoldt JK. Intermittent peritoneal dialysis: urea kinetic modeling and implications of residual kidney function. Perit Dial Int 2012; 32:142-8. [PMID: 22135316 PMCID: PMC3525398 DOI: 10.3747/pdi.2011.00027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 07/21/2011] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intermittent peritoneal dialysis (IPD) is an old strategy that has generally been eclipsed, in the home setting, by daily peritoneal therapies. However, for a select group of patients with exhausted vascular access or inability to receive PD at home, in-center IPD may remain an option or may serve as an incremental strategy before initiation of full-dose PD. We investigated the residual kidney clearance requirements necessary to allow thrice-weekly IPD regimens to meet current adequacy targets. METHODS The 3-pore model of peritoneal transport was used to examine 2 thrice-weekly IPD dialysis modalities: 5 - 6 dwells with 10 - 12 L total volume (low-dose IPD), and 50% tidal with 20 - 24 L total volume (high-dose IPD). We assumed an 8-hour dialysis duration and 1.5% dextrose solution, with a 2-L fill volume, except in tidal mode. The PD Adequest application (version 2.0: Baxter Healthcare Corporation, Deerfield, IL, USA) and typical patient kinetic parameters derived from a large dataset [data on file from Treatment Adequacy Review for Gaining Enhanced Therapy (Baxter Healthcare Corporation)] were used to model urea clearances. The minimum glomerular filtration rate (GFR) required to achieve a total weekly urea Kt/V of 1.7 was calculated. RESULTS In the absence of any dialysis, the minimum residual GFR necessary to achieve a weekly urea Kt/V of 1.7 was 9.7 mL/min/1.73 m(2). Depending on membrane transport type, the low-dose IPD modality met urea clearance targets for patients with a GFR between 6.0 mL/min/1.73 m(2) and 7.6 mL/min/1.73 m(2). Similarly, the high-dose IPD modality met the urea clearance target for patients with a GFR between 4.7 mL/min/1.73 m(2) and 6.5 mL/min/1.73 m(2). CONCLUSIONS In patients with residual GFR of at least 7.6 mL/min/1.73 m(2), thrice-weekly low-dose IPD (10 L) achieved a Kt/V urea of 1.7 across all transport types. Increasing the IPD volume resulted in a decreased residual GFR requirement of 4.7 mL/min/1.73 m(2) (24 L, 50% tidal). In patients with residual kidney function and dietary compliance, IPD may be a viable strategy in certain clinical situations.
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Affiliation(s)
- Steven Guest
- Baxter Healthcare, Renal Division, McGaw Park, Illinois, USA.
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Susantitaphong P, Koulouridis I, Balk EM, Madias NE, Jaber BL. Effect of frequent or extended hemodialysis on cardiovascular parameters: a meta-analysis. Am J Kidney Dis 2012; 59:689-99. [PMID: 22370022 DOI: 10.1053/j.ajkd.2011.12.020] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 12/16/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Increased left ventricular (LV) mass is a risk factor for cardiovascular mortality in patients with chronic kidney failure. More frequent or extended hemodialysis (HD) has been hypothesized to have a beneficial effect on LV mass. STUDY DESIGN Meta-analysis. SETTING & POPULATION MEDLINE literature search (inception to April 2011), Cochrane Central Register of Controlled Trials and ClinicalTrials.gov using the search terms "short daily HD," "daily HD," "quotidian HD," "frequent HD," "intensive HD," "nocturnal HD," and "home HD." SELECTION CRITERIA FOR STUDIES Single-arm cohort studies (with pre- and post-study evaluations) and trials examining the effect of frequent or extended HD on cardiac morphology and function and blood pressure parameters. Studies of hemofiltration, hemodiafiltration, and peritoneal dialysis were excluded. INTERVENTION Frequent (2-8 hours, >3 times weekly) or extended (>4 hours, 3 times weekly) HD compared with conventional (≤4 hours, 3 times weekly) HD. OUTCOMES Absolute changes in cardiac morphology and function, including LV mass index (LVMI; primary) and blood pressure parameters (secondary). RESULTS We identified 38 single-arm studies, 5 crossover trials, and 3 randomized controlled trials. By meta-analysis of 23 study arms, frequent or extended HD significantly reduced LVMI from baseline (-31.2 g/m(2), 95% CI, -39.8 to -22.5; P < 0.001). The 3 randomized trials found a less pronounced net reduction in LVMI (-7.0 g/m(2); 95% CI, -10.2 to -3.7; P < 0.001). LV ejection fraction improved by 6.7% (95% CI, 1.6% to 11.9%; P = 0.01). Other cardiac morphologic parameters showed similar improvements. There also were significant decreases in systolic, diastolic, and mean blood pressure and mean number of antihypertensive medications. LIMITATIONS Paucity of randomized controlled trials. CONCLUSIONS Conversion from conventional to frequent or extended HD is associated with improvements in cardiac morphology and function, including LVMI and LV ejection fraction, respectively, and several blood pressure parameters, which collectively might confer long-term cardiovascular benefit. Trials with long-term clinical outcomes are needed.
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Affiliation(s)
- Paweena Susantitaphong
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St. Elizabeth's Medical Center, Boston, MA 02135, USA
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Lacson E, Xu J, Suri RS, Nesrallah G, Lindsay R, Garg AX, Lester K, Ofsthun N, Lazarus M, Hakim RM. Survival with three-times weekly in-center nocturnal versus conventional hemodialysis. J Am Soc Nephrol 2012; 23:687-95. [PMID: 22362905 DOI: 10.1681/asn.2011070674] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Whether the duration of hemodialysis treatments improves outcomes remains controversial. Here, we evaluated survival and clinical changes associated with converting from conventional hemodialysis (mean=3.75 h/treatment) to in-center nocturnal hemodialysis (mean=7.85 h/treatment). All 959 consecutive patients who initiated nocturnal hemodialysis for the first time in 77 Fresenius Medical Care facilities during 2006 and 2007 were eligible. We used Cox models to compare risk for mortality during 2 years of follow-up in a 1:3 propensity score-matched cohort of 746 nocturnal and 2062 control patients on conventional hemodialysis. Two-year mortality was 19% among nocturnal hemodialysis patients compared with 27% among conventional patients. Nocturnal hemodialysis associated with a 25% reduction in the risk for death after adjustment for age, body mass index, and dialysis vintage (hazard ratio=0.75, 95% confidence interval=0.61-0.91, P=0.004). With respect to clinical features, interdialytic weight gain, albumin, hemoglobin, dialysis dose, and calcium increased on nocturnal therapy, whereas postdialysis weight, predialysis systolic blood pressure, ultrafiltration rate, phosphorus, and white blood cell count declined (all P<0.001). In summary, notwithstanding the possibility of residual selection bias, conversion to treatment with nocturnal hemodialysis associates with favorable clinical features, laboratory biomarkers, and improved survival compared with propensity score-matched controls. The potential impact of extended treatment time on clinical outcomes while maintaining a three times per week hemodialysis schedule requires evaluation in future clinical trials.
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Affiliation(s)
- Eduardo Lacson
- Fresenius Medical Services, Fresenius Medical Care North America, Waltham, MA 02451-1457, USA.
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Effects of thrice weekly nocturnal hemodialysis on arterial stiffness. Atherosclerosis 2012; 220:477-85. [DOI: 10.1016/j.atherosclerosis.2011.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 11/04/2011] [Accepted: 11/10/2011] [Indexed: 11/20/2022]
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Wald R, Yan AT, Perl J, Jiang D, Donnelly MS, Leong-Poi H, McFarlane PA, Weinstein JJ, Goldstein MB. Regression of left ventricular mass following conversion from conventional hemodialysis to thrice weekly in-centre nocturnal hemodialysis. BMC Nephrol 2012; 13:3. [PMID: 22260388 PMCID: PMC3297503 DOI: 10.1186/1471-2369-13-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 01/19/2012] [Indexed: 01/20/2023] Open
Abstract
Background Increased left ventricular mass (LVM) is associated with adverse outcomes in patients receiving chronic hemodialysis. Among patients receiving conventional hemodialysis (CHD, 3×/week, 4 hrs/session), we evaluated whether dialysis intensification with in-centre nocturnal hemodialysis (INHD, 3×/week, 7-8 hrs/session in the dialysis unit) was associated with regression of LVM. Methods We conducted a retrospective cohort study of CHD recipients who converted to INHD and received INHD for at least 6 months. LVM on the first echocardiogram performed at least 6 months post-conversion was compared to LVM pre-conversion. In a secondary analysis, we examined echocardiograms performed at least 12 months after starting INHD. The effect of conversion to INHD on LVM over time was also evaluated using a longitudinal analysis that incorporated all LVM data on patients with 2 or more echocardiograms. Results Thirty-seven patients were eligible for the primary analysis. Mean age at conversion was 49 ± 12 yrs and 30% were women. Mean pre-conversion LVM was 219 ± 66 g and following conversion, LVM declined by 32 ± 58 g (p = 0.002). Among patients whose follow-up echocardiogram occurred at least 12 months following conversion, LVM declined by 40 ± 56 g (p = 0.0004). The rate of change of LVM decreased significantly from 0.4 g/yr before conversion, to -11.7 g/yr following conversion to INHD (p < 0.0001). Conclusion Conversion to INHD is associated with a significant regression in LVM, which may portend a more favourable cardiovascular outcome. Our preliminary findings support the need for randomized controlled trials to definitively evaluate the cardiovascular effects of INHD.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and Univerity of Toronto, Toronto, Ontario, Canada.
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Sirich TL, Luo FJG, Plummer NS, Hostetter TH, Meyer TW. Selectively increasing the clearance of protein-bound uremic solutes. Nephrol Dial Transplant 2012; 27:1574-9. [PMID: 22231033 DOI: 10.1093/ndt/gfr691] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The toxicity of bound solutes could be better evaluated if we could adjust the clearance of such solutes independent of unbound solutes. This study assessed whether bound solute clearances can be increased while maintaining urea clearance constant during the extended hours of nocturnal dialysis. METHODS Nine patients on thrice-weekly nocturnal dialysis underwent two experimental dialysis treatments 1 week apart. The experimental treatments were designed to provide the same urea clearance while providing widely different bound solute clearance. One treatment employed a large dialyzer and high dialyzate flow rate (Qd) of 800 mL/min while blood flow (Qb) was 270 mL/min. The other treatment employed a smaller dialyzer and Qd of 300 mL/min while Qb was 350 mL/min. RESULTS Treatment with the large dialyzer and higher Qd greatly increased the clearances of the bound solutes p-cresol sulfate (PCS: 27±9 versus 14±6 mL/min) and indoxyl sulfate (IS: 26±8 versus 14±5 mL/min) without altering the clearance of urea (204±20 versus 193±16 mL/min). Increasing PCS and IS clearances increased the removal of these solutes (PCS: 375±200 versus 207±86 mg/session; IS: 201±137 versus 153±74 mg/session), while urea removal was not different. CONCLUSIONS The removal of bound solutes can thus be increased by raising the dialyzate flow and dialyzer size above the low levels sufficient to achieve target Kt/V(urea) during extended treatment. Selectively increasing the clearance of bound solutes provides a potential means to test their toxicity.
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Affiliation(s)
- Tammy L Sirich
- Department of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, CA, USA.
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Lacson E, Diaz-Buxo J. In-center nocturnal hemodialysis performed thrice-weekly--a provider's perspective. Semin Dial 2011; 24:668-73. [PMID: 22106828 DOI: 10.1111/j.1525-139x.2011.00998.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Favorable clinical outcomes related to morbidity, mortality, patient well-being, laboratory biomarkers, and medication use have been reported with in-center nocturnal hemodialysis (INHD); nevertheless, it is not entirely clear how much patient selection or physiologic mechanisms related to better fluid management and phosphorus (and calcium) metabolism may explain these outcomes. There are indications that INHD may be a preferred treatment option in specific cases, such as in patients with high interdialytic weight gain, poor tolerance to high ultrafiltration rate, hyperphosphatemia, or for those patients who work or go to school during the day. In the era of the new prospective payment system where quality standards become intertwined with reimbursement, an INHD program may be a useful method to help attain quality goals in facilities that have patients with unfavorable case-mix. The experience of the past decade has shown INHD to be safe and well tolerated by patients. The growth of INHD therapy is a testament to sustainability and feasibility of this treatment option. Prospective clinical trials are needed in this area. If the promise of INHD is fulfilled, it may also prove to be a valuable option for potential success of Accountable Care Organizations where providers need to assume responsibility for more patient-centered care and improvement in clinical outcomes. In summary, based on the current experience, INHD is a viable and valuable option as an additional, alternative hemodialysis (HD) regimen to conventional HD.
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Affiliation(s)
- Eduardo Lacson
- Fresenius Medical Care, North America, Waltham, Massachusetts 02451-1457, USA.
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Agar BU, Akonur A, Lo YC, Cheung AK, Leypoldt JK. Kinetic model of phosphorus mobilization during and after short and conventional hemodialysis. Clin J Am Soc Nephrol 2011; 6:2854-60. [PMID: 22034502 DOI: 10.2215/cjn.03860411] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The kinetics of plasma phosphorus (inorganic phosphorus or phosphate) during hemodialysis treatments cannot be explained by conventional one- or two-compartment models; previous approaches have been limited by assuming that the distribution of phosphorus is confined to classical intracellular and extracellular fluid compartments. In this study a novel pseudo one-compartment model, including phosphorus mobilization from a large second compartment, was proposed and evaluated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Clinical data were obtained during a crossover study where 22 chronic hemodialysis patients underwent both short (2-hour) and conventional (4-hour) hemodialysis sessions. The model estimated two patient-specific parameters, phosphorus mobilization clearance and phosphorus central distribution volume, by fitting frequent intradialytic and postdialytic plasma phosphorus concentrations using nonlinear regression. RESULTS Phosphorus mobilization clearances varied among patients (45 to 208 ml/min), but estimates during short (98 ± 44 ml/min, mean ± SD) and conventional (99 ± 47 ml/min) sessions were not different (P = 0.74) and correlated with each other (concordance correlation coefficient ρ(c) of 0.85). Phosphorus central distribution volumes for each patient (short: 11.0 ± 4.2 L and conventional: 11.9 ± 3.8 L) were also correlated (ρ(c) of 0.45). CONCLUSIONS The reproducibility of patient-specific parameters during short and conventional hemodialysis treatments suggests that a pseudo one-compartment model is robust and can describe plasma phosphorus kinetics under conditions of clinical interest.
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Affiliation(s)
- Baris U Agar
- Renal (MedicalProducts), Baxter Healthcare Corporation, McGaw Park, Illinois, USA
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