Beginning Of Hemodialysis Treatment Research Articles

#4298 DOES STARTING RENAL REPLACEMENT THERAPY WITH INCREMENTAL HAEMODIALYSIS WORSEN OUTCOMES?

Abstract Background and Aims Most patients start maintenance haemodialysis (HD) with a fixed dose of 3 HD sessions per week (3HD/Wk), regardless of their residual kidney function (RKF). This intense schedule is considered the “standard” or “conventional” modality (cHD). It is widely accepted, and no randomised controlled trial (RCT) has examined whether other less frequent schedules are inappropriate or harmful. Thus, the optimal modality for incident patients is currently unknown. Incremental HD (iHD), on the other hand, adjusts the frequency of sessions to the RKF, increasing their number to compensate for any subsequent reduction in RKF. While iHD approaches precision medicine by customising the number of sessions, it raises concerns about long intersession periods and the risk of under-dialysis. Pending ongoing RCTs [1], our aim is to analyse the efficacy and safety of iHD in our incident patients. Method The policy of our Centre is to try to start with iHD in incident patients who are clinically stable and with RKF. We start with 1 session (1HD/Wk) if the RKF is above 4 ml/min/1.73 m2 and with 2 sessions (2HD/Wk) if the RKF is between 4 and 2.5 ml/min/1.73 m2. We progress from 1HD/Wk to 2HD/Wk and from 2 to 3HD/Wk depending on the RKF and ultrafiltration rates required, which are assessed at least monthly. Since 2012, we have treated 186 incident patients with iHD, of whom 168 had a follow up ≥ 90 days. 72% (128 patients) started with 1HD/Wk and the remaining 28% (40 patients) with 2HD/Wk. We compared the results with 410 incident patients who from baseline receive 3 sessions/Wk (cHD) and with 80 incident patients on Peritoneal Dialysis (PD). We also analysed 27 iHD patients who after 60 days were already dialysed with 3 sessions (3HD/Wk/60d group). We calculated the mortality rate (deaths/365 days in %) in each group and survival in the iHD technique (sessions not performed). Results The mean age in the iHD group was higher than in cHD or PD (Table 1). Mortality in iHD patients was similar to cHD patients, although the latter were younger. Patients who stayed less time in iHD (3HD/Wk/60d group) had the highest mortality rate (Table 1). Survival in technique (time in which 50% of patients remain on iHD) was 12 months, avoiding 86 sessions/patient. The cost reduction was €17,200/patient (session + transport = €200). Conclusion iHD is efficient, as it considerably reduces the number of sessions performed and thus costs, thereby improving quality of life. It is safe, as it has a similar mortality rate to cHD. Being on iHD for more than 60 days does not worsen the results. On the contrary, requiring 3 weekly sessions at the beginning of HD treatment may be associated with a poor prognosis.

MO746CARDIAC REMODELING AND PULMONARY HYPERTENSION IN HEMODIALYSIS PATIENTS

Abstract Background and Aims An important predictor of cardiovascular mortality and morbidity in hemodialysis patients is left ventricular hypertrophy. Also, pulmonary hypertension is a risk factor for mortality and cardiovascular events in hemodialysis patients. The aim of this study was to investigate cardiac remodeling and the dynamics of pulmonary arterial pressure during a year-long hemodialysis treatment and to evaluate relationship between pulmonary arterial pressure and blood flow in arteriovenous fistula. Method Hemodialysis patients (n=88; 42 males, 46 females, mean age was 51.7±13.0 years) were studied. Echocardiography and Doppler echocardiography were performed in the beginning of hemodialysis treatment and after a year. Echocardiographic evaluation was carried out on the day after dialysis. Left ventricular mass index (LVMI) was calculated. Left ventricular ejection fraction (LVEF) was measured by the echocardiographic Simpson method. Arteriovenous fistula flow was determined by Doppler echocardiography. Pulmonary hypertension was diagnosed according to criteria of Guidelines for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology. Results Pulmonary hypertension was diagnosed in 47 (53.4%) patients. Left ventricular hypertrophy was revealed in 71 (80.7%) patients. Only 2 (2.3%) patients had LVEF<50%. At the beginning of hemodialysis correlation was detected between systolic pulmonary arterial pressure and LVMI (r=0.52; P<0.001). Systolic pulmonary arterial pressure negatively correlated with left ventricular ejection fraction (r=-0.20; P=0.04). After a year of hemodialysis treatment LVMI decreased from 140.49±42.95 to 123.25±39.27 g/m2 (р=0.006) mainly due to a decrease in left ventricular end-diastolic dimension (from 50.23±6.48 to 45.13±5.24 mm, p=0.04) and systolic pulmonary arterial pressure decreased from 44.83±14.53 to 39.14±10.29 mmHg (р=0.002). Correlation wasn’t found between systolic pulmonary arterial pressure and arteriovenous fistula flow (r=0.17; p=0.4). Conclusion Pulmonary hypertension was diagnosed in half of patients at the beginning of hemodialysis treatment. Pulmonary hypertension in hemodialysis patients was associated with left ventricular hypertrophy, systolic left ventricular dysfunction. After a year-long hemodialysis treatment, a regress in left ventricular hypertrophy and a partial decrease in pulmonary arterial pressure were observed. There wasn’t correlation between arteriovenous fistula flow and systolic pulmonary arterial pressure.

Assessment of the muscular strength of the global handgrip and physical activity in patients treated with renal replacement therapy (RRT) by hemodialysis

Introduction
 Chronic Kidney Disease (CKD) is a social problem. Hemodialysis is the most common method of renal replacement therapy. At the beginning of hemodialysis treatment, physical activity is reduced by 50-60%. The aim of the study was to compare physical activity, handgrip strength and selected anthropometric parameters, and to assess the relationship between handgrip strength, selected anthropometric parameters and the level of physical activity.
 Material and methods 
 The study included 30 patients aged 65.92 ± 14.65 treated by hemodialysis. The study consisted of patients completing a proprietary survey questionnaire, assessing physical activity using the International Physical Activity Questionnaire (IPAQ), handgrip strength, and performing selected anthropometric measurements. The examinations were performed at baseline (E0) and after three months of hemodialysis (E3) treatment and the results were compared.
 Results 
 There were no significant differences in the study group for physical activity and global handgrip strength at baseline and after three months of the study. There was no statistically significant differences beetwen physical activity and handgrip strength in study and control group. 
 Conclusions
 Patients treated with renal replacement present less physical activity compared to people with normal kidney function. The BMI value and level of physical activity does not affect the handgrip strength in hemodialysis patients.

Different response to human recombinant erythropoietin in patients undergoing hemodialysis treatment

Treatment with recombinant human erythropoietin enabled the correction of anemia in the patients on regular hemodialysis but large individual differences in the dose required to achieve the target hemoglobin level were observed. In this study the erythropoietin resistance index was calculated in patients on hemodialysis in order to examine variations in the response to erythropoietin and factors that influence it. The study included 48 patients (25 males) of mean age 67.5 years, who had been on regular hemodialysis in Samac for 43.9 months on average. All were treated with erythropoietin from the beginning of hemodialysis treatment. Their response to erythropoietin therapy was estimated by the erythropoietin resistance index. The use of erythropoietin enabled the correction of anemia but different doses were needed to achieve and maintain the target hemoglobin level. The individual weekly dose of erythropoietin ranged from 15 U/kg/week to 244 U/kg/week and the erythropoietin resistance index ranged from 0.13 U/kg/week/g/l to 2.46 U/kg/week/g/l. A satisfactory erythropoietin response with erythropoietin resistance index below 0.5 U/kg/week/g/l was found in 14 (30%) patients, while 19 (40%) patients had this index above 0.7 U/kg/week/g/l and 10 (21%) above 0.9 U/kg/week/g/l. Multivariate linear regression analysis detected C-reactive protein as a significant predictor of erythropoietin resistance index. Target hemoglobin levels were achieved and maintained by different doses of erythropoietin in individual patients, which resulted in great individual differences in response as estimated by the erythropoietin resistance index. Multivariate analysis indicated C-reactive protein as a variable significantly associated with this index.

Recovery of renal function in patients receiving haemodialysis treatment.

The aim of this study was to review all cases of recovery of renal function in chronic haemodialysis patients, observed in the last ten years. During the study period, 218 chronic renal failure patients were managed on haemodialysis for a minimum of 90 days. In 17 cases (8%), it was possible to interrupt dialysis after 95 to 529 days. The probability of renal function recovery was higher in patients with chronic interstitial nephritis (P=.04) or autoimmune diseases (P=.07), as well as in those starting haemodialysis treatment at a frequency of two sessions per week (P=.02). No significant differences in age, gender, glomerular filtration rate at the beginning of haemodialysis treatment, or comorbidity rate were observed. Seven patients returned to haemodialysis treatment after a dialysis-free period of 11 +/- 7 months. Two patients died for reasons unrelated to renal failure treatment, and another patient was moved to another hospital following 35 months without dialysis. The other 14 patients are alive and 8 are dialysis-free, with a monitoring period of 13 to 106 months. The conclusion reached is that there is no reason why residual kidney function should inexorably worsen after the start of haemodialysis treatment, and that functional recovery is possible in some patients.

A Case of IgG4-related Tubulointerstitial Nephritis Diagnosed after the Beginning of Hemodialysis Treatment

A Case of IgG4-related Tubulointerstitial Nephritis Diagnosed after the Beginning of Hemodialysis Treatment

Influence of blood pressure control on maintenance of residual function in patients treated by haemodialysis

Residual renal function (RRF) in the patients treated by haemodialysis (HD) is associated not only with better volume and blood pressure control but also with better metabolic control.The condition of the cardiovascular system significantly affects RRF. The aim of the study was to find if there was any association between blood pressure regulation and the achieved HD ultrafiltration in the first year of haemodialysis treatment and the maintenance of RRF. In this retrospective study, 53 patients were analyzed in the period 1994-2002. Residual clearance of urea (RCU) was measured for the first time at the beginning of HD treatment, and for the second time one year later. Laboratory data and values of blood pressure as well as the achieved HD ultrafiltration were taken from the electronic database of the Nephrology Hospital. The value of RCU less than 1 ml/min was considered as the loss of RRF and, at the beginning of HD treatment, 14 patients (26.4%) had that result. The rise of mean arterial pressure (MAP) was associated in linear regression analysis with a drop of residual diuresis volume (beta = -0.28; p = 0.04), but there was no association with RCU. The patients with MAP > 105 mm Hg had RKU less than the patients with MAP < 105 mm Hg (t = 2.23; p = 0.03). The rise of the HD ultrafiiltration significantly affected the loss of RRF obtained by the linear regression analysis (beta = -0.44; p = 0.0001). The greater HD ultrafiltration is related to a drop of RCU values. Only prospective randomised trials with the use of multiple regression analysis could define a more precise association between hypertension and RKU.

Association between Mean Arterial Pressure and Mortality in Chronic Hemodialysis Patients

Background/Aims: Low mean arterial pressure (MAP) is associated with poor outcome in patients with cardiovascular disease; however, the prognostic role of MAP for chronic hemodialysis (HD) patients is unknown. This study was conducted to determine the association between MAP and mortality in chronic HD patients. Methods: We prospectively analyzed all chronic HD patients between February 2001 and February 2006. The averages of blood pressure measurements from the beginning of HD treatment or February 2001 were analyzed using Kaplan-Meier analysis with log-rank tests and stepwise forward Cox regression with adjustments for age, gender, and diabetes. Results: In an average of 36.3 ± 20.2 months, 834 patients (414 men and 420 women) were analyzed and 205 (24.6%) patients died. Patients with predialytic MAP <90 mm Hg and patients with an increase of MAP >15 mm Hg during HD sessions were associated with increasing mortality in Kaplan-Meier analysis (p = 0.033 and p = 0.012). In adjusted Cox regression, predialytic MAP <90 mm Hg and MAP rose with HD was associated with an increase hazard of death (p = 0.044 and p = 0.002). Conclusion: We found that lower predialytic mean arterial pressure and mean arterial pressure rose with HD treatment is associated with increasing mortality in Asia HD patients. More interventional studies are needed to determine the optimal treatment for hypertensive HD patients.

An Electrocardiogram-Based Method for Early Detection of Abrupt Changes in Blood Pressure during Hemodialysis

Clinical techniques for early detection of acute hypotension during conventional hemodialysis treatment are lacking, even though intradialytic hypotension is the most common acute complication. In this article, intradialytic hypotension is identified by means of signal analysis of data recorded at two clinics. The database consists of 30 treatments with concurrently acquired signals: the 12-lead electrocardiogram, continuous blood pressure, hematocrit, oxygen saturation, relative blood volume, and important hemodialysis variables. This article presents two characteristics, a heart rate turbulence (HRT) measure called turbulence slope (TS), and the LF/HF ratio, which provide information, at the beginning of hemodialysis treatment, on the patient's propensity to hypotension (TS: p = 0.0038, and LF/HF ratio: p = 0.0028). The authors also present a novel dynamic echocardiography-based method for detecting intradialytic hypotension using complementary information on heart rate variability (HRV) and ectopic beat patterns. These two types of information reflect different mechanisms of cardiac activity. It is essential that both types are used for the detection of hypotension, because HRV analysis is inappropriate when several ectopic beats are present. The proposed dynamic echocardiography-based method offers early identification of the cases with acute intradialytic hypotension of the database.

Left ventricular hypertrophy and risk factors for its development in uraemic patients

Cardiovascular diseases are the major cause of mortality in uraemic patients treated by hemodialysis. Left ventricular hypertrophy (LVH) is considered to be a major cardiac risk factor. To investigate the presence of some potential adverse risk factors in hemodialysis patients with developed LVH echocardiography verified and determine their relative contribution to the LVH in comparison with patients with normal LV. The study included 50 patients with end-stage renal disease in the first 2 years of hemodialysis treatment, who were followed up during one year. All participants have the echocardiography performed as well as serial measurements of potential modifiable cardiovascular risk factors. This investigation showed that LVH is present in high percentage (72%) in uraemic patients, even at the beginning of hemodialysis treatment. This LV morphological abnormality is statistically significantly related to anaemia (p<0,001), systolic (p<0,001) and diastolic hypertension (p<0,001)), elevated mean arterial pressure (p<0,001) and hyperparathyroidism (p=0,002). Modification of existing risk factors in uraemic patients could contribute to prevention and treatment of LV hypertophy and thus reduce cardiovascular morbidity and mortality.

Prognostic value of stress myocardial perfusion imaging using adenosine triphosphate at the beginning of haemodialysis treatment in patients with end-stage renal disease.

Non-invasive detection of coronary artery disease (CAD) remains difficult in patients with end-stage renal disease (ESRD). This study evaluated the ability of pharmacologic stress myocardial perfusion imaging to predict cardiac events in patients with ESRD. A prospective study was carried out in 49 consecutive patients with ESRD. Thallium-201 single photon emission computed tomography (SPECT) using high-dose adenosine triphosphate (ATP) was performed within 1 month of the beginning of haemodialysis. The study end-point was a cardiac event or the 1-year anniversary of the SPECT study. Twenty-four patients (17 diabetics, 57% and seven non-diabetics, 37%) had myocardial perfusion defects. The remaining 25 patients had normal perfusion images. Fifteen patients had non-fatal cardiac events and two patients died of a cardiac cause. All patients who had non-fatal cardiac events underwent myocardial revascularization and survived until the end of follow-up. The 1-year cardiac event-free survival rate was 34% among patients with perfusion defects and 96% among patients without perfusion defects (P<0.001). The presence of a myocardial perfusion defect was the only independent predictor of 1-year cardiac events both in overall (HR, 49.91; 95% CI, 5.15-484.00; P<0.001) and in diabetic patients (HR, 33.72; 95% CI, 2.96-383.5; P = 0.005). Diabetes and an increased C-reactive protein were associated with the progression of CAD. Normal myocardial perfusion imaging by stress thallium-201 SPECT using high-dose ATP performed within 1 month after the beginning of haemodialysis treatment is a powerful predictor of cardiac event-free survival in patients with ESRD.

ACE inhibitors in hemodialysis patients: Does survival improve?

ACE inhibitors in hemodialysis patients: Does survival improve?

Chronic Induction of C-Reactive Protein by Hemodialysis, but Not by Peritoneal Dialysis Therapy

Evaluation of the inflammatory activity in patients on chronic peritoneal dialysis (PD) and patients on chronic hemodialysis (HD) in comparison to patients with chronic renal insufficiency without dialysis treatment and healthy volunteers. Open, nonrandomized prospective study. Nephrology Department, including HD and PD therapy in a university hospital. Twenty-four patients on chronic PD,21 patients on chronic HD therapy using a cuprophan dialyzer,16 patients with chronic renal insufficiency without dialysis treatment, and 33 healthy volunteers; 8 additional patients before and after initiation of chronic HD therapy. All patients and controls were without infection or immunosuppressive therapy. As a marker of the inflammatory activity in the different patient groups, C-reactive protein (CRP) was measured serially using a sensitive, enzyme-linked, immunosorbent assay in order to detect values below the detection limit of standard assays. Patient groups had CRP levels higher than the normal controls (p < 0.01). Patients on HD had CRP levels significantly higher than PD patients (p < 0.01) whose levels were comparable to patients without dialysis therapy. Accordingly, longitudinal measurements before and after initiation of chronic HD showed a significant increase in CRP levels after the beginning of HD treatment (p < 0.04). The results suggest that induction of the inflammatory activity is lower during PD compared to HD, since stimulation by the dialyzer membrane, dialysate buffer, or bacterial fragments in the dialysate is avoided. This observation might indicate a possible lower risk of long-term complications in patients with PD.

Relationship between formaldehyde-related antibodies and cross-reacting anti-N-like antibodies in patients undergoing chronic haemodialysis.

An attempt was made to determine the sequence of events leading to the production of two distinct antibodies in patients with chronic renal failure who regularly undergo haemodialysis with formaldehyde-resterilizable dialysis units by Multipoint (UK) or Cordis (USA). A distinct pattern emerged-namely, the production of anti-formaldehyde red cells started about six months after the beginning of haemodialysis treatment. Only when the titre of these antibodies reached 64 or 128 another, apparently cross-reacting, antibody appeared which reacted like an anti-N antibody. A strong direct antiglobulin reaction was found to be positive for formalin-treated red cells after five minutes' contact with specific antibody, indicating a high affinity of the antibody fo the formalin-altered red cell.