Delivered Dialysis Dose Research Articles

Sustained Low-EfficiencyDialysis (SLED) with Regional Citrate Anticoagulation (RCA)and new dialysis equipment: a prospective study with serum citrate measurements and electrolyte monitoring.

Sustained-Low Efficiency Dialysis (SLED) is an increasingly used Kidney Replacement Therapy (KRT) modality in critically ill patients. This study was aimed at evaluating the safety and efficacy of simplified Regional Citrate Anticoagulation(RCA) for SLED using new hemodialysis equipment. The8-hour SLED sessions were performed with a Surdial X Nipro® hemodialysis machine and a cellulose triacetate filter. A concentrated citrate solution (ACD-A) was infused in predilution with a target circuit citrate concentration of 2.5-3mmol/L. Blood recalcification in the extracorporeal circuit mainly occurred through the backfiltration phenomenon by dialysis fluid (Ca2+ 1.5mmol/L). Serum citrate levels were directly measured during KRT by enzymatic methods and an extensive daily laboratory workup was performed. Changes in laboratory variables at the end of the SLED sessions were analyzed with mixed-effects linear models for repeated measures. Eighty-one SLED treatments were performed in 27 patients (APACHE II score 21 ± 6). The prescribed duration was attainedfor the majority of the treatments (72/81, 88%). No major bleeding episodes or side effects ofcitrate accumulation occurred. While calcium infusion was needed in 19/81 SLED sessions (23%), phosphate and magnesium supplementation was necessary following about 25% of all SLED sessions. Our simplified regional citrate anticoagulationprotocol for SLED with a new "conventional" dialysis machine resulted safe and effective, also for critically ill patients, ensuring a good match between the prescribed and delivered dialysis dose. Close electrolyte monitoring and early supplementation allowed to tailor the dialysis prescription to the patient's actual needs, while avoiding KRT-related complications.

Nonstandardized High-Intensity Dialysis Dose Improves Survival in Patients With End-Stage Renal Disease.

Introduction One of the most important critical determinants of quality of life and adequacy of hemodialysis (HD) performed in patients is the recorded survival and mortality rates. Nowadays, as an adequately performed HD dialysis, we accept the one with reaching values for the index single pool Kt/V (spKt/V) higher than 1.2. In recent years, more intensive HD regimens with spKt/V≥1.5 have been increasingly discussed, which can significantly improve patient survival. However, their benefit has yet to be proven, as extremely high spKt/V values can be misleading as they may result from malnutrition leading to reduced survival and increased relative risk of death. The aim of this study is to present to the community the impact of nonstandardized high dialysis doses (spKt/V>1.5) on annual survival and mortality rates in the dialysis population and to explore new strategies for enhancing quality of life and survival, as well as to promote their regular implementation in clinical practice and personalized patient care. Material and methods The present retrospective study was conducted at the Clinic of Nephrology and Dialysis at University Hospital St. Marina in Varna, Bulgaria for a period of five years. It involved a survival analysis of 100 dialysis patients who met the inclusion and exclusion criteria. The dialysis dose delivered was the criterion for their allocation into three studied groups: Group 1 with adequate dose (standardized) - spKt/V = 1.2-1.49, Group 2 with high dose (nonstandardized) - spKt/V≥1.5, and Group 3 with inadequate dose (low) - spKt/V≤1.19. We recorded total annual mortality and survival rates, analyzing their relationship with the delivered dialysis dose and assessing the relative risk of death and expected survival. Results The analysis results indicated that high-intensity regimens with an spKt/V≥1.5 were linked to a better patient prognosis, with a significantly lower risk of death compared to standard regimens and increased survival expectancy. Data from the survival analysis suggested that the long-term impact of increasing the dialysis dose (spKt/V≥1.5) on survival becomes evident after the third year. Additionally, nutritional status parameters emerged as key risk factors for deterioration, along with the indicators of dialysis adequacy. Discussion Improved survival rates have been observed in patients undergoing nocturnal HD. In the latter, significantly higher spKt/V values have been achieved due to extended dialysis sessions, as well as in those performing dialysis at home. Despite concerns about possible misinterpretation of extremely high spKt/V values (>1.5) as a sign of malnutrition when urea volume of distribution is reduced, it is found that when only urea clearance (Kt) is used, without volume counts, the risk of death decreases by 2% for each liter increase in clearance. This demonstrates that the assessment of dialysis adequacy is a much broader concept than the values of generally accepted indicators and should be focused on individualized care and risk assessment tailored to each patient. Conclusions We believe that the modern nephrological community should strive to achieve a high dialysis dose (spKt/V≥1.5) to improve clinical outcomes and patient prognosis. Assessing dialysis adequacy is complex and goes beyond a simple numerical value such as spKt/V. It requires careful monitoring of nutritional status and the management of all HD-related complications.

Real-Time Dialysis Dose: Ionic Dialysis Versus Classical Urea Kinetic Modeling Indices.

Introduction Worldwide, over 850 million people need renal replacement therapy, and over 80% of them are on hemodialysis. The term "dialysis adequacy" is most often associated with the achievement of minimally acceptable indices - single pool Kt/V (spKt/V) and urea reduction ratio (URR%) and largely does not take into account other clinical indicators in patients. In addition, it should be taken into account that in the conditions of clinical practice, their measurement is carried out according to standards controlled by the regulatory structures and is carried out with a frequency between one and three months, and not during each dialysis procedure. Accordingly, based on the obtained value, we assume that it refers to the urea clearance of the entire dialysis prescription. A new methodology for measuring dialysis adequacy through ionic dialysis allows dose estimation in real time without the need for additional blood testsby recording the difference in sodium ion conductivity at the dialyzer inlet and outlet. The latter corresponds to the dialysis dose delivered and can be measured at each dialysis session, enabling timely therapeutic intervention at minimal cost to the community. The aim of this original article is to present ion dialysis to the community as a reliable and inexpensive alternative to classical urea kinetic modeling (UKM), evaluating the comparability of the two methods and the possible sources of error in the result. Material and methods This was a retrospective study of 32 patients undergoing hemodialysis at the Clinic of Nephrology and Dialysis at the University Hospital St. Marina (Varna, Bulgaria) for the period between January and December 2020.For each of the patients, four measurements (every three months) of the delivered dialysis dose were performed by ion dialysis and classical urea kinetic modeling in order to assess the comparability and reliability of the two methods. Results The analysis of the results proved a high correlation between the validated indicators of dialysis adequacy (spKt/V; URR) and those registered with online monitoring (online clearance monitor) by ionic dialysis - online Kt/V (onKt/V)while at the same time reporting a significant difference in the two methods - primarily based on the anthropometric formulas used to estimate the volume. The established regression models confirmed the high predictive value of ionic dialysis in relation to the actually delivered dose. Discussion Despite the high bond strength, our recorded values ​​for onKt/V are 8% lower compared to results using UKM. Therefore, onKt/V as an assessment metric has the ability to underestimate the dialysis dose received. Various factors as a possible source of error and its cause have been reported by some authors. Several studies have reported differences of 2-5% in instantaneous conductance measurements, which they associate mainly with differences in the diffusion coefficients of urea and sodium, as well as different effects of dialysis membrane charge or inadequate ultrafiltration correction. Conclusions Our study confirms that online clearance monitoring (OCM) is a practical non-invasive tool for daily use that complements the classic performance of OCM by helping to deliver an adequate dialysis dose with increased patient benefit and minimal cost of financial resources.

A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation

BackgroundRegional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH.MethodsThis is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time.ResultsWe included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur.ConclusionsWe describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules.Trial registrationThe study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.

#2268 Dialysis patients survival in HD centres from Belgium, Estonia, Spain, and Sweden—association with BMI and hypocalcemia

Abstract Background and Aims Several factors are known to influence the morbidity and mortality of ESKD patients, among them cardiovascular disease, nutritional status, delivered dialysis dose, uremic toxins levels, and infectious diseases. This observational study aimed to analyse factors that impact the survival of ESKD patients on haemodialysis. Method We analysed 3- and 5-year survival of 76 patients during the period of 2018-2023 (17 females, 59 males, aged 63.6 ± 15.9 years) from four separate dialysis centres from countries with diverse life expectancies, renal replacement therapy incidences, and kidney transplant rates: North Estonia Medical Centre, Tallinn, Estonia (21 patients); Linköping University Hospital, Linköping, Sweden (21 patients); Ghent University Hospital, Ghent, Belgium (14 patients) and Fundación Jiménez Díaz University Hospital Health Research Institute, Madrid, Spain (20 patients). We included stable chronic haemodialysis patients receiving three times per week post-dilution ol-HDF treatment. Patients with central dialysis catheter, acute coronary syndrome or stroke within three months were excluded. Cox proportional-hazard regression analysis was used to detect the factors affecting the survival of patients. In the Cox model, the 3-year survival was set as a dependent parameter. Age, gender, BMI, and serum levels of creatinine, phosphate, calcium, total protein, and uric acid were set as independent parameters. Kaplan-Meier survival analysis was performed to study survival in the subgroups of patients. Results Out of 76 patients, 22 died in 3-years and 34 in five years (Fig. 1a and b). Our Cox model (adjusted with the age, gender, creatinine, phosphate, total protein, and uric acid serum levels) indicated patients' body mass index (BMI, p = 0.014) and calcium (p = 0.033) levels as statistically significant factors in 3-year survival. Kaplan-Meier survival analysis showed statistically significant increased survival in the group where BMI was higher than 27.6 kg/m2 (Fig. 2a) and in the group where serum calcium levels were higher than 2.25 mmol/L (Fig. 2b). Conclusion This study shows that among prevalent haemodialysis patients 3-year survival is about 65% and 5-year survival 45%, and a higher risk of mortality could be associated with low BMI and low serum calcium levels. Our findings are in accordance with previous studies, where survival benefit for haemodialysis patients with higher BMI is shown [1, 2]. It is proposed that this phenomenon among advanced CKD patients with higher BMI could be due to better nutritional reserve that helps resist chronic inflammation and wasting. The negative effects of excess calcium load for haemodialysis patients are well known, and nowadays, non-calcium-based phosphorus binders, calcimimetics, and low-calcium concentrates in haemodialysis are used more often, thus putting the patients at risk of hypocalcaemia. Though less studied, long-term hypocalcaemia is shown to increase mortality among haemodialysis patients [3], as concurs with our results. Safe calcium concentration limits for these patients are still debatable and need further investigation.

#2454 Meeting guideline goals at hemodialysis patients impact their survival?

Abstract Background and Aims The Institute of Medicine (IOM) defines clinical practice guidelines as "statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options". First publication of Clinical Guidelines by the National Kidney Foundation (NKF), addressing good clinical practice in hemodialysis, was published in 1998. The aim of the present study was to investigate the influence of adherence to current guidelines of Mineral and Bone Disorders, Anemia and Adequacy of Dialysis, on their survival in patients undergoing hemodialysis. Method This is a single center retrospective study of 113 chronic hemodialysis patients (79 males and 34 females), with median age 70 years (56, 78), median duration on hemodialysis 52 months (21, 95). Based on whether or not they met the KDIGO guidelines’ targets for anemia, bone disease, dialysis adequacy, and the targets of all three guidelines during the last three years, patients were divided in two groups: group A with the patients who met the goals of the guidelines and group B with the patients who did not meet the goals. Clinical and biochemical parameters were compared among the groups of patients as well as hemodialysis adequacy (Kt/V). The survival analysis of the patients was calculated by Kaplan-Meier, while the possible effect of any parameter on survival was also evaluated with Cox-Regression. Results There was significant difference between the two groups in age, phosphorous (P), PTH, Kt/V, URR and Alb. There was no significant difference between the two groups in sex, duration of HD, Hemoglobin (Hg), Calcium (Ca++), Hypertension and Diabetes (Table). In Cox analyses, patient survival was associated with delivered dialysis dose (single pool Kt/V, p=0.044). There was no significant difference between the two groups when we compare the adherence to guidelines for MBD (p=0.507) and anemia (p=0.394). There was no statistical difference when we compare the achievement of targets of all three guidelines (p=0.796). We identified as an independent risk factor for patient survival the serum albumin (p<0.001). Patient survival was better with higher dialysis dose and adequate serum albumin level. Conclusion Clinical guidelines are useful tools for good clinical practice for hemodialysis patients. Adherence to clinical guidelines regarding dialysis adequacy is an independent risk factor for better survival of patients undergoing hemodialysis.

Characteristics of and Outcomes After Dialysis-Treated Acute Kidney Injury, 2009-2018: A Taiwanese Multicenter Study

Dialysis-treated acute kidney injury (AKI) is increasingly common in intensive care units (ICUs) and is associated with poor outcomes. Few studies have explored the temporal trends in severity of acute illness at dialysis initiation, indications for dialysis, and their association with patient outcomes. Multicenter retrospective cohort study. 9,535 adult patients admitted to the ICU who received their first dialysis treatment from Chang Gung Memorial Hospital system in Taiwan from 2009 through2018. Calendar year. ICU mortality and dialysis treatment at discharge among hospital survivors. The temporal trends during the study period were investigated using test statistics suited for continuous or categorical data. The association between the study year and the risk of mortality was analyzed using multivariable Cox regression with adjustment for relevant clinical variables, including the severity of acute illness, defined by Sequential Organ Failure Assessment (SOFA) score. The mean SOFA score at dialysis initiation decreased slightly from 14.0 in 2009 to 13.6 in 2018. There was no significant trend in the number of indications for dialysis initiation that were fulfilled over time. Observed ICU mortality decreased over time, and the curve appeared to be reverse J-shaped, with a substantial decrease from 56.1% in 2009 to 46.3% in 2015 and a slight increase afterward. The risk of mortality was significantly reduced from 2013 to 2018 compared with 2009 in adjusted models. The decreasing trend in ICU mortality over time remained significant. There was an increase in dialysis treatment at discharge among survivors, mainly in patients with estimated glomerular filtration rate<60mL/min/1.73m2, from 36.8% in 2009 to 43.9% in2018. Residual confounding from unmeasured factors over time such as severity of comorbidities, detailed medication interventions, and delivered dialysis dose. We observed reductions in mortality among ICU patients with dialysis-treated acute kidney injury between 2009 and 2018, even after adjusting for dialysis indication and severity of illness at dialysis initiation. However, dialysis treatment at discharge among survivors has increased over time, mainly in patients with preexisting kidney disease. The current medical management of severe acute kidney injury (AKI) is primarily limited to supportive care and kidney replacement therapy if indicated, leading to perceptions that outcomes among intensive care unit (ICU) patients with dialysis-treated AKI have not improved. In this multicenter retrospective study of ICU patients with dialysis-treated AKI between 2009 and 2018 in Taiwan, patient mortality decreased over time despite increasing comorbidities. Moreover, the decreasing linear trends remained significant even when considering severity of acute illness at dialysis initiation, which was based on physiologic and laboratory measurements seldom evaluated in previous studies. Further research should explore the basis for these improvements.

Use of Relative Blood Volume Monitoring to Reduce Intradialytic Hypotension in Hospitalized Patients Receiving Dialysis

Use of Relative Blood Volume Monitoring to Reduce Intradialytic Hypotension in Hospitalized Patients Receiving Dialysis

MO1007RELATIONSHIP BETWEEN DIALYSIS ADEQUACY, ULTRAFILTRATION RATE AND SURVIVAL IN YOUNG HEMODIALYSIS (HD) PATIENTS HAVING INITIATED CHRONIC HD IN CHILDHOOD*

Abstract Background and Aims Hemodialysis (HD) adequacy is currently assessed based on weight-normalized small solute clearance (spKt/V), with same targets in both adult and pediatric patients on chronic thrice weekly hemodialysis, despite lack of pediatric studies to support this. It has been hypothesised that pediatric patients of small size may require higher spKt/V targets, due to higher ratio of body surface area (BSA) to body weight and/or greater post-dialysis urea rebound. Ultrafiltration rates (UFR) &amp;gt;10-13 mL/kg/h, associated with increased mortality in adults, are furthermore routinely exceeded in pediatric patients with uncertain consequences. We aimed to characterize how different delivered HD adequacy metrics and UFR are associated with survival in a large cohort of patients who started HD in childhood. Method Retrospective analysis on a cohort of patients &amp;lt;30y on chronic HD since childhood (&amp;lt;19y), having received thrice-weekly HD 2004-2016 in outpatient DaVita dialysis centers. Mean delivered dialysis dose (spKt/V) and alternative measures of HD adequacy and fluid balance, including eKt/V, body-surface normalized Kt (Kt/BSA) and ultrafiltration rate (UFR), were investigated as predictors of survival in a Weibull regression model. Results A total of 1780 patients were included (age at initiation of HD: 0-12y: n=321, &amp;gt;12-18y: n=1459), with median spKtV=1.55, eKt/V=1.31, Kt/BSA=31.2 L/m2 and UFR=10.6 mL/kg/h. Kt/BSA was a better predictor of survival than spKt/V or eKt/V (P&amp;lt;0.001 versus P=0.002, respectively). UFR was associated with survival (P&amp;lt;0.001), with increased mortality &amp;lt;10/&amp;gt;18 mL/kg/h. Associations remained significant after adjusting for age, ethnicity, and etiology of kidney disease. Conclusion We found that targeting Kt/BSA&amp;gt;30 L/m2 in children and young adults on maintenance HD is associated with improved long-term outcomes, corresponding to spKt/V&amp;gt;1.4 (&amp;gt;12 years) and &amp;gt;1.6 (&amp;lt;12 years), respectively. Relatively high UFR of 10-18 ml/kg/h appears to be risk-free in this HD population.

Clinical effectiveness of a Malaysian-manufactured CAPD product: A randomised trial.

We compared the clinical effectiveness of a new peritoneal dialysis (PD) product with polyvinyl chloride-containing tubing (Stay Safe Link®, SSL) with the plastic-free alternative (Stay Safe®, STS) in patients on continuous ambulatory peritoneal dialysis (CAPD). A multicentre, parallel, randomised, controlled, open-label, non-inferiority trial was conducted. Adult patients receiving CAPD were randomised in a 1:1 ratio to SSL or STS. The primary outcome was the rate of peritonitis after 1 year of follow-up. A total of 472 subjects were randomised (SSL, n = 233; STS, n = 239). One subject in each group was excluded from the analysis as they withdrew consent before the first dialysis dose. Four hundred and seventy subjects (SSL, n = 232; STS, n = 238) were included in the modified intention-to-treat analysis. Non-inferiority between two groups was established as no significant difference was found in peritonitis rate (incident rate ratio: 0.91, 95% CI: 0.65-1.28). No significant difference was detected in weekly Kt/V (p = 0.58) and creatinine clearance (p = 0.55). However, the average ultrafiltration volume was significantly lower in SSL, with a mean difference of 93 ml (p < 0.01). SSL also demonstrated a 2.57-times higher risk of device defect than STS (95% CI: 1.77-3.75). SSL was non-inferior in peritonitis rate compared to plastic-free STS over 1 year in patients requiring CAPD. There was no difference in the delivered dialysis dose, but there was a higher rate of device defects with SSL.

Hemodialysis (HD) dose and ultrafiltration rate are associated with survival in pediatric and adolescent patients on chronic HD\u2014a large observational study with follow-up to young adult age

BackgroundHemodialysis (HD) dose targets and ultrafiltration rate (UFR) limits for pediatric patients on chronic HD are not known and are derived from adults (spKt/V>1.4 and <13 ml/kg/h). We aimed to characterize how delivered HD dose and UFR are associated with survival in a large cohort of patients who started HD in childhood.MethodsRetrospective analysis on a cohort of patients <30 years, on chronic HD since childhood (<19 years), having received thrice-weekly HD 2004–2016 in outpatient DaVita centers. Outcome: Survival while remaining on HD. Predictors: (I) primary analysis: mean delivered dialysis dose stratified as spKt/V ≤1.4/1.4–1.6/>1.6 (Kaplan–Meier analysis), (II) secondary analyses: UFR and alternative dialysis adequacy measures [eKt/V, body-surface normalized Kt/BSA] on continuous scale (Weibull regression model).ResultsA total of 1780 patients were included (age at the start of HD: 0–12y: n=321, >12–18y: n=1459; median spKt/V=1.55, eKt/V=1.31, Kt/BSA=31.2 L/m2, UFR=10.6 mL/kg/h). (I) spKt/V<1.4 was associated with lower survival compared to spKt/V>1.4–1.6 (P<0.001, log-rank test), and spKt/V>1.6 (P<0.001), with 10-year survival of 69.3% (59.4–80.9%) versus 83.0% (76.8–89.8%) and 84.0% (79.6–88.5%), respectively. (II) Kt/BSA was a better predictor of survival than spKt/V or eKt/V. UFR was additionally associated with survival (P<0.001), with increased mortality <10/>18 mL/kg/h. Associations did not alter significantly following adjustment for demographic characteristics (age, etiology of kidney disease, and ethnicity).ConclusionsOur results suggest usefulness of targeting Kt/BSA>30 L/m2 for best long-term outcomes, corresponding to spKt/V>1.4 (>12 years) and >1.6 (<12 years). In contrast to adults, higher UFR of 10–18 ml/kg/h was not associated with greater mortality in this population.

Status of Nutrition In Hemodialysis Patients Survey (SNIPS): Malnutrition risk by diabetes status.

BackgroundIncreased malnutrition risk has been observed in more than 40% people on haemodialysis in Israel. It is not clear that this risk is homogeneously distributed among people with versus without diabetes.ObjectivesTo examine the influence of diabetes on malnutrition risk among people on haemodialysis.MethodsThis cross‐sectional study included a representative sample of 375 individuals on haemodialysis treated in hospital dialysis centres throughout Israel. Of these, 126 had diabetes. Dietary intake, biochemistry, anthropometric and hemodynamic measures were recorded. Malnutrition risk categories were defined: “minimal”: body mass index (BMI) ≥23 kg/m2 and serum albumin ≥38 mmol/L; “mild”: BMI <23 kg/m2 and albumin ≥38 mmol/L; “moderate”: BMI ≥23 kg/m2 and albumin <38 mmol/L; “severe”: BMI<23 k/m2 and serum albumin <38 mmol/L. These categories were dichotomized to “minimal” versus elevated malnutrition risk.ResultsDespite greater BMI, elevated malnutrition risk was identified in 58.8% of individuals with versus 39.3% without diabetes. Adherence to International Society for Renal Nutrition and Metabolism nutrition guidelines was poor regardless of diabetes status. In multivariable logistic regression analysis, diabetes: OR 2.15; C‐reactive protein (nmol/L): OR 1.02; delivered dialysis dose (Kt/V): OR 6.07; and haemoglobin (g/L): OR 0.79, predicted elevated malnutrition risk, even after controlling for age, sex and years on haemodialysis.DiscussionIndividuals on haemodialysis who have diabetes have elevated malnutrition risk compared to those without diabetes despite greater BMI.

Impact of the intensity of intermittent renal replacement therapy in critically ill patients.

Intermittent renal replacement therapy (IRRT) is prescribed across intensive care units (ICU) worldwide. While research regarding the prescribed dialysis dose has not yielded results concerning mortality, it is still unknown whether the same applies to the actual delivered dose. We retrospectively analyzed two different cohorts of patients (562 IRRT sessions) who were admitted to the intensive care units at Hospital Clínic of Barcelona and required renal replacement therapy with IRRT. The first cohort included patients with acute kidney injury (AKI) (n = 42) and the second included patients already on chronic hemodialysis (CKD 5D) (n = 47). Only patients who had at least 3 recorded hemodialysis sessions in the ICU and with no previous continuous renal replacement therapy (CRRT) were included. The achieved dose was measured as Kt (L) by ionic dialysance and the primary endpoint was 90-day mortality. Ninety-day mortality was 40.5% (n = 17) in the AKI cohort and 23.9% (n = 11) in the CKD 5D cohort with mean Kt of 43 ± 8.27 L and 47 ± 9.65 L respectively. Kt dose of IRRT was associated with 90-day mortality in the AKI cohort in a multivariate surveillance analysis adjusted for confounding factors (HR 0.935 [0.88-0.99], p = 0.02). Only the Kt dose and age remained statistically associated with the outcome in the AKI cohort. Delivered dialysis dose as measured by ionic-dialysance Kt may be associated with survival in critically-ill patients with AKI, while it does not seem to affect outcomes in critically-ill CKD 5D patients. This exploratory analysis will need confirmation in larger prospective studies.

P1253ASSOCIATION OF PREDIALYSIS PULSE PRESSURE (PP) AND ITS INTRADIALYTIC VARIATIONS IN 5 YEAR MULTICENTER COHORT STUDY

Abstract Background and Aims Elevated PP, as a surrogate marker of elastic properties the arteries vessel wall, is important characteristics of the cardiovascular system and may be associated with poor survival both in the general eldery population with arterial hypertension and in patients on maintenance hemodialysis (HD). It has been shown, that increase predialysis PP in HD patients was associated with a higher risk of hospitalization or death, but the relationship between PP changes during HD was not well investigated in large prospective cohort studies. The aim of the study was to assess the effect of elevated predialisis PP and its intradialytic PP variations on survival in the Kaplan-Meir curves and in the Cox regression models. Method The retrospective cohort included patients who underwent maintenance HD in the large chain of B. Braun Avitum free standing HD units in Russia from 2011 to 2016 years (n = 3704). The mean age of the patients was 54,8±13,7 years, 45% were women and 55% men. All patients were on B. Braun Dialog+ Evolution dialysis machines with Adimea option for on-line KT/V measurement and synthetic alpha-polysulphone Xevonta series dialyzers (surface area 1,8, 2,0 and 2,3 sq. m.) The delivered dialysis dose, according to the Daugirdas 2nd generation formula was 1,6 ± 0.23 (spKt/V). Statistical analysis in a Kaplan-Meier curves and proportional Cox regression model were performed. The study used averaged BP data measured over the entire observation period and PP calculation. Patients were divided into subgroups according PP calculation &amp;lt;35, 35-55, 55-75 and more than 75 mm Hg. Variations in intradialytic PP (ΔPP) were divided into groups according to PP average change during HD procedure: -25 and lower decrease, -25 - -10, -10 - 0, 0 - 10, and 10 - 25 increase, mm Hg. Results From total cohort of 3704 patients, 207 (5,6%) has highly elevated PP (&amp;gt; 75 mmHg) and another 1549 (41,8%) has slightly elevated PP (55-75 mm hg). During the study, 393 deaths occurred. The Kaplan-Meyer survival curves clearly demonstrate that the worst survival rate occurs in the subgroup of patients with the markedly elevated predialysis PP (n=207, 35 deaths; HR = 1,7 CI = 1,3 – 2,6; p &amp;lt;0,001; Pic. 1). Then we analyze association of intradialytic PP changes and mortality in total cohort (n=3704) and the subgroups with elevated PP (n=1756). Both marked PP drop down and PP increase during HD worsen survival: the most poor demonstrate patients with highest decrease in PP (-25 mm Hg and more) and then with highest increase in PP (+10-25 mm hg) within HD procedure (Pic. 2). In unadjusted Cox model predialytic PP and survival remain significant (p=0,01), but not PP changes (p=0,3). After multivariable adjustments in the Cox regression model with main demographic factors (age, treatment duration) and key laboratory indices (spKT/V, urea, creatinine, hemoglobin, albumin, Ca, PO4, PTH) there were no association between both predialysis PP and PP changes and mortality (p=0,9 and 0,1, respectively). Among the independent risk factors in our model, highest hazard ratio affecting survival has for ultrafiltration (UF) speed both for predialytic PP and PP variations (tabl. 1 and table 2). Conclusion In our study PP and its intradialytic variations show statistical significant association with mortality in single factor survival analysis and in unadjusted Cox regression model, but were not independent factor in adjusted multivariate HR model. UF speed has the highest impact on mortality in our model. We can hypothesize, that patients with elevated PP are vulnerable for high UF rate and prone for intradialytic hypotension and higher mortality on maintenance HD.

SAT-213 Relationship of Cardiovascular disease with dialysis dosage

Cardiovascular Disease (CVD) is the leading cause of death in End Stage Renal Disease (ESRD) patients on Maintenance Hemodialysis (MHD). The accumulation of uremic toxins play a part in the pathophysiology of cardiovascular disease that may progress to myocardial fibrosis, cardiomyopathy, left ventricular hypertrophy, vascular calcification and atherosclerosis. Thus, morbidity and mortality in hemodialysis patients is closely correlated to the delivered dialysis dose. The delivered dose is measured in MHD patients either by blood samples to calculate single pool Kt/V or by measuring the ionic dialysance in real time using online clearance monitoring (OCM). The aim of our study is to evaluate the influence of dialysis dose on the presence of CVD and to assess its relationship with echocardiographic parameters. 34 ESRD patients on MHD were included in the study from June 2019 to September 2019. Patients’ record, pre- and post- dialysis labs, Kt/V,OCM,URR, echocardiographic parameters including Left Atrial Volume Index (LAVI), Ejection Fraction (EF), Pulmonary Artery Systolic Pressure (PASP), presence of diastolic dysfunction and Left Ventricular Hypertrophy (LVH) were studied. Patients with a history of any cardiac event, a reduced EF or segmental wall motion abnormality on echocardiography were labelled as having CVD. Baseline echocardiographic measurements for each patient were analyzed. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 25. Of the 34 hemodialysis patients there were 16 females and 18 males with age ranging from 17 to 87 years and mean age of 59.6 years (table 1). Patients had MHD vintage ranging from half a month to 79 months with a mean vintage of 33.9 months. 55.9% of patients had CVD. 14.7%(5) patients had a Kt/V of <1.4 and 85.3% (29) had Kt/V of >1.4. Average EF of patients with CVD was 46.9% and without CVD was 55.1%. Presence of CVD correlated negatively with EF (r = -0.541, p=0.001). Mean LAVI was 40.3ml/m2. 82.4% patients had a LAVI of >34ml/m2. Markers of dialysis dose OCM (r= -0.467, p=0.005), KT/V (r= -0.405, p=0.017), URR (r= -0.364, p=0.034) correlated negatively with the presence of CVD. Patients with a Kt/V of <1.4 had a higher prevalence of CVD and diastolic dysfunction. as compared to patients with Kt/V of >1.4 (table 3). A higher PASP was prevalent in patients with lower Kt/V as compared to those with high Kt/V. Patients with a Kt/V of <1.4 had a higher prevalence of moderately enlarged LAVI (42-48 ml/m2). OCM had a significant negative correlation with LAVI (r= -0.359, p=0.037). However, there was no statistically significant correlation of Kt/V with any of the parameters on echocardiography.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) The presence of Cardiovascular disease is related to dialysis dose. Sub-optimal dialysis is associated with CVD. Many echocardiographic parameters were related to the dose of dialysis. Patients with a lower Kt/V had higher LAVI and PASP. There was also an increased presence of diastolic dysfunction in patients with lower Kt/V. Thus, clearance during dialysis can influence cardiac clinical and echocardiographic parameters.

Protocol for a randomised, open-label, parallel group, multicentre controlled study to evaluate the clinical performance and safety of Stay Safe Link compared with Stay Safe in patients with end-stage kidney disease on continuous ambulatory peritoneal dialysis

IntroductionPeritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD), the risk of which is significantly influenced by the type of PD transfer system. Although the Y-disconnect and double-bag...

Haemodialysis vascular access function in dialysis patients at the Kenyatta National Hospital

Background: The number of patients requiring renal replacement therapy (RRT) worldwide has been on the rise. Vascular access is the lifeline for these patients when haemodialysis (HD) is the treatment of choice. Access-related morbidity is a leading cause of hospitalization so that the function and patency of access are essential for the optimal management of patients. There is a need to recognize when a vascular access is dysfunctional because intervention must maintain function as well as preserve future vascular access sites. Methods: This was a cross-sectional study that evaluated the haemodialysis vascular access function in patients undergoing chronic haemodialysis at the Kenyatta National Hospital, Nairobi, Kenya. Peak access blood flow rates, urea reduction ratio (URR) and Kt/V were analysed in 150 patients.Results: The temporary (non-tunnelled) central venous dialysis catheters had poor function, with only 48% achieving a mean blood flow rate &gt; 300 mL/min. The comparable rate for arteriovenous fistulae (AVF) was 88% and for tunnelled dialysis catheters 82%. One-quarter of the patients had a URR &lt; 65%. Higher mean blood flow rates were associated with higher URR (P = 0.004) and Kt/V (P = 0.009) values. AVF stenosis was present in 12.5% and thrombosis in 3% of patients. Aneurysms were the commonest AVF complication (47%) but were not haemodynamically significant. Conclusions: Tunnelled haemodialysis catheters offered adequate blood flows and achieved adequate delivered dialysis, comparable to arteriovenous fistulae. Non-tunnelled catheters delivered poor blood flow rates and dialysis dose. Greater blood flow rates were associated with a higher delivered dialysis dose. There is a need for routine surveillance and affordable interventional procedures to prevent loss of vascular access.

The effect of increasing blood flow rate and dialysate flow rate on dialysis adequacy in maintenance hemodialysis patients

Objective A few publications show that increasing dialysate flow rate(Qd) no longer lead to an increase in Kt/V measurement with using high-flux membrane dialyzers. The aim of this study is to assess the effect of increasing dialysis flow rate or blood flow rate(Qb) during hemodialysis with low-flux membrane dialyzer on the adequacy of dialysis. Methods In this study, 54 patients with maintenance HD were assessed. All patients were dialysed with conventional bicarbonate heamodialysis and three sessions per week with each Qb(250 mL/min or 500 mL/min) and Qd (500 mL/min or 800 mL/min) were performed. Delivered dose of dialysis, measured by Kt/Vsp, was assessed during last dialysis session per week. Kt/Vsp was calculated according to the equations by Daugirdas. Blood samples were drawn immediately predialysis and postdialysis from the arterial of the access. HD parameters were acquired directly from the monitor display: effective blood flow rate, Qd, ultrafiltration volume and dialysis time. Results A total number of 46 patients including 30 males and 16 females were studied. The mean age of the studied population was (52.78±11.12) years and the mean dialysis duration was 1057 days. There was no statistical difference in ultrafiltration volumes per week. The relative gains in Kt/Vsp for increasing Qb from 250 to 300 mL/min and Qd from 500 to 800 mL/min was 8% and 4%, respectively. When Qd was 800 mL/min, we spent 2.2 L of acid concentrate and 72.76 L of water more than when Qd was 500 mL/min in only one patient per HD session. Conclusions Increasing Qb from 250 to 300 mL/min is associated with a more efficient increase in Kt/Vsp than increasing Qd and also less water consumption. Key words: Renal Dialysis; Renal Blood Flow, Effective; Dialysis Solutions

Application of on-line clearance monitoring in evaluating Kt/V of dialysis patients

Objective To evaluate the role of monitoring hemodialysis Kt/V by online clearance monitoring(OCM) in assessing dialysis sufficiency of maintenance hemodialysis (MHD) patients by different dialysis modes. Methods This is a prospective single-centre study in china. In this study, 46 patients with MHD were assessed including 30 males. The study was conducted over a period of 4 weeks. All patients were dialysed with conventional bicarbonate heamodialysis and three sessions per week. In the first and second week, blood flow rate was 250 mL/min, dialysate flow rate was performed at 500 mL/min and 800 mL/min, respectively. In the third and forth week, blood flow rate was 300 mL/min, dialysate flow rate was performed at 500 mL/min and 800 mL/min, respectively. The type and size of dialyzer was kept constant. The treatment time was 4 hours. Delivered dose of dialysis, measured by Kt/Vocm, was determined from serial measurements of ionic dialysance made throughout each treatment. Meanwhile, blood urea nitrogen(BUN) of pre-and post- dialysis were examined. Then Kt/V was calculated according to the equation Daugirdas and the correlation between Kt/V by OCM and by calculation in different blood flow rates or dialysate flow rates was evaluated. Results There was no statistical differences between ultrafiltration volumes per week. From 1 to 4 week, the correlation coefficient of linear regression analysis was γ1=0.895, γ2=0.919, γ3=0.913 and γ4=0.940, respectively(P<0.001). The value for Kt/Ve minus Kt/Vocm was (0.176±0.111), (0.209±0.110), (0.182±0.091) and (0.193±0.105) , respectively(P<0.05). The ROC curve for the Kt/Vocm was formed for dialysis adequancy: AUC=0.900, 95%CI(0.835, 0.966) , P<0.001. The marginal value of Kt/Vocm1.1 was the absolute criterion for the minimum dialysis dose. Conclusions OCM can display the Kt/V data conveniently and accurately, don’t need blood sample. It is very useful in monitoring the adequacy of dialysis and the correlation between Kt/Ve and Kt/Vocm is not be affected by increasing Qd or Qb. Key words: Renal Dialysis; Urea; Metabolic Clearance Rate

Prospective Study of Routine Heparin Avoidance Hemodialysis in a Tertiary Acute Care Inpatient Practice

IntroductionExtracorporeal circuit (EC) anticoagulation with heparin is a key advance in hemodialysis (HD), but anticoagulation is problematic in inpatients at risk of bleeding. We prospectively evaluated a heparin-avoidance HD protocol, clotting of the EC circuit (CEC), impact on dialysis efficiency, and associated risk factors in our acute care inpatients who required HD (January 17, 2014 to May 31, 2015).MethodsHD sessions without routine EC heparin were performed using airless dialysis tubing. Patients received systemic anticoagulation therapy and/or antiplatelets for non-HD indications. We observed patients for indications of CEC (interrupted HD session, circuit loss, or inability to return blood). The primary outcome was CEC. Logistic regression with generalized estimating equations assessed associations between CEC and other variables.ResultsHD sessions (n = 1200) were performed in 338 patients (204 with end-stage renal disease; 134 with acute kidney injury); a median session was 211 minutes (interquartile range [IQR]: 183−240 minutes); delivered dialysis dose measured by Kt/V was 1.4 (IQR: 1.2 Kt/V 1.7). Heparin in the EC was prescribed in only 4.5% of sessions; EC clotting rate was 5.2%. Determinants for CEC were temporary catheters (odds ratio [OR]: 2.8; P < 0.01), transfusions (OR: 2.4; P = 0.04), therapeutic systemic anticoagulation (OR: 0.2; P < 0.01), and antiplatelets (OR: 0.4; P < 0.01). CEC was associated with a lower delivered Kt/V (difference: 0.39; P < 0.01). Most CEC events during transfusions (71%) occurred with administration of blood products through the HD circuit.DiscussionWe successfully adopted heparin avoidance using airless HD tubing as our standard inpatient protocol. This protocol is feasible and safe in acute care inpatient HD. CEC rates were low and were associated with temporary HD catheters and transfusions. Antiplatelet agents and systemic anticoagulation were protective.ClinicalTrials.gov Identifier:NCT02086682.