Dialysis Clinic Research Articles

Energy consumption models in dialysis clinics for agent-based decision support

This paper describes an approach to predict the consumptions of water and power in dialysis clinics by simulating the internal processes. Better understanding is essential to prevent and mitigate adverse health impact on patients. Our methods are based on literature about dialysis processes and dialysis clinics, which are first-hand technical reports. The nonlinear model comprises the energy consumption of the technical systems together with their working schedules and the time schedule of the number of patients to be treated. Our model will be used as sub-model in an agent-based simulation system aiming to optimise the use of resources in an emergency with power outages or brownouts. The results presented in this study can be treated as a benchmark for decision makers to estimate the performance of a dialysis clinic or centre based on the amount of electricity and water needed and available.

Covid-19 pandemic: from carnival masks to surgical masks.

Given the high transmissibility of SARS-CoV-2, COVID-19 pandemic has a huge impact on our health system. Even in developed countries, strategic resources soon become insufficient. Although people over 60 and with comorbidities are at greater risk of developing severe forms, younger people may also require precious and scarce care. Hence, the World Health Organization recommend tests - PCR and serological tests - for detecting infected people on a large scale. The most common symptoms are fever, fatigue, dry cough, anorexia, myalgia, and dyspnea, with tomographic pulmonary findings being frequent even in asymptomatic cases. The Brazilian Society of Nephrology has published guidelines for the management of hypertensive, diabetic, dialysis, and transplant patients. In its alerts, care and precautions in dialysis units are also being detailed, both for the health team and for the patients. Although important renal manifestations are not yet evident in the admission of positive cases, recent studies with renal patients and performed in nephrology services are listed here. This pandemic lead us to learn from its progress in order to face new challenges in dialysis clinics, transplant services, and intensive care services.

Implementing Evidence-Based Vitamin D Protocol in the Dialysis Clinic: An Educational Approach

Vitamin D deficiency is prevalent among patients with chronic kidney disease (CKD) and even more pronounced in patients with kidney failure who are undergoing peritoneal dialysis and hemodialysis. This project was a nurse practitioner-led quality improvement project conducted in an outpatient hemodialysis unit that focused on determining if educating providers and hemodialysis unit clinical staff on vitamin D guidelines increased the awareness and monitoring of patients on hemodialysis. The number of patients screened for vitamin D levels increased from 29% to 100%, and 70% of patients tested were deficient in vitamin D. While the follow-up monitoring yielded a result of only 32%, we recommend processes and structures for long-term sustainability, such as periodic re-education, reminders and prompts for conducting needed follow-up, continued outcome monitoring, and champions to support the ongoing processes and structures.

Assessing the Impacts of Misclassified Case-Mix Factors on Health Care Provider Profiling: Performance of Dialysis Facilities.

Quantitative metrics are used to develop profiles of health care institutions, including hospitals, nursing homes, and dialysis clinics. These profiles serve as measures of quality of care, which are used to compare institutions and determine reimbursement, as a part of a national effort led by the Center for Medicare and Medicaid Services in the United States. However, there is some concern about how misclassification in case-mix factors, which are typically accounted for in profiling, impacts results. We evaluated the potential effect of misclassification on profiling results, using 20 744 patients from 2740 dialysis facilities in the US Renal Data System. In this case study, we compared 30-day readmission as the profiling outcome measure, using comorbidity data from either the Center for Medicare and Medicaid Services Medical Evidence Report (error-prone) or Medicare claims (more accurate). Although the regression coefficient of the error-prone covariate demonstrated notable bias in simulation, the outcome measure—standardized readmission ratio—and profiling results were quite robust; for example, correlation coefficient of 0.99 in standardized readmission ratio estimates. Thus, we conclude that misclassification on case-mix did not meaningfully impact overall profiling results. We also identified both extreme degree of case-mix factor misclassification and magnitude of between-provider variability as 2 factors that can potentially exert enough influence on profile status to move a clinic from one performance category to another (eg, normal to worse performer).

Good practices recommendations from the Brazilian Society of Nephrology to Peritoneal Dialysis Services related to the new coronavirus (Covid-19) epidemic.

ABSTRACTConsidering the new coronavirus epidemic (Covid-19), the Brazilian Society of Nephrology, represented by the Peritoneal Steering Committee, in agreement with the and the Dialysis Department, developed a series of recommendations for good clinical practices for peritoneal dialysis (PD) clinics, to be considered during the period of the Covid-19 epidemic. We aim to minimize the disease spread, protecting patients and staff, and ensuring the quality of the treatment provided and adequate follow-up for PD patients. The recommendations suggested at this moment must be adapted to each clinic’s reality and the conditions of the structural and human resources, dependent on the adequate financial provision of the public health system for its full implementation.

Efforts made by a dialysis clinic to accept HIV-infected patients

Efforts made by a dialysis clinic to accept HIV-infected patients

Social Support in the Peritoneal Dialysis Experience: A Qualitative Descriptive Study.

Background:People with end-stage kidney disease can either pursue conservative (palliative) management or kidney replacement therapy. Although transplant is preferred, there is a limited number of organs available rendering the majority of patients treated with some form of dialysis. Hemodialysis and peritoneal dialysis are equivalent regarding clinical outcomes, but peritoneal dialysis is much less costly to provide. Peritoneal dialysis is most often done in the home by the patient or a support person and carries a self-care burden on patients and families. Social support is important for patients receiving peritoneal dialysis and in sustaining peritoneal dialysis therapy. Few studies have comprehensively explored social support in the context of peritoneal dialysis.Objective:To explore how patients, family members, and nurses view social support.Design:Qualitative, descriptive study.Setting:An outpatient peritoneal dialysis clinic in Western Canada.Participants:Patients, family members, and nurses.Methods:Patients (n = 15), family members (n = 6), and nurses (n = 11) were interviewed between January and May 2018. Content analysis was undertaken using 4 attributes of social support (ie, emotional support, instrumental support, informational support, and appraisal support) as an analytic framework.Results:Themes related to the 4 attributes of social support were identified: addressing emotional needs and managing emotion (emotional support); peritoneal dialysis tasks and life tasks (instrumental support); accessing information, receiving information, and learning (informational support); and affirmation/external reassurance and self-confidence (appraisal support). The social support needs of both patients and family members varied and were dependent on their existing support networks and individual perspectives of support.Limitations:It is possible that some of the study findings were gender-bound as well as context-specific. The study findings could be different if the patient and caregiver sample were more balanced based on sex. There are also unique attributes of each peritoneal dialysis program that may impact the transferability of these findings to other practice settings.Conclusion:Home-based peritoneal dialysis has potential benefit to patients and health care systems. However, receiving peritoneal dialysis requires support. If health care providers wish to promote this treatment, they must also understand how to best support patients and their family members.Trial Registration:Not applicable.

Effect of Hemodiafiltration on Self-Reported Sleep Duration: Results from a Randomized Controlled Trial

Introduction: Dialysis patients suffer from poor sleep duration and quality. We examined the self-reported sleep duration in patients randomized to either high-volume hemodiafiltration (HDF) or high flux hemodialysis (HD). Methods: Patients from 13 Brazilian dialysis clinics were enrolled in the HDFIT randomized controlled trial (RCT) investigating the impact of HDF on physical activity and self-reported outcomes. Self-reported sleep duration was taken from patient diaries recording sleep start and end time over a week during baseline, months 3 and 6, respectively. Sleep duration was analyzed by shift and nights relative to dialysis. Results: The HDFIT study enrolled 197 patients; sleep data were available in 173 patients (87 HD; 86 HDF). Patients’ age was 53 ± 15 years, 57% were white, 72% were male, 34% had diabetes, Kt/V was 1.54 ± 0.40, and albumin 3.97 ± 0.36 g/dL. Most patients reported sleeping 510–530 min/night. At 3 months, HDF patients slept 513 ± 71 min/night, HD patients 518 ± 76 min/night. At 6 months, HDF patients slept 532 ± 74 min/night, HD patients 519 ± 80 min/night. At baseline, 1st shift patients slept 406 ± 86 min the night before HD, 534 ± 64 min the night after HD, and 496 ± 99 min the night between 2 non-HD days. Compared to patients in the 2nd and 3rd shifts, patients dialyzed in the 1st shift slept less in the night before dialysis. Similar patterns were seen after 3 and 6 months. Conclusion: In our RCT, the dialysis modality (HDF vs. HD) had no effect on self-reported sleep duration. In both groups, dialysis in the 1st shift adversely affected self reported sleep duration.

Provider Attitudes and Support of Patients' Autonomy for Phosphate Binder Medication Adherence in ESRD.

This cross-sectional study of 56 dialysis providers from 3 dialysis clinics examined providers’ attitudes and perception of autonomy support for patients’ medication adherence behaviors. Respondents completed surveys assessing attitudes and perception of autonomy support. Compared to all other provider types, physicians and nurse practitioners (MD/NP) thought it was “less true” that phosphate binder medications are very important for dialysis patients (MD/NP vs others: 5.1 [1.4] vs 6.1 [1.1]; P = 0.02). More dialysis technicians (19%) offered the highest level of support. Attitudes and perception of autonomy support for medication adherence are suboptimal, vary by dialysis provider type, and are targets for quality improvement in dialysis care. This study addresses critical gap in existing knowledge about these two novel provider-based psychosocial factors and their potential impact on phosphate binder medication adherence.

Reavaliação laboratorial da infecção pelo vírus da hepatite C em dialisados atendidos na década de 1990, em Belém, estado do Pará, Brasil

ABSTRACT OBJECTIVE: To describe aspects of laboratory serological and molecular diagnosis of hepatitis C virus (HCV) infection in patients undergoing treatment at a dialysis clinic in Belem, Para State, Brazil, from 1990 to 1993. MATERIALS AND METHODS: Retrospective study for reassessment of serum samples from dialysed patients using serological tests for the detection of HCV (anti-HCV and Ag-Ab HCV) and HCV-RNA by molecular RT-PCR. RESULTS: A total of 115 dialysed patients with serum samples collected during the study period were included. Analysis of these samples showed a 16.5% prevalence of anti-HCV reagent, among which 4.3% showed an indicator of active viral replication (HCV-RNA reagent). Seroconversion rate was detected in 55.2% of patients in the analyzed period. The anti-HCV group, Ag-Ab HCV and HCV-RNA reagent were the most prevalent (41.7%). For non-reactive anti-HCV samples, viral replication with HCV-RNA reagent was 22.7%. Genotypes 1 and 3 were detected. Genotype 1 was prevalent in 73.0% of the samples. CONCLUSION: When laboratory screening for HCV (anti-HCV) was introduced in the dialysis clinic, it was possible to observe: high prevalence of HCV infection among patients under treatment; high rates of seroconversion; equation between serological results using second and third generation ELISA methods; presence of viral replication among nonreactive anti-HCV patients; and higher prevalence of HCV genotype 1. Keywords: Hepatitis C Virus; Serological Tests; Hemodialysis

Management of Hemodialysis Graft/Fistula Aneurysms

Renal failure patients are obligated to have constant life-saving dialysis access. This retrospective review was designed to evaluate graft and fistula aneurysms. Once the dialysis access procedures are performed, care of patients is relegated to the nephrologists and dialysis clinics. This review is designed to validate surgical intervention of dialysis access procedures as a safe and durable procedure and determine if proactive steps could be taken to avoid this complication.

Patient Perspectives on Renal Replacement Therapy Modality Choice: A Multicenter Questionnaire Study on Bioethical Dimensions

Background:Peritoneal dialysis (PD) incidence and prevalence in Germany are low compared with hemodialysis (HD), an underachievement with multifactorial causes. Patient perspectives on renal replacement therapy (RRT) choice play a growing role in research. To date, and to the best of our knowledge, the importance of bioethical dimensions in the context of RRT choice has not been analyzed. The aim of this multicenter questionnaire study was to delineate differences in patient perspectives of PD vs HD in terms of bioethical dimensions, thus helping nephrologists target potential PD candidates more efficiently.Methods:A total of 121 stable outpatients from 2 tertiary care hospitals and 4 dialysis clinics were surveyed for bioethical dimensions ("autonomy," "beneficence," "non-maleficence," "justice," and "trust") with ranking and Likert scale items. Inclusion criteria were RRT > 3 months, age ≥ 18 years, and sufficient cognitive and language skills.Results:A surprisingly high percentage of patients felt excluded from the RRT choice process. Peritoneal dialysis patients were more critical of RRT. They used more versatile information sources on RRT, whereas HD patients were mainly informed by their nephrologist. Peritoneal dialysis patients felt more often dissatisfied with RRT than HD patients and had less trust in their co-patients. However, PD patients felt less autonomy impairment regarding body integrity, fluid balance, and dialysis in general.Conclusions:Our study demonstrates that PD patients showed more scrutiny of their situation as patients, especially their co-patients. Their treatment empowered them toward feeling more autonomous than HD patients. These new insights into patient perspectives on RRT choice might facilitate modality choice for nephrologists.

Is Health Literacy of Dialyzed Patients Related to Their Adherence to Dietary and Fluid Intake Recommendations?

Non-adherence to dietary and fluid intake recommendations (NADFIR) is an important factor for the effective treatment of dialyzed patients and may be hindered by low health literacy (HL). Therefore, we assessed whether low HL of dialyzed patients is associated with their NADFIR. We performed a multicentric cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; response rate: 70.1%; mean age = 63.6 years; males: 60.7%). We assessed the association between nine domains of HL and non-adherence (high serum potassium, high serum phosphate, relative overhydration, and self-reported NADFIR) using general linear models adjusted for age and gender. Moreover, we assessed the moderation by socioeconomic status (SES). We found higher NADFIR among patients with less sufficient information for health management (high serum phosphate level; odds ratio (OR): 0.77; 95% confidence interval (CI): 0.63–0.94), with a lower ability to actively manage their health (self-reported diet non-adherence; OR: 0.74; 95% CI: 0.62–0.89), and those less able to actively engage with healthcare providers (overhydrated; OR: 0.78; 95% CI: 0.65–0.94). Moreover, SES modified this relation. Low HL affects the adherence of dialyzed patients. This shows a need to support patients with low HL and to train healthcare providers to work with these patients, taking into account their SES.

A Walking Intervention to Increase Weekly Steps in Dialysis Patients: A Pilot Randomized Controlled Trial

Patients receiving dialysis report very low physical activity. We implemented a pilot trial to assess the feasibility of a pedometer-based intervention to gather preliminary evidence about its impact on physical activity, symptoms, and surrogates of cardiovascular risk. Pilot randomized controlled trial. 60 dialysis patients from San Francisco dialysis clinics. Participants were randomly assigned 1:1 to receiving pedometers with weekly step goals or usual care for 3 months. The primary outcome was step counts, measured using pedometers. Secondary outcomes included physical performance using the Short Physical Performance Battery, the Physical Function and Vitality scales of the 36-Item Short Form Health Survey, the Dialysis Symptoms Index, and the Center for Epidemiologic Studies-Depression Scale, with endothelial function as a secondary and heart rate variability as an exploratory surrogate measure of cardiovascular risk. Targeted enrollment was 50% and targeted completion was 85%. 49% of approached patients were enrolled, and 92% completed the study. After 3 months, patients randomly assigned to the intervention (n=30) increased their average daily steps by 2,256 (95% CI, 978-3,537) more than the 30 controls (P<0.001). Heart rate variability (standard deviation of N-N intervals) increased by 14.94 (95% CI, 0.31-33.56) millisecondsin the intervention group as compared with controls (P= 0.05). There were no statistically significant differences across intervention groups in symptoms, physical performance, or endothelial function. Participants in the intervention group reverted to baseline steps during the postintervention follow-up. The Northern California study setting may limit generalizability. Walking does not capture the full spectrum of physical activity. A short-term pedometer-based intervention led to increased step counts in dialysis patients, but the increase was not sustained. Pedometer-based interventions are feasible for dialysis patients, but future studies are needed to address whether more prolonged interventions can improve physical function or symptoms. Supported by grants from the American Kidney Fund, National Institutes of Health-National Institute of Diabetes and Digestive and Kidney Diseases, and International Society of Nephrology. Registered at ClinicalTrials.gov with study identifier NCT02623348.

Underimmunization of the solid organ transplant population: An urgent problem with potential digital health solutions.

Solid organ transplant recipients are at risk for potentially life-threatening infections due to lifelong immunosuppression. Vaccine-preventable infections result in graft injury, morbidity, mortality, and significantly increased medical costs. Unfortunately, the majority of transplant recipients continue to be underimmunized at the time of transplant and thereafter. Given the rising rates of vaccine hesitancy and refusal in the general population, transplant recipients can no longer rely on herd immunity to protect them from vaccine-preventable infections. Novel tools are desperately needed to overcome transplant-specific immunization barriers to improve immunization rates in this high-risk population. Digital health technologies may offer a solution by addressing transplant-specific barriers: specifically, providing accurate information about vaccine safety, efficacy, and timing in the pre- and posttransplant periods; making a complete immunization record universally available and easily accessible; enabling communication between patients and multiple providers; and providing automated vaccine reminders to both patients and providers when vaccines are due using transplant-specific immunization guidelines. Digital health has transformed health care by empowering patients with their own health information and connecting patients, their providers, and public health officials. In doing so, it offers a potential platform to address and overcome the problem of underimmunization in the transplant population.

A spectrum of approaches to health information interaction: From avoidance to verification

AbstractPeople respond to illness in a range of ways, and take different approaches to engaging with health information throughout the course of their illness. This study describes and explains the variety of approaches to health information interactions made by patients on hemodialysis. Ethnographic observations (156 hours) were conducted in three hemodialysis clinics, and semistructured interviews about health information were held with 28 patients. Demographic data were collected. Data were analyzed qualitatively. We found a spectrum of five approaches to health information: avoiders, who close themselves off from health information; receivers, who encounter information in the dialysis clinic but do not seek it out; askers, who only pose questions about health to their healthcare providers but otherwise do not seek; seekers, who actively look for health information both in and out of the clinic; and verifiers, who seek information and triangulate it among multiple sources. Trust in healthcare providers and coping sociality differed across approaches. The findings indicate that health information should be provided to patients using strategies tailored to their preferences and existing approaches to information interaction.

A cross-sectional study exploring levels of physical activity and motivators and barriers towards physical activity in haemodialysis patients to inform intervention development

Purpose To describe physical activity (PA) levels and motivators and barriers to PA amongst haemodialysis (HD) patients and to identify an appropriate approach to increasing their PA. Methods A cross-sectional mixed methods study conducted in a tertiary and satellite HD unit. One hundred and one participants aged 18 years and over, receiving regular HD for at least four months, were recruited. Patients with recent hospital admission or acute cardiac event were excluded. Participants completed health status (EQ-5D-3L™) and activity (Human Activity Profile (HAP)) questionnaires. A subgroup was invited to wear accelerometers and wearable cameras to measure PA levels and capture PA episodes, to inform subsequent semi-structured interviews on motivators and barriers. Semi-structured interviews were analysed using the framework method informed by constructs of the Health Belief Model. Results 98/101 completed the study (66 males, 32 females). For 68/98 participants, adjusted activity scores from the HAP indicated “impaired” levels of PA; for 67/98 participants, the EQ-5D-3L indicated problems with mobility. Semi-structured interviews identified general (fear of falls, pain) and disease specific barriers (fatigue) to PA. Motivators included tailored exercise programmes and educational support from health care professionals. Conclusions Participants indicated a need for co-development with healthcare professionals of differentiated, targeted exercise interventions. Implications for rehabilitation Healthcare professionals should encourage and motivate haemodialysis patients to participate in physical activity (PA). As part of this approach, there is a need to increase patient knowledge of safe beneficial exercise activities and help individuals identify and overcome barriers. To allow for individualised approaches, clinical interventions should focus on other community activities that patients can do outside the dialysis clinic setting and utilise existing networks such as the British Renal Society Rehabilitation Network. The dialysis clinic provides professionals the opportunity to monitor and motivate patients. Relevant education is needed for staff about the benefits of PA and how to engage patients and their carers in safe and effective approaches.

Estimating Residual Native Kidney Urea Clearance in Hemodialysis Patients With and Without 24-Hour Urine Volume

Rationale & ObjectiveQuantification of residual native kidney function is rarely performed in patients receiving hemodialysis. Methods of estimating residual kidney urea clearance that use commonly available laboratory and clinical data, with or without urine volume information, may be useful tools.Study DesignRetrospective, predictive modeling and model validation.Setting & ParticipantsInitial timed urine collections in 604 incident in-center hemodialysis patients on thrice-weekly treatments from a single academic center in which residual kidney urea clearance is measured in usual care.PredictorsModels using a combination of serum creatinine and urea levels, age, weight, height, sex, race, fluid weight gains, and with and without 24-hour urine volume.OutcomesResidual kidney urea clearance.Analytic ApproachGeneralized linear model was used for model development for residual kidney urea clearance using the first urine collection in 604 patients, as both a continuous and binary outcome (for >2.5 mL/min). Model validation was done by bootstrap resampling of the development cohort and with 1,093 follow-up measurements.ResultsUrine volume alone was the strongest predictor of residual kidney urea clearance. The model that included 24-hour urine volume with common clinical data had high diagnostic accuracy for residual kidney urea clearance > 2.5 mL/min (area under the curve, 0.91 in both development and bootstrap validation) and R2 of 0.56 with outcome as a continuous residual kidney urea clearance value. Our model that did not use urine volume performed less well (eg, area under the curve, 0.75). Analyses of follow-up urine collections in these same participants yielded comparable or improved performance.LimitationsData were retrospective from a single center, no external validation, not validated in 2- or 4-times-weekly hemodialysis patients.ConclusionsEstimation equations for residual kidney urea clearance that use commonly available data in dialysis clinics, with and without urine volume, may be useful tools for evaluation of hemodialysis patients who still have residual kidney function for individualization of dialysis prescriptions.

Demographics and Pattern of Ocular Diseases in Patients with Chronic Kidney Disease at the University of Port Harcourt Teaching Hospital

Aims: To determine the demographics and pattern of ocular diseases in patients with Chronic Kidney Disease at the University of Port Harcourt Teaching Hospital.&#x0D; Study Design: This was a hospital-based cross-sectional study.&#x0D; Place and Duration of Study: This study was carried out at the Dialysis clinic of the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria from February 2013 to February 2014.&#x0D; Methodology: The Sample size was estimated to be 85 adult patients and cconsecutive adult patients with chronic renal failure who are having haemodialysis were enrolled into the study. The patients who met the inclusion criteria were randomly booked at the Dialysis Clinic and had no prior knowledge of the study; hence there was no bias in case selection. Ethical approval was obtained from the institutions ethical committee. Each participant had a comprehensive ocular examination including fundus photography. Subjects needing further evaluation and treatment were referred to the Eye Clinic of the Ophthalmology Department of the University of Port Harcourt Teaching Hospital, Port Harcourt.&#x0D; Results: A total of 170 eyes of 85 persons were examined in this study (100% coverage). A total of 30 (35.4%) females and 55 (64.6%) males were examined giving a male to female ratio of 1.8:1.&#x0D; Approximately half of the study subjects (54.1%) had no previous eye problem prior to developing chronic renal failure while about a quarter (n= 20, 23.5%) had refractive error and difficulty in reading near prints .After diagnosis of chronic kidney disease however a total of 40 (47%) of study subjects had visual impairment while 2(2.4%) were blind and 43(50.6%) of the study population however had normal vision.&#x0D; Conclusion: Chronic Kidney disease is an important cause of ocular morbidity in our environment with majority of those affected being males in the third to fifth decades of life. Posterior segment disorders were the commonest disorders seen.

Lipids, Lipoprotein Distribution and Nutritional Parameters over the Ramadan Period in Hemodialysis Patients.

The period of Ramadan (R) is associated with dramatic changes in eating habits involving extended periods of fasting on a daily basis. The current study assessed whether lipids and lipoproteins were impacted during R in chronic hemodialysis (HD) patients. Forty-five subjects in an outpatient dialysis clinic in Saudi Arabia were evaluated for anthropometric and lipid changes on a monthly basis before, during as well as one and two months after R. In addition to routine biochemical measures, anthropometric assessments including hand-grip strength (HGS), mid-arm muscle circumference (MAMC), plasma lipids and lipoproteins were evaluated. Dietary assessment was carried out using 24 h recalls. Over the course of the study, changes in renal-related parameters (creatinine, albumin, Kt/V) were minor, as were changes in plasma lipids. Large high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) accounted for the majority of their respective lipoproteins and their proportions did not change over the study period. Mean LDL particle diameters were higher during the R period, but the changes over the study period were small. Calorie intake during R (2139 ± 709 kcal/d) was significantly higher than the value noted two month post-R (1755 ± 424 kcal/d) and this was associated with significant increases in protein (69 ± 24 vs. 60 ± 24 g/d) and fat (97 ± 38, vs. 73 ± 35 g/d), respectively. No changes were noted with respect to HGS and MAMC. These data show that for HD patients, the period of R results in temporal or non-significant effects on plasma lipids, despite changes in nutrient intake.