Duration Of Dialysis Session Research Articles

Patient Survival With Extended Home Hemodialysis Compared to In-Center Conventional Hemodialysis

More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up. We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters. The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR]= 0.60; 95% confidence interval [CI] 0.45 to 0.80; P< 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement. These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.

#4470 THE IMPACT OF RESIDUAL NATRIURESIS ON INTRADIALYTIC HYPERTENSION IN PATIENTS ON ISONATRIC DIALYSIS: A MONOCENTRIC STUDY AT THE FRANCK JOLY HOSPITAL CENTER

Abstract Background and Aims Intradialytic hypertension (IDH) is an elevation of blood pressure recorded during dialysis monitoring and at the end of the session relative to the values recorded at the connection. Hypervolemia and positive sodium balance are the main mechanisms. Isonatric dialysis allows a restoration of natremia corresponding to an optimal state of cellular hydration at the end of the session, and residual natriuresis is related to the state of extracellular hydration. Hence, their potential role in the appearance of IDH. The objective of this study is to measure the impact of residual natriuresis on IDH in patients on chronic isonatric hemodialysis. Method Transversal, descriptive and analytical study, having examined 12 last dialysis sessions of December 2023 of 65 patients in chronic hemodialysis (780 dialysis sessions) at the FRANCK JOLY Hospital Center in French Guiana. The primary outcome was the presence of intradialytic hypertension (IDH), defined as a difference in mean blood pressure ≥ 15 mmHg at disconnection from branching, or the need for antihypertensive treatment during the session with as main explanatory variables: residual natriuresis and sodium perdialytic concentration. Welche, Mann Whitney, Fisher and chi2 tests were used in univariate analysis and logistic regression in multivariate analysis to determine factors associated with IDH. The significance threshold was set at: p &amp;lt; 0.005. Results The 65 files analyzed had a predominance of women at 55%. 780 dialysis sessions were reviewed, including 206 with IDH, or nearly 1/4 of the sessions. 37% of patients were affected by IDH with a sex ratio of 1. 94% of patients had a history of hypertension and 22% were diabetic. 57% of patients had zero residual diuresis. The average interdialytic weight gain was 2.3 kg. 48% had at least triple antihypertensive therapy. The average duration of a dialysis session was 4 hours, the mean KT/V was 1.2; The mean natremia was 138 mEq/L and the mean perdialytic sodium concentration was 140 mEq/L. The median residual natriuresis was 8.55[0; 26.2] mEq/L. The mean NT-proBNP level was 2407 pg/ml. In univariate analysis, residual natriuresis and perdialytic natremia were not statistically associated with HID. Factors significantly associated with IDH were a number of antihypertensive treatments, NT-proBNP level and duration of dialysis session. In multivariate analysis: the high number of antihypertensive treatments and the increased duration of the dialysis session emerged as risk factors for IDH. Indeed, when the number of antihypertensives increased by 1 unit, the IDH score was multiplied on average by 2.74 (p&amp;lt;0.001), and when the session duration (h) increased by 0.1 units, the IDH score was multiplied by an average of 1.39 (p = 0.019). Residual natriuresis appeared as a protective factor against interdialytic weight gain, because when urinary sodium (mEq/l) increased by 10 units, mean interdialytic weight gain (kg) decreased by an average of -0.116 (p = 0.043). Conclusion Intradialytic hypertension is common and multifactorial. Antihypertensive combination therapy, usually reflecting resistant high blood pressure, is a major risk factor. The present study, at the expense of the definition criteria used, did not find significant associations with perdialytic natremia and residual natriuresis. However, the latter remains protective against interdialytic hypervolemia. Hence, the need for its preservation.

Fatigue assessment and its predictors in pediatric patients with chronic kidney disease stages III to V

BackgroundChronic fatigue is an intense subjective feeling of mental or physical exhaustion. It influences patients’ daily functioning and quality of life, delays recovery, and increases mortality, especially in chronic kidney disease (CKD) patients. The aim of this study is to assess and determine predictors of chronic fatigue in children with ESRD, dialysis, and pre-dialysis stages that can affect the patients’ quality of life (QOL).MethodsWe conducted a cross-sectional study on 114 patients diagnosed with CKD stages III to V, following at the nephrology outpatient clinic and hemodialysis (HD) unit of Cairo University Children’s Hospital during the period September 2020 till April 2021. Demographic and laboratory data of patients were gathered, and dialytic analysis in the form of frequency, duration of dialysis sessions, and adequacy of hemodialysis was calculated. The fatigue severity score (FSS) questionnaire was used to assess fatigue’s effects on daily functions, querying its relationship to motivation, physical activity, work, family, and social life.ResultsThe mean age in the current study was (8.8 ± 1.8) years, with 62% being males. The median FSS score was 5.8, with a higher FSS score in stage V CKD patients. High e-GFR, serum sodium, folic acid, and L-carnitine supplementation all reduced the intensity of fatigue, while prolonged HD duration, acidosis, hypertension, and non-compliance to vitamin D replacement increased tiredness severity.ConclusionRoutine fatigue assessment and measures to reduce it is a fundamental issue in pediatric CKD patients for better QOL.

A step towards the application of an artificial intelligence model in the prediction of intradialytic complications

ABSTRACT Introduction Acute intradialytic complications remain a major burden in end stage renal disease (ESRD) patients on hemodialysis (HD). They often lead to early termination of the HD session affecting dialysis adequacy and patient overall health. The aim of the study was to create an artificial intelligence model and to assess its performance in the prediction of the occurrence of intradialytic clinical events. Methods We studied 6000 HD sessions performed for 215 ESRD patients, recording many predictors that included: patient, machine, and environmental factors. These data were collected within 24 weeks, including 12 weeks in the COVID 19 era and were used to develop and train an artificial neural network model (ANN) to predict the occurrence of intradialytic clinical events such as: hypotension, headache, hypertension, cramps, chest pain, nausea, vomiting, and dyspnea. Findings Our ANN model showed mean precision and recall of 96% and AUC of 99.3% in binary ANN to predict occurrence of an intradialytic complication (event or no event), while the accuracy of the categorical ANN in predicting the type of event was 82%. We found that heart rate changes, mean systolic pressure, ultrafiltration rate, dialyzate sodium, meal, urea reduction ratio, room humidity and dialysis session duration most strongly influence occurrence of an intradialytic complication. Discussion Our ANN model can be used to predict the risk of intradialytic clinical events among HD patients and can support decision-making for healthcare in the frequently under-staffed dialysis units, especially in COVID 19 era.

High-volume hemodiafiltration decreases the pre-dialysis concentrations of indoxyl sulfate and p-cresyl sulfate compared to hemodialysis: a post-hoc analysis from the HDFit randomized controlled trial.

Although high-volume online hemodiafiltration has been associated with higher clearance and lower pre-dialysis concentration of middle molecular weight toxins compared to hemodialysis, its effect on protein-bound uremic toxins has shown inconclusive results. In this study, we investigated whether hemodiafiltration impacts pre-dialysis plasma levels of the toxins indoxyl sulfate, p-cresyl sulfate, and indole-3-acetic acid compared to high-flux hemodialysis. This is a post-hoc analysis of the multicenter, randomized controlled trial HDFit (ClinicalTrials.gov: NCT02787161). Uremic toxins were determined by high performance liquid chromatography at baseline, 3, and 6months. Mean differences in monthly changes of pre-dialysis uremic toxin concentrations between hemodiafiltration and high-flux hemodialysis were analyzed using linear mixed-effect models. One hundred ninety-three patients (mean age 53years old, 71% males) were analyzed. There were no differences between groups regarding clinical and biochemical characteristics at baseline or duration of dialysis session and blood flows throughout the follow-up. Mean differences in rates of change (μM/month, [confidence interval CI]) in high-flux hemodialysis vs. hemodiafiltration were 2.4 [0.3 to 4.56], 3.94 [- 1.54 to 9.41] and 0.06 [- 0.6 to 0.5] for indoxyl sulfate, p-cresyl sulfate and indole-3-acetic acid, respectively. In the exploratory analysis, these differences in high-flux hemodialysis vs. hemodiafiltration subgroup with convective volume > 27.5L were 2.86 [0.43 to 5.28], 7.43 [0.7 to 14.16] and - 0.19 [- 0.88 to 0.50]. These exploratory findings suggest that hemodiafiltration is more effective in reducing indoxyl sulfate as compared to standard high-flux hemodialysis, and also that this effect was extended to p-cresyl sulfate in patients achieving higher convective volumes.

Pharmacokinetics of Vancomycin in Pediatric Patients Receiving Intermittent Hemodialysis or Hemodiafiltration

IntroductionVancomycin is a common antibiotic used to treat hemodialysis (HD) or hemodiafiltration (HDF)-related infections in pediatric patients, but optimal dosing remains unknown. This is the first observational study to characterize the pharmacokinetics and evaluate dosing of vancomycin in this population.MethodsEligible patients received IV vancomycin 10 mg/kg per dose postdialysis followed by a series of serum vancomycin concentrations collected before, immediately after, 1 hour after, and 4 hours after dialysis. The pharmacokinetic parameters were estimated using 1- and 2-compartment models and a nonlinear least-squares algorithm.ResultsAmong 42 vancomycin courses in 16 patients, 1 compartment model had the best fit for observed data. The net drug removal was 43 ± 13% (39% for HD and 50% for HDF) from an average 3-hour HD/HDF session. The mean elimination constant was 0.28 h−1 (standard deviation [SD], 0.11 h−1) during the intradialytic period compared with 0.0049 h−1 (SD, 0.004 h−1) when off dialysis. The mean volume of distribution was 0.65 (SD, 0.19) L/kg. Duration of dialysis session and mode of dialysis (HD vs. HDF) were significant predictors of vancomycin pharmacokinetic parameters. Half-life was shorter for HDF compared with HD (2.1 vs. 3.5 hours).ConclusionsBased on the simulations, an initial vancomycin dose of 10 mg/kg per dose and redosing postdialysis was optimal to achieve a vancomycin concentration range of 5 to 12 mg/L at 4 hours postdialysis and 24-hour area under the curve over minimum inhibitory concentration of ≥400 hours. Therapeutic drug monitoring is necessary to account for residual variability in vancomycin elimination in pediatric patients receiving HD/HDF.

The Impact of a National Surgical Mask Wearing Policy on COVID-19 Transmission in Haemodialysis Units in the Republic of Ireland

The Impact of a National Surgical Mask Wearing Policy on COVID-19 Transmission in Haemodialysis Units in the Republic of Ireland

The Impact of Blood Flow Rate and Duration of Dialysis Session on Nutritional Status in Hemodialysis Patients

BACKGROUND: Blood flow rate (BFR) and time of dialysis are important determinants of dialysis adequacy. This study aimed to determine the impact of higher BFR and longer dialysis time on nutritional status in chronic hemodialysis (HD) patients. &#x0D; &#x0D; METHODS: Real-world evidence (RWE) studies of 3 HD units in different hospitals that differ in BFR and/or dialysis time. Group I, HD 5 hr and BFR 200-250 mL/min; group II, HD 4 hr and BFR 270-320 mL/min, and group III, HD 4 hr and BFR 200-250 mL/min. All HD units use the same dialysate flow and dialysis frequency. Nutritional status was assessed using a 3-point scale Subjective Global Assessment. &#x0D; &#x0D; RESULTS: A total of 233 chronic HD patients were included, mean of age was 52 &amp;plusmn; 12.9 years, 46.5% were male. There are 69.5% on SGA class A, 27.5% on SGA class B, and 3% on SGA class C. The proportion of SGA class A in group II was highest compared to group II and III (93.5% vs 79.0% vs 32.1% (p &amp;lt;0.05). There was no SGA class C in group II, whereas 2.4% in group I and 7.4% in group III. In group II there was lower interdialytic weight gain (IDWG) and less use of anti-hypertensive drugs compared to group III (p &amp;lt;0.05). &#x0D; &#x0D; CONCLUSION: Our study showed that higher BFR and longer dialysis time are associated with better nutritional status in chronic HD patients. A higher BFR seems to have a more substantial impact compared to a longer dialysis time.&#x0D; &#x0D; Keywords: blood flow rate, dialysis time, subjective global assessment, nutritional status

P1070ONLINE HIGH-VOLUME HEMODIAFILTRATION REDUCES PRE-DIALYSIS LEVELS OF INDOXYL SULFATE COMPARED TO HIGH-FLUX HEMODIALYSIS: RESULTS FROM HDFIT MULTICENTRIC RANDOMIZED CONTROLLED TRIAL

Abstract Background and Aims Online High-Volume Hemodiafiltration (OL-HDF) combines convective and diffusive clearances and is associated with better outcomes compared to standard hemodialysis (HD). Although HDF has been shown to improve the clearance and pre-dialysis concentration of middle size uremic toxins, little is known about its effect on concentration of protein-bound uremic toxins (PBUT), particularly in comparison to high-flux HD. Here, we investigated whether high-volume post-dilution OL-HDF impacts pre-dialysis plasma levels of PBUT indoxyl sulfate (IxS), p-cresyl sulfate (pCS) and indole 3-acetic acid (IAA) compared to high-flux HD over time, since accumulation of these PBUT has been associated with increased overall mortality of CKD patients. Method This is post hoc analysis of the multicentric randomized controlled trial (RCT) studying the impact of post-dilution high-volume OL-HDF versus high-flux HD on measured physical activity (HDFit - clinicalTrials.gov: NCT02787161), which included clinically stable HD patients with a vintage &amp;gt;3 to &amp;lt;24 months. Total plasma levels of IxS, pCS and IAA were determined by high performance liquid chromatography (HPLC) with fluorescence detection at baseline, 3 and 6 months. The difference between HDF and HD in respect to changes in the PBUT concentrations during the follow up, analyzed using linear mixed effect models, was compared. Results are presented as mean differences between groups in the change from baseline along with 95% confidence intervals (CI). Results 193 patients (mean age 53 years old, 70% males and 60% white – no differences between groups) were analyzed. There were no differences between HD and OL-HDF groups regarding clinical and biochemical characteristics at the baseline. In the OL-HDF group, 99% of patients achieved a convective volume higher than 22 L and both groups had similar dialysis session duration and blood flows throughout the follow up. The mean differences (95% CI) in concentrations over time for PBUTs among HDF and HD groups are shown in Figure 1. HDF group presented a significantly lower trajectory of IxS levels and a lower trajectory of pCS levels than HD group. Trajectories of IAA levels were not different between groups. Conclusion OL-HDF reduced the pre-dialysis concentration of IxS and pCS through 6 months-period compared to high-flux HD.

SAT-232 HEMODIALYSIS IN CHILDREN AND ADOLESCENTS: A SYSTEMATIC REVIEW

Hemodialysis (HD) in children is often utilized in situations such as acute or chronic kidney disease, severe electrolyte imbalance, toxicities, and hyperammonemia. Proper HD in children require careful manipulation of technical parameters including blood and dialysate flow rate, type/size of dialyzer and dialysate composition. Although general principles of hemodialysis are similar between adults and children, there are several unique aspects of HD inherent to the pediatric population. Issues of hemodynamic stability, obtaining ideal vascular access and preventing complications from HD can prove challenging in this patient population. In this systematic review, we evaluate the existing literature regarding the use of hemodialysis in children and young adults (ages 1-20 years). Furthermore, we summarize this data to compile guidelines for best practice. A systematic search of all relevant studies and abstracts was conducted using several electronic databasesby utilizing appropriate key words by an expert hospital librarian. Eligible studies included children aged 1-20 years with acute or chronic indications for hemodialysis. Studies prior to Jan 1990 or on continuous renal replacement therapy, peritoneal dialysis, modified forms of hemodialysis (nocturnal, hemodiafiltration, etc.) were excluded. In addition, studies that were non-English or involved < 5 patients were excluded. Titles and abstracts were screened by two independent reviewers, followed by a full text review of included articles. Data on HD indications, specific parameters of the HD protocol, including dialysate composition, dialysate flow, blood flow, urea reduction rate and ultrafiltration goals were collected. We also collected data regarding medications, anticoagulation and blood transfusions required along with outcomes such as mortality and kidney transplantation. Preliminary results of this systematic search returned a total number of 16,196 papers. After screening for relevant titles and abstracts, and exclusion based on criteria defined above, a total of 102 papers remained. Further assessment of full text of articles led to inclusion of 55 papers in this review. Results showed that congenital abnormalities, glomerulopathy and obstructive uropathy were some of the most common indications of HD. The mean age of HD was 12.7 ±2.9 years. Mean dialysis session duration was 223.7 ±65.6 min/session, with 3.2 ±0.6 sessions/week. Mean dialysate flow was 480±46.8 ml/min and mean blood flow was 192.5±65.5 ml/min. A subset of studies (n=5) reported mean blood flow relative to body weight as 4.7±0.5 ml/kg/min. Mean urea reduction ratio was 44.9±30.0%. Most common types of vascular access were central venous catheters and arteriovenous fistulas. The most common complications were access-related infection and thrombosis. From studies with reported outcomes, 7.68% of children died and 42% were transplanted. The use of HD in children presents unique challenges due to age-related differences in physiology, risk of complications and increased emphasis on long-term health. This systematic review summarizes the available literature on HD, in terms of indication, technical aspects and outcomes. Ultimately, this data can help to guide safe, effective HD treatment in children and in formulating guidelines for best practice.

Comparison of characteristics of centers practicing incremental vs. conventional approaches to hemodialysis delivery - postdialysis recovery time and patient survival.

Conventional haemodialysis (HD) involves treatment times of around 4 hours thrice weekly, taking no account of residual kidney function (RKF). In incremental HD the frequency and duration of dialysis sessions are individualized according to RKF. There are no studies comparing these approaches. We utilized data from a recent multicenter study to compare patient characteristics and outcomes between a center practicing incremental HD and others using a conventional approach. Seven hundred and nine patients attending for routine outpatient HD in five UK centers were studied. One center practiced incremental dialysis (n = 254) and four conventional HD (n = 455). Data collected included demographics, comorbidity, dialysis parameters, routine biochemistry and hematology, recovery time postdialysis, and Beck Depression Inventory-II score (BDI-II). Patients were followed for a minimum of 12 months. Pre- and postdialysis BP, serum calcium and phosphate were higher in the incremental center, whilst sessional Kt/Vurea was lower (all P < 0.001), as was the proportion of patients with a mean postdialysis BP <100 mmHg (P = 0.011). Patients recovered from their HD session more quickly in the incremental center, with significantly more patients reporting recovery within 1 and 4 hours Short-term survival was significantly better in the incremental center both unadjusted and adjusted for age, gender, ethnicity, dialysis vintage, anuria, history of cancer, heart disease, diabetes mellitus, body mass index, serum albumin, BDI-II score, and sessional Kt/V. The association between incremental dialysis, shorter postdialysis recovery times and improved short-term survival may be related to reduced haemodynamic stress as a consequence of less intensive ultrafiltration and reduced length of dialysis sessions. Prospective studies are required to test this hypothesis.

The Effect of Acidosis on Albumin Level in Patients Treated With Regular Hemodialysis (Single Center Study)

BACKGROUND: Hypoalbuminemia is the most powerful predictor of mortality in end-stage renal disease on hemodialysis. Metabolic acidosis induces net negative nitrogen and total body protein balance. Some patients undergoing maintenance dialysis have low plasma bicarbonate levels due to inadequate dialysis. We aimed to evaluate the role of metabolic acidosis on serum albumin concentration in patients with end stage renal disease on hemodialysis, and to determine differences of serum bicarbonate level before and after hemodialysis in actual situation. &#x0D; &#x0D; METHODS: This cross sectional comparative study was conducted in the Iraqi Center for Hemodialysis/ Baghdad Teaching Hospital from June to December 2015. It included 100 subjects with end stage renal disease on hemodialysis. They were divided equally into cases with low albumin and comparison group with normal albumin level. Serum bicarbonate and the Kt/V were measured for all subjects before, after, and before next hemodialysis session to show the adequacy of dialysis.&#x0D; &#x0D; RESULTS: There was a significant association between low bicarbonate and low albumin level in hemodialysis patient and between numbers and duration of dialysis session with albumin. Low Kt/V was significantly associated with hypoalbuminemia. There was no statistically significant association between age and gender with hypoalbuminemia.&#x0D; &#x0D; CONCLUSION: This study shows that patients with metabolic acidosis had a lower serum albumin concentration and there was a significant correlation between numbers, duration and adequacy of hemodialysis sessions and albumin level. We recommend to increase the numbers of dialysis centers in Iraq and adjust the bicarbonate doses in dialysate according to patient&amp;rsquo;s bicarbonate levels.

Initial Session Duration and Mortality Among Incident Hemodialysis Patients

The association of dialysis session duration with mortality in patients undergoing maintenance hemodialysis is unclear. We compared mortality rates of patients treated in dialysis facilities that used initial session durations of either ≥ 4 versus 3 hours for all incident patients. Retrospective cohort study. Patients with end-stage renal disease beginning maintenance hemodialysis therapy in January 2006 to December 2010 and followed up through December 2012, including 39,172 patients in 852 facilities who initiated treatment for ≥ 4 hours and 47,721 patients in 631 facilities who initiated treatment for 3 hours. Initial session duration of ≥ 4 hours versus 3 hours. 2- and 1-year mortality rates. Total numbers of deaths observed within 2 years after initiating dialysis therapy were 8,945 in the ≥ 4-hour group and 15,624 in the 3-hour group. The corresponding numbers of deaths observed within 1 year were 5,492 and 10,372, respectively. The 2-year adjusted HR in the ≥ 4-hour versus 3-hour group was 0.79 (95% CI, 0.73-0.86). The corresponding 1-year adjusted HR was 0.77 (95% CI, 0.70-0.84). Results were robust when analyses were restricted to specific subgroups of patients classified by age, sex, race, and select clinical characteristics. We did not observe hemodialysis duration in sessions subsequent to initiation. We only included patients treated in facilities with uniform session length (at initiation) for all their patients. Furthermore, we lacked information for dialysis dosage and patients' baseline residual kidney function. Patients in facilities routinely initiating hemodialysis therapy for ≥ 4 hours may have substantially lower mortality as compared with patients in facilities initiating for only 3 hours of treatment.

Incremental Hemodialysis - A European Perspective.

Most patients initiating hemodialysis have residual renal function (RRF). Whereas RRF is monitored prior to commencing hemodialysis, once dialysis is started most centres simply rely on dialyzer urea clearance to determine adequate uremic toxin clearance and disregard the effect of RRF. However sustaining RRF is important for the dialysis patient, as RRF reduces inter-dialytic weight gains, increases middle molecule and protein bound toxin clearances and is associated with better quality of life assessments. Paradoxically, more frequent dialysis and longer dialysis sessions appear to be associated with more rapid loss of RRF. As such, starting patients with less frequent or shorter dialysis sessions, depending upon individual patient comorbidity, may lead to better preservation of RRF. However to prevent inadequate uremic toxin clearance or volume overload, RRF needs to be regularly monitored. Unfortunately, the 24-hour urine collection for urea and creatinine clearance remains the mainstay for RRF assessment. This measurement chiefly represents glomerular clearance rather than tubular function, but the latter may be also important for the dialysis patients. Incremental dialysis with less initial dialysis treatment may lower costs and will allow others to dialyze more frequently. The key to start a successful incremental hemodialysis approach is the regular monitoring of the patient, so that as RRF is lost an appropriate decision can be made regarding increasing dialysis session duration and frequency on an individual patient basis or consider switching modalities to hemodiafiltration.

Effect of Membrane Permeability on Cardiovascular Risk Factors and β2m Plasma Levels in Patients on Long-Term Haemodialysis: A Randomised Crossover Trial

Survival of haemodialysis (HD) patients is influenced by many factors. Mortality is mainly of cardiovascular (CV) origin and related to both traditional and nontraditional CV risk factors. Low plasma Beta2-microglobulin (β2m) levels are associated with improved HD patient survival. HD session times that are longer than the conventional 4 h (i.e., extended dialysis) provide better middle molecule clearance and are also associated with a survival advantage. In this crossover randomised trial, we investigated the effect of membrane flux on CV risk factors and on β2m plasma levels in patients treated with extended dialysis. Dialysis session duration was between 5 and 8 h for all patients. Patients were randomly assigned to the treatment sequences low-flux/high-flux dialysis versus high-flux/low-flux dialysis in a crossover design after a 3-month run-in period, with each phase lasting 9 months. Of the initially enrolled 168 patients, 155 patients started the study after the run-in period, 117 patients completed Phase 1, and 83 patients completed the whole study. Lp(a), homocystein, LDL cholesterol, HDL cholesterol and serum albumin were comparable in the low-flux and high-flux treatments. The average β2m level was 43.3 ± 11.1 mg/l at the end of the low-flux phase. Independent of sequence assignation, average β2m was significantly lower at the end of the high-flux phase (27.5 ± 76.0 mg/l, p < 0.0001 versus end of low-flux phase). Both phosphate and nPNA were significantly lower at the end of the high-flux phase compared to the low-flux phase (p = 0.045 and p = 0.002, respectively). Inclusion of those patients who completed Phase 1 and who dropped out of the study during Phase 2 did not significantly change the results. In conclusion, this study did not find an influence of high-flux filters on several traditional CV risk factors in a population of HD patients treated with extended dialysis. However, high-flux filters are necessary to optimise middle molecule clearance and reduce the β2m level.

Dialysis Fluid Endotoxin Level and Mortality in Maintenance Hemodialysis: A Nationwide Cohort Study

The quality of dialysis fluid water might play an important role in hemodialysis patient outcomes. Although targeted endotoxin levels of dialysis fluid vary among countries, evidence of the contribution of these levels to mortality in hemodialysis patients is lacking. Retrospective cohort study using data from the Japan Renal Data Registry, a nationwide annual survey. 130,781 patients receiving thrice-weekly in-center hemodialysis for more than 6 months were enrolled at 2,746 facilities in Japan at the end of 2006. None of the patients changed facility or treatment modality during2007. Highest endotoxin level in dialysis fluid reported by each facility during 2006. Patients were categorized by facility endotoxin level into the following groups:<0.001, 0.001 to<0.01, 0.01 to<0.05, 0.05 to<0.1, and≥0.1EU/mL. Age, sex, dialysis vintage, diabetes mellitus as a primary cause of end-stage renal disease, Kt/V, normalized protein catabolic rate, dialysis session duration, serum albumin, and hemoglobin were measured as potential confounders. All-cause mortality, censored by transplantation; withdrawal from dialysis treatment; or end of follow-up. Of 130,781 hemodialysis patients, 91.2% had facility endotoxin levels below the limit set for dialysis fluid in Japan (<0.05EU/mL). During a 1-year follow-up, 8,978 (6.9%) patients died of all causes. The rate of all-cause mortality at 1 year was highest in the≥0.1-EU/mL category (88.0 deaths/1,000 person-years). Patients in the≥0.1-EU/mL group exhibited an increased risk of all-cause mortality of 28% (95% CI, 10%-48%) compared to the<0.001-EU/mL group. Endotoxin level in dialysis fluid is reported as categorical data. No information about variation in endotoxin levels in dialysis fluid over time. Higher facility endotoxin levels in dialysis fluid may be related to increased risk for all-cause mortality among hemodialysis patients. Correcting this modifiable facility water management practice might improve the outcome of hemodialysis patients.

Evaluation of acute intradialytic complications, management &amp; outcome in end-stage renal disease patients

Little is known about the challenges of routine renal replacement therapy in Bangladesh. We investigated the fatal and nonfatal acute hemodialysis complications in patients with end stage renal disease (ESRD) in dialysis centers in Mymensingh. 500 consecutive hemodialysis sessions incurred over a 4-month period by 50 patients with ESRD, receiving two weekly hemodialysis sessions of 4 hours each were considered. Personal and clinical profiles before, during, and within 24 hours after hemodialysis sessions were used to diagnose complications. The mean age of the patients was 45.5 ± 16.8 years and the lowest and highest ages were 17 and 82 years respectively. Male was predominant of the patients and male to female ratio was 2:1. Hypotension, muscular cramps, pruritus, nausea and vomiting were the common complications in end-stage renal disease patients. Twenty eight percent of patients presented with hypertensive crisis, 34% fever, 18% bleeding, 44% headache, 32% vomiting, 16% lumber pain, 16% palpitations, 22% disequilibrium syndrome, 36% dyspnea, 28% chest pain, 20% syncope, 32% abdominal problem, 44% neurological problem, 46% electrolyte imbalance, 34% articular &amp; musculoskeletal problems, 48% cramps, 38% convulsions and 20% loss of consciousness. The vascular access was the main bleeding site of the patients (44.5%), followed by 33.3% through nose and 22.2% digestive tract bleeding. Most of patients experienced muscular cramps, hypertensive crisis, pruritus, vomiting, palpitations, disequilibrium syndrome, dyspnea, chest pain, neurologic problem, electrolyte disorders, nausea, vomiting, convulsions and loss of consciousness in shorter duration of dialysis than those in longer duration of dialysis sessions. Bleeding, disequilibrium syndrome and cardiovascular disease were leading cause of death in end-stage renal disease patients. Those complications occurred mostly during understaffed periods. Urgent strategies are needed to quickly solve the human capital crisis in the health care sector. DOI: http://dx.doi.org/10.3329/cbmj.v2i2.16696 Community Based Medical Journal 2013 July: Vol.02 No 02: 35-40

Time to recovery after a hemodialysis session: impact of selected variables.

BackgroundPatients maintained on hemodialysis (HD) have an impaired health-related quality of life (HRQOL). One factor that has been suggested to contribute to this impairment is the prolonged recovery time after completing a conventional HD session. The present study was designed to carefully examine the time to recovery (TTR) in patients maintained on three times/week conventional HD and evaluate the clinical and demographic features associated with the TTR.MethodsTwo hundred and sixty-seven patients on conventional three times/week HD were studied during three successive HD treatments. Patients were asked how long it took them to recover from their previous session. Detailed demographic and clinical data as well as data involving the most recent HD session were reviewed.ResultsThe mean ± SD age was 66.4 ± 15.7 and the mean duration of renal replacement therapy was 40.1 ± 37.6 months. The mean time to recovery was 246 ± 451 min. A multivariate regression analysis including age, gender, number of comorbidities, months on renal replacement therapy, occurrence of hypotension during dialysis, amount of ultrafiltration and duration of dialysis session revealed that none of these covariates was significantly associated with TTR from HD.ConclusionsThe present study is important since it clarifies that the TTR after an HD session is not related to various demographic and clinical factors that one might have expected would impact on this variable.

Cardiac and vascular structure and function parameters do not improve with alternate nightly home hemodialysis: An interventional cohort study

BackgroundNightly extended hours hemodialysis may improve left ventricular hypertrophy and function and endothelial function but presents problems of sustainability and increased cost. The effect of alternate nightly home hemodialysis (NHD) on cardiovascular structure and function is not known.MethodsSixty-three patients on standard hemodialysis (SHD: 3.5-6 hours/session, 3-5 sessions weekly) converted to NHD (6-10 hours/session overnight for 3-5 sessions weekly). 2Dimensional transthoracic echocardiography and ultrasound measures of brachial artery reactivity (BAR), carotid intima-media thickness (CIMT), total arterial compliance (TAC) and augmentation index (AIX) were performed post dialysis at baseline and 18-24 months following conversion to NHD. In 37 patients, indices of oxidative stress: plasma malonyldialdehyde (MDA) and anti-oxidant enzymes: catalase (CAT), glutathione peroxidase (GPX) and superoxide dismutase (SOD) activity and total antioxidant status (TAS) were measured at baseline, 3 and 6 months.ResultsLeft ventricular mass index (LVMI) remained stable. Despite significant derangement at baseline, there were no changes in diastolic function measures, CIMT, BAR and TAC. AIX increased. Conversion to NHD improved bone mineral metabolism parameters and blood pressure control. Interdialytic weight gains increased. No definite improvements in measures of oxidative stress were demonstrated.ConclusionsDespite improvement in uremic toxin levels and some cardiovascular risk factors, conversion to an alternate nightly NHD regimen did not improve cardiovascular structure and function. Continuing suboptimal control of uremic toxins and interdialytic weight gains may be a possible explanation. This study adds to the increasing uncertainty about the nature of improvement in cardiovascular parameters with conversion to intensive hemodialysis regimens. Future randomized controlled trials will be important to determine whether increases in dialysis session duration, frequency or both are most beneficial for improving cardiovascular disease whilst minimizing costs and the impact of dialysis on quality of life.

Using dialysis machine technology to reduce intradialytic hypotension

Intradialytic hypotension remains the most frequent complication associated with routine outpatient hemodialysis. Although increasing dialysis frequency and also lengthening dialysis session duration can reduce the risk of intradialytic hypotension, in practice, these options are limited to a small minority of dialysis patients. To help reduce intradialytic hypotension, a number of technological developments have been incorporated into the hemodialysis machine, based around relative blood volume monitoring, an indirect assessment of plasma volume. Further developments based on so called "fuzzy" logic feedback systems designed to adjust either or both the ultrafiltration rate and dialyzate sodium concentration according to relative changes in plasma volume. In addition, cooling and dissipation of the heat generated during dialysis also reduces the risk of intradialytic hypotension, and this can be regulated by cooling of the dialyzate using thermal control systems. In addition, convective therapies, such as online hemodialfiltration, have also been reported to reduce the frequency of intradialytic hypotension; whether this effect is simply due to increased cooling remains to be determined. Although all these developments have been reported to reduce the frequency of serious intradialytic hypotensive episodes, they have not been able to totally abolish hypotension, as they can not alone compensate for excessive weight gains and consequent excessive ultrafiltration requirements. Thus, in addition to the advances in hemodialysis machine technology designed to reduce intradialytic hypotension, attention also needs to be focused on reducing interdialytic weight gains, so reducing ultrafiltration requirement.