Duration Of Hemodialysis Sessions Research Articles

Boosted machine learning model for predicting intradialytic hypotension using serum biomarkers of nutrition

Intradialytic hypotension (IDH) is a serious complication of hemodialysis (HD), with an incidence of more than 20%. IDH induces ischemic organ damage and even reduces the ultrafiltration and duration of HD sessions. Frequent attacks of IDH are a risk factor for death in HD patients. Malnutrition is common in HD patients and is also associated with mortality. Although the link between IDH episodes and malnutrition has been observed in practice, it has not been supported by the data. To study the relationship, we propose a promising hybrid model called BSCWJAYA_KELM, which is a wrapper feature selection method based on a variant of the JAYA optimization algorithm (SCWJAYA) and Kernel extreme learning machine (KELM). In this paper, we verify the optimization capability of the SCWJAYA algorithm in the model by comparing experiments with some state-of-the-art methods for IEEE CEC2014, IEEE CEC2017, and IEEE CEC2019 benchmark functions. The prediction accuracy of BSCWJAYA_KELM is validated by the public datasets and the HD dataset. In the experiments on the HD dataset, 1940 HD sessions of 178 HD patients are analyzed by the developed BSCWJAYA_KELM model. The key indicators selected from vast amounts of data are serum uric acid, dialysis vintage, age, diastolic pressure, and albumin. The BSCWJAYA_KELM method is a stable and excellent prediction model that can achieve a more accurate prediction of IDH.

Changes in total and segmental extracellular and intracellular volumes with hypotension during hemodialysis measured with bioimpedance spectroscopy.

Bioelectrical impedance analysis (BIA) devices have been advocated to guide volume management in hemodialysis (HD) patients. We hypothesized that understanding the dynamics of fluid shifts in different body segments may provide additional insight on preventive measures to reduce the risk of intradialytic hypotension. A prospective observational study was conducted among 42 HD patients at risk of hypotension who were admitted as emergencies inpatient. A total of 191 BIA measurements were made during the 42 HD sessions, and hypotension occurred during 52 measurements (27%). The extracellular water (ECW) to intracellular water ratio (EIR) was measured in different body segments and declined significantly only in the non-access arm with increasing HD session duration (β=-0.04; 95% confidence interval (CI): -0.05 to -0.03, p<0.01). There was no significant association between EIR and hypotension with respect to the different body segments. Only pre-HD N-terminal-pro b-type natriuretic peptide was significantly associated with hypotension (β=0.20, 95% CI: 0.04 to 0.89, p=0.04). There was no association between relative blood volume monitoring change and EIR. In summary, we found that segmental BIA during HD was unable to detect or predict hypotension during dialysis. Although BIA is able to provide information about ECW and guide clinical assessment of volume in HD patients prior to dialysis, our findings did not suggest the use of serial measurements of changes in EIR in different body segments during HD provided sufficient information to predict intradialytic hypotension. Similarly, changes in EIR did not provide information on changes in plasma volume that could potentially trigger interventions to prevent or reduce intra-dialytic hypotension.

Symptom Burden’s Associated Factors among Hemodialysis Patients

Many patients with chronic kidney disease undergoing hemodialysis (CKD-HD) had a high symptom burden, which can worsen their health conditions and quality of life. The known factors associated to symptom burden were age, gender, hemodialysis (HD) session duration, post dialysis recovery time, hemoglobin level, nutrition status, physical activity, depression level and social support. The aim of this study was to analyze the most dominant factor associated to symptom burden among CKD-HD patients. Using a cross-sectional design, a convenience sample of eighty-five respondents were recruited from HD unit at Adventist Bandung Hospital, who underwent HD &gt; 3 months, HD frequency 2-3 times a week, aged ≥ 18 years, able to communicate and speak Indonesian. Data were retrieved via seven self-reported questionnaires and health records, and the symptom burden was assessed using the validated Indonesian version of the CKD-Symptom Burden Index. The data was analysed with Spearman correlation test, Chi square test, and multivariate logistic regression. Based on quartile category, most of the respondents (50.6%) had a high symptom burden (33.56±12.23). The factors significantly associated to symptom burden were age (p=0.015), post-dialysis recovery time (p=0.007) and depression level (p=0.000). In the final model, duration of HD session (OR=5.27, 95% CI 1.50-18.49) and depression level (OR=8.84, 95% CI 2.57-30.36) were the factors associated to high symptom burden. Depression level was the most dominant factor associated to high symptom burden. CKD-HD patients with depression are more at risk of experiencing a high symptom burden. Thus, symptom management may consider to modify depression level factor by screening for depression, providing assistance and nursing interventions, or developing depression-related interventions to reduce symptom burden in CKD-HD patients.

Evolution and change in paradigm of hemodialysis in children: a systematic review.

There are similarities in hemodialysis (HD) between adults and children and also unique pediatric aspects. In this systematic review, we evaluated the existing HD literature, including vascular access, indications, parameters, and outcomes as a reflection on real-life HD practices. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were systematically searched for literature on HD in children (1-20years). Two reviewers independently assessed the literature and data on indications; vascular access, outcomes, and specific parameters for HD were extracted. Fifty-four studies (8751 patients) were included in this review. Studies were stratified into age groups 1-5, 6-12, and 13-20years based on median/mean age reported in the study, as well as era of publication (1990-2000, 2001-2010, and 2011-2019). Across all age groups, both arteriovenous fistulas and central venous catheters were utilized for vascular access. Congenital abnormalities and glomerulopathy were the most common HD indications. HD parameters including HD session duration, dialysate and blood flow rates, urea reduction ratio, and ultrafiltration were characterized for each age group, as well as common complications including catheter dysfunction and intradialytic hypotension. Median mortality rates were 23.3% (3.3), 7.6% (14.5), and 2.0% (3.0) in ages 1-5, 6-12, and 13-20years, respectively. Median transplantation rates were 41.6% (38.3), 52.0% (32.0), and 21% (25.6) in ages 1-5, 6-12, and 13-20, respectively. This comprehensive systematic review summarizes available literature on HD in children and young adults, including best vascular access, indications, technical aspects, and outcomes, and reflects on HD practices over the last three decades.

IMPACT OF DURATION OF HEMODIALYSIS ON LIPID PROFILE IN END STAGE RENAL DISEASE PATIENTS RECEIVING HEMODIALYSIS.

End Stage Renal Disease (ESRD) patients receiving hemodialysis are at a higher risk of developing dyslipidemia which is undoubtedly a predisposing factor of cardiac related disease in these patients. Objectives: To assess serum lipid profile in subjects having end stage renal disease and receiving maintenance hemodialysis and to compare it with normal healthy controls and also to assess the effects of duration of hemodialysis on the lipid profile. Study Design: A case-control study. Setting: Executed in the Nephrology Department of JPMC. Period: January 2018 to January 2019. Material and Methods: Blood samples were obtained from a total of 90 subjects. Subjects were stratified into 3 groups including cases of ESRD receiving maintenance hemodialysis and matched healthy controls. Analysis for serum triglyceride, serum VLDL, total cholesterol, LDL and HDL was done. Results: A significant rise in serum triglyceride content and total serum cholesterol of hemodialysis patients (p &lt; 0.01) was detected as compared to healthy controls. A statistically significant decrease was found in serum HDL level (p &lt; 0.01) in hemodialysis patients in comparison to healthy controls. The impact of the hemodialysis duration was found to deteriorate the lipid profile of patients having longer duration of hemodialysis. Conclusion: Dyslipidemia was found to be evident in hemodialysis patients. The duration of hemodialysis sessions was found to affect the lipid profile of ESRD patients, which may play a role in higher incidence of atherosclerotic related cardiac events among these patients.

P1081DIALYSATE SODIUM ALLIGNMENT AND SODIUM SET-POINT STABILITY IN HEMODIALYSIS PATIENTS: TWO-YEAR OBSERVATION

Abstract Background and Aims The low dialysate sodium (NaD) reduces intradialytic weight gain (IDWG) and blood pressure (BP), which are associated with improved outcomes. However, the intervention probably also increases intradialytic hypotension and reduces serum sodium (NaS), that are associated with increased mortality risk, so NaD should be individualized and brought closer to NaS. Predialysis natraemia in hemodialysis (HD) patients is considered constant (set-point) but some observations contradict this statement. The significance of clinical parameters, dialysis parameters and body water distribution is not clear. Method We undertake the retrospective observation among 45 HD patients for 24 months before large-scale prospective intervention investigation for individualization of NaD. We used two-year routinely monthly fixed data: NaS, NaD, IDWG, frequency of intradialysis hyper- and hypotension and seizures, peri- and intradialysis BP, home BP estimates, clinically and by bioimpedance estimated dry weight, ultrafiltration rate, frequency and duration of HD sessions. Results We included 27 males and 18 females of 60 (34-83) years old, with median HD vintage of 63 (29÷93) months. 1048 NaS measurements revealed mean natraemia of 137.1±2.8 (Q5-Q95 132-141) mmol/l (corrected for glucose). No differences in mean NaS according to gender, age, HD vintage, cardiac or liver dysfunction and residual renal function were found. Intraindividual NaS mean varied from 132 to 141 mmol/l and median of coefficient of variation (CV) was 1.4% (1.2÷1.6) (range 0.9-2.0%) which could be attributed mainly to measurement accuracy. The intraindividual NaS Q10-Q90 did not exceed 6 mmol/l with its median 3.0 (2.7÷3.7). Among whole group we revealed slow decreasing NaD trend (-0.12 mmol/l per year, R?0.45) which was accompanied by more prominent trend in systolic BP (-3.3 mmHg/year, R?0.64) and diastolic BP (-1.6 mmHg/year, R?0.49). In parallel, the frequency of intradialytic hypotension increased by 1.6 episodes/100HD per year (mean 2.3±0.6 after excluding the trend). 33 patients (73%) showed no significant individual trend in NaS (&amp;lt;1 mmol/l per year) for 24 months, 8 (18%) demonstrated decreasing trend (mean -1.5 mmol/l per year) while only 4 (9%) - increasing trend (mean +1.6 mmol/l per year). We observed no trend in prescribed bicarbonate level in dialysate. There were no significant associations between intraindividual deviations from individual mean weight before HD and from mean individual NaS. In whole group, intraindividual variations in NaS had no link with mean NaS. We observed the significant variations in NaS only in patients with large CV of predialysis weight (Q90-Q10&amp;gt;5 kg over 2 years). Overall mean of sodium serum to dialysate gradient (NaG) was slightly positive (+0.15±3.0 mmol/l) while 58% of patients had negative or neutral NaG. The latter had lesser IDWG but no difference in intradialytic hypotension frequency. We evaluated the number of random consecutive monthly predialysis NaS need to get acceptable estimation of real mean two-year predialysis NaS: five values gave 94% hit in range -1÷ +1 mmol/l. Conclusion Serum sodium is stable over time in HD patients with the only exception of patients with large intraindividual predialysis weight variation. Pre-HD serum sodium may be used as a parameter for individualizing dialysate sodium prescription.

Epidemiological and Clinical Profile of Dermatoses Observed in Chronic Hemodialysis Patients at the National Teaching Hospital (NTH-HKM) of Cotonou, Benin.

Introduction. Dermatological damage in chronic hemodialysis patients is not uncommon. In Benin, to date, no study on the dermatological manifestations of chronic hemodialysis patients has been carried out. However, the presence of cutaneous signs is evident in these patients, and the need for dermatological care is not negligible. The objective of this study was to identify the epidemiological and clinical profile of the main dermatological manifestations presented by chronic hemodialysis patients at the NTH-HKM of Cotonou (Benin). Methods This was a descriptive cross-sectional study conducted in chronic hemodialysis patients from May 15th to September 15th, 2018. Included were all patients seen during the study period who had been on hemodialysis for at least three months, had at least one dermatological manifestation, and gave verbal or written consent. Chronic hemodialysis patients who did not wish to participate in the survey were excluded. Results 87 patients were included in the study for a hospital frequency of 33.8%. The sex ratio (male to female) was 2. The median age was 49 years (IQ [40.75–59]). Median age in hemodialysis was 36 months with two weekly sessions. The main dermatological manifestations were xerosis (48.3%), pruritus (34.5%), alopecia (14%), nail dystrophy (9.2%), equisegmented nails (8%), and melanoderma (8%). Pruritus was associated with a longer duration of hemodialysis sessions (p=0.01), while xerosis, alopecia, and melanoderma were associated with seniority in hemodialysis. Conclusion Cutaneous manifestations in hemodialysis patients were frequent and dominated by xerosis, pruritus, and alopecia. Factors associated with some of these dermatologic manifestations were seniority in hemodialysis, long duration of the hemodialysis session, and female gender.

Different Clinical Practice in Hemodialysis in Mexico and Colombia

Chronic kidney disease is the structural or functional damage of the kidneys for more than three months and is considered a public health problem, since one out of every ten adults suffer from; the hemodialysis is a therapeutic modality that replaces kidney function (excretion of waste products, regulation of water balance and regulation of the acid-base balance) improving the quality and years of life in patients with chronic kidney disease. However, clinical practices used (dialyzers, duration of hemodialysis sessions, vascular access and health personnel) vary in each country, which has an impact on the quality of life and patient mortality. Objective: To describe the differences in the reuse of dialyzers, duration of hemodialysis sessions, goals for the type of vascular access used and the health personnel who are in each renal unit, from the rules, between Mexico and Colombia. Conclusions: The differences that exist in clinical practices of hemodialysis between Mexico and Colombia are given from the health standards, however, it is necessary reinforce aspects in the both countries to provide better care for patients with chronic kidney disease.

Hemodialysis Session Duration, Ultrafiltration Rate, Interdialytic Weight Gain and their Association with Albumin in Patients on Intermittent Hemodialysis in a Regional Dialysis Unit: A Cross-sectional Study.

AimSeveral studies suggest that a low pre-dialysis serum albumin level (<40g/L) is associated with increased mortality in dialysis patients. The objective of this study was to assess if hemodialysis session duration (HSD), ultrafiltration rate (UFR) and interdialytic weight gain percentage (IDWG%) are associated with pre-dialysis serum albumin levels (markers of all-cause mortality), thus influencing mortality. Method This is a cross-sectional analytical study in which data were collected from a regional cohort of 59 prevalent chronic hemodialysis patients using a national electronic database (eMED). Continuous data were analyzed using a regression model to assess for an association between HSD, IDWG% and UFR with albumin levels.ResultsFifty-six patients were included in the study. Multiple linear regression models demonstrated a cross-sectional association between longer HSD and higher serum albumin levels and a statistically significant positive correlation (r = 0.353; p < 0.05). No significant association of UFR (p = 0.169) and IDWG% (p = 0.549) with albumin was observed. Mean albumin was 38.07 ± 3.96 g/L in the HSD <240 min group compared to 40.50 ± 2.83g/L in the HSD ≥240 min group which was statistically significant (p < 0.05).ConclusionLonger HSD has a cross-sectional association with higher pre-dialysis serum albumin with patients having HSD ≥240 min demonstrating the highest levels of serum albumin. Our study suggests longer HSD may improve mortality in the dialysis population.

Adverse Events During Hemodialysis in LVAD Recipients

Introduction Over the past decade, implantable left ventricular assist devices (LVAD) have become an acceptable alternative to support patients with advanced heart failure, either as a bridge to transplantation or as destination therapy for patients who are not candidates for heart transplantation. As the number of LVAD implantation increases, greater number of LVAD recipients requiring long term renal replacement therapy (RRT), usually chronic hemodialysis (HD), will be seen. This is due to common simultaneous chronic kidney disease in patients with heart failure, but more frequently due to irreversible acute kidney injury occurring in the peri-implantation period. There though is limited data on HD in LVAD recipients. We sought to assess adverse events that required early termination of HD sessions in HeartWare LVAD recipients while they were hospitalized after LVAD implantation. Methods Between 2015 and 2017 at the University of Maryland Medical Center, 7 patients required HD after LVAD implantation. These 7 patients had a total of 92 HD sessions during their hospitalizations. The average age of the patients was 46 +/- 11.9 years old. Two patients had ESRD and were on HD prior to LVAD implantation. The remaining five patients had CKD but were not on HD. The pre-LVAD creatinine average for all 7 patients was 2.55 +/- 1.8. After LVAD implantation, all of the patients were initially on continuous renal replacement therapy before being transitioned to HD. HD was started anywhere from within 2 to 57 days after LVAD implantation. Results LVAD settings were typically not adjusted during HD sessions. Additionally, during HD all patients were on midodrine, vasopressors, or fludrocortisone to help increase blood pressure. There were seven HD sessions that required early termination due to symptomatic hypotension (3), asymptomatic hypotension (2), sinus tachycardia and cramping and discomfort. The average duration of all HD sessions was 172 minutes and the average duration of HD sessions that were terminated early was 148 minutes. Low flow LVAD alarms did not activate during any of the sessions. Conclusion 7 out of 92 sessions required early termination and the most common reasons (5 out of 7) were related to hypotension. Complications related to blood pressure was also found to be the most common reason for termination of HD in previous study of HD sessions in Heartmate LVAD patients. As a result of continuous-flow technology, in most LVAD recipients, there is an absence of pulse, precluding the standard assessment of blood pressure, making assessment of blood pressure during dialysis difficult. There needs to be more research on how to address this in addition to how to optimize and change LVAD settings during HD sessions.

Interplay of volume, blood pressure, organ ischemia, residual renal function, and diet: certainties and uncertainties with dialytic management.

Extracellular fluid volume overload and its inevitable consequence, hypertension, increases cardiovascular mortality in the long term by leading to left ventricular hypertrophy, heart failure, and ischemic heart disease in dialysis patients. Unlike antihypertensive medications, a strict volume control strategy provides optimal blood pressure control without need for antihypertensive drugs. However, utilization of this strategy has remained limited because of several factors, including the absence of a gold standard method to assess volume status, difficulties in reducing extracellular fluid volume, and safety concerns associated with reduction of extracellular volume. These include intradialytic hypotension; ischemia of heart, brain, and gut; loss of residual renal function; and vascular access thrombosis. Comprehensibly, physicians are hesitant to follow strict volume control policy because of these safety concerns. Current data, however, suggest that a high ultrafiltration rate rather than the reduction in excess volume is related to these complications. Restriction of dietary salt intake, increased frequency, and/or duration of hemodialysis sessions or addition of temporary extra sessions during the process of gradually reducing postdialysis body weight in conventional hemodialysis and discontinuation of antihypertensive medications may prevent these complications. We believe that even if an unwanted effect occurs while gradually reaching euvolemia, this is likely to be counterbalanced by favorable cardiovascular outcomes such as regression of left ventricular hypertrophy, prevention of heart failure, and, ultimately, cardiovascular mortality as a result of the eventual achievement of normal extracellular fluid volume and blood pressure over the long term.

Parameters of hemodialysis adequacy and patients’ survival depending on treatment modalities

Retrospective studies showed that hemodiafiltration was associated with a reduced risk of mortality compared with standard hemodialysis in the patients with end-stage renal disease. Recently, a few prospective randomized clinical trials found no advantage in survival with hemodiafiltration as compared with high-flux hemodialysis and low-flux hemodialysis. The aim of this study was to compare the parameters of hemodialysis adequacy and two-year survival of patients depending on the modality of hemodialysis. A total of 159 hemodialysis patients were divided into 3 groups according to the type of hemodialysis treatment: group A - low-flux hemodialysis, group B - high-flux hemodialysis, and group C - hemodiafiltration. All patients had the same duration of hemodialysis sessions. The analysis included average one-year biochemical parameters, and two-year survival of patients. The patients on hemodiafiltration were significantly younger, they had longer dialysis vintage and higher index of dialysis adequancy as compared with the patients on low-flux hemodialysis and high-flux hemodialysis, but without a difference between the two latter groups. Compared to the patients on low-flux hemodialysis, the patients on hemodiafiltration and high-flux hemodialysis had significantly higher hemoglobin value with less frequent erythropoietin stimulating agent use. According to Kaplan-Meier survival analysis, the patients on hemodiafiltration and high-flux hemodialysis had significantly better two-year survival than the patients on low-flux hemodialysis. Cox proportional hazards model confirmed that high-flux hemodialysis caused a significantly lower relative risk of mortality (56% reduction) compared to low-flux hemodialysis (hazard ratio 0.44; P=0.026), and hemodiafiltration caused a 58% reduction in the relative risk of mortality compared to low-flux dialysis (hazard ratio 0.42; P=0.105), but without a statistical significance. This study has demonstrated two-year survival benefit with high-flux hemodialysis and hemodiafiltration compared with low-flux hemodialysis. There was no difference in survival between high-flux hemodialysis and hemodiafiltration groups.

Hemodialysis performance and outcomes among end stage renal disease patients from Sokoto, North-Western Nigeria

The cost of managing end stage renal disease (ESRD) is prohibitive in Nigeria and the burden is solely borne by patients and their relatives. Despite increasing number of dialysis centers in urban areas, actual utilization of such facilities is very low. It is unclear if the outcomes of these patients have improved in recent times. We evaluated pattern of hemodialysis (HD) performance and outcome among ESRD patients. A 5-year prospective cross-sectional study of all ESRD patients on HD was undertaken. The final outcomes included duration on maintenance dialysis, death from inability to sustain dialysis, absconded, confirmed deaths within or outside health facility or referral for kidney transplant. A total of 540 (54%) of 976 cases of ESRD commenced HD, out of which 7 (1.3%) eventually had live-related kidney transplant in India. The male to female ratio was 2:1 with male and female mean ages of 43 ± 17 and 36 ± 16 years respectively. There was a progressive annual increase in the number of ESRD patients. The commonest underlying renal disorder was chronic glomerulonephritis. The mean HD session duration was 8.11 ± 5.4 hours, while the mean duration of stay on HD was 8.72 ± 1.0 weeks. In conclusion, ESRD is common and is being increasingly recognized. Financial constraint and late presentation are major contributory factors to poor outcomes despite the widespread availability of HD facilities. Therefore, effort should be geared towards aggressive strategies for early detection and treatment. Government commitment in terms of funding and/or subsidy for patient with ESRD is advocated.

Restless legs syndrome in dialysis patients: a comparison between hemodialysis and continuous ambulatory peritoneal dialysis

Restless legs syndrome (RLS) is common in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). A few studies so far have investigated RLS prevalence in ESRD patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The aim of this study was to compare the prevalence, characteristics, consequences and predictors of RLS between HD and CAPD patients. We recruited 58 HD and 28 CAPD patients. A neurologist expert in sleep medicine performed RLS diagnosis during a face-to-face interview. The prevalence of RLS was slightly higher in HD than in CAPD patients (19 vs. 10.7%). RLS appeared after the onset of kidney complaint in HD patients; in contrast, in CAPD patients RLS preceded the occurrence of renal disease. Five HD patients reported that RLS symptoms occurred throughout the dialysis session. HD patients with RLS(+) had a higher mean number of HD sessions per week and a longer mean duration of HD session than the RLS(-) ones. Prevalence of females was significantly higher in CAPD patients with RLS(+) than in the RLS(-) ones. RLS frequently affects both HD and CAPD patients. RLS impaired sleep in both groups, but use of dopaminergic agents was uncommon in our sample. Dialysis schedule was associated with RLS in HD patients, while female sex was related to RLS in CAPD patients. Awareness concerning RLS identification and treatment in HD and CAPD patients is recommended.

Bioimpedance and the Duration of the Hemodialysis Session

Bioelectrical impedance analysis (BIA) is composed of resistance (R) and reactance (Xc). The aim of this study was to investigate whether BIA may be influenced by the duration of hemodialysis (HD) sessions. Eleven uremic patients underwent one 4-hour and one 8-hour bicarbonate HD session. Volume of blood and dialysate processed, volume of ultrafiltration (V(UF)), and dialysate electrolyte concentrations were prescribed to be the same. R and Xc were determined at the start and the end of each session, injecting 800 μA at 50 kHz alternating sinusoidal current (BIA 101; Akern, Italy). Mean pre- and postdialysis body weights and V(UF) were not significantly different in the 4-hour and 8-hour treatments. Postdialysis R, ΔR (the difference between post- and predialysis R values), and percent increase of R values were significantly higher in the 8-hour sessions, when compared with the corresponding values of the 4-hour sessions (p < 0.0001, 0.02, and 0.02, respectively). In conclusion, this study shows that 8-hour HD sessions were associated with postdialysis R, ΔR, and percent increase of R values significantly higher than the corresponding ones of 4-hour sessions. If higher R values may represent a proxy of a correct dry body weight, it remains a matter of future research.

Residual renal function: considerations on its importance and preservation in dialysis patients.

Residual renal function (RRF) remains important even after commencement of dialysis. Its role in the adequacy of peritoneal dialysis (PD) is well recognized and is increasingly utilized in incremental PD regimes, but it is also vitally important in hemodialysis (HD) patients, in whom it, as in PD patients, may improve survival. It may allow for a reduction in the duration of HD sessions. It reduces the need for dietary and fluid restrictions in both PD and HD patients. Other contributions include improved middle molecule clearance, better hemoglobin, phosphate, potassium, and urate levels, enhanced nutritional status and quality of life scores, and better outcomes in pregnancy. On the negative side, hypoalbuminemia may be prolonged in patients with persistent nephrotic-range proteinuria. Contrary to popular belief, RRF does not necessarily decline rapidly with the initiation of HD. PD may be better than HD in preserving RRF, although this difference may not persist if biocompatible membranes, bicarbonate buffer, and ultrapure water are used. Nocturnal ambulatory peritoneal dialysis (APD) patients may fare worse than continuous ambulatory peritoneal dialysis (CAPD) patients. RRF can be adversely affected by angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, and radiocontrast agents. Diuretics can help maintain fluid balance but not RRF.

Which Kt/V Is the Most Valid for Assessment of Both Long Mild and Short Intensive Hemodialyses?

It is unclear at present which mathematical modeling Kt/V_urea is valid for assessment of both long mild hemodialysis (HD) and short intensive HD, the single-pool modeling Kt/V (Kt/Vsp) based on the pre- and postdialysis serum urea concentrations, double-pool modeling Kt/V (Kt/Vdp) based on the predialysis concentration and the estimated postdialysis equilibrated concentration, or Kt/V calculated on the basis of dialyzer urea clearance, HD session duration and urea distribution volume (Kt/Vdl). Thus, the respective Kt/V during a short intensive HD was compared with its counterpart Kt/V during a long mild HD, where the same amount of urea is removed during both HD treatments. It was found that the Kt/Vsp and Kt/Vdl during short intensive HD were significantly greater than the respective Kt/V during the long mild HD. On the other hand, there was no significant difference in the Kt/Vdp between the long mild and short intensive HDs. In conclusion, Kt/Vdp may be more valid for assessment of both long mild and short intensive HDs.

Improved urea reduction ratio and Kt/v in large hemodialysis patients using two dialyzers in parallel

Delivered dose of hemodialysis (HD) in large patients with end-stage renal disease is often less than adequate. Fourteen chronic HD patients with weights greater than 80 kg participated in a prospective, cross-over study comparing urea reduction ratio (URR ± SEM) and the fractional clearance index for urea (eKt/Vurea ± SEM) on a single polysulfone dialyzer for a control (HDC) period of 4 weeks versus clearances obtained with two dialyzers in parallel during an intervention (HDP) period of 4 weeks. Clearance of the surrogate middle molecule iohexol (CIo ) was also measured. Health status was assessed with the SF-36. Blood and dialysate flow rates and duration of HD sessions were constant. URR increased from 0.67 ± 0.006 during HDC to 0.72 ± 0.006 with HDP (P < 0.0001). eKt/Vurea increased from 1.16 ± 0.021 to 1.34 ± 0.021 (P < 0.0001). Increased URR and eKt/Vurea occurred in all 14 during HDP (P < 0.05). CIo during HDP averaged 182 ± 7.7 mL/min compared with 131 ± 5.4 mL/min in HDC sessions (P < 0.00001). Health status improved in six of eight categories. Expense increased approximately $14.27 per dialysis with HDP. In 11 of 14 patients continued on two dialyzers in parallel for 1 year, monthly eKt/V averaged 1.46 ± 0.066, and health status further improved in five of eight categories. In large patients, two dialyzers in parallel increased urea and iohexol clearance. Increased urea clearance was maintained for 1 year, and health status improved.