Treatment Of Hemodialysis Patients Research Articles

Benefits and Adverse Effects of Statins, Atorvastatin Calcium Hydrate, Pitavastatin Calcium, and Pravastatin Sodium, for Dyslipidemia in Patients on Hemodialysis

Objective: Risk factors development are similar to those implicated in cardiovascular diseases (cardiac failure, ischemic heart disease, and peripheral arterial disease), hypertension, diabetes mellitus, and dyslipidemia in hemodialysis (HD). Therefore, it is necessary to optimize the treatment (dyslipidemia) of these patients. Methods: We examined changes in physiological parameters, renal function markers and lipid profiles induced by statins, such as pravastatin sodium (water-soluble, PS), atorvastatin calcium hydrate (fat-soluble, ACH) and pitavastatin calcium (fat-soluble, PC). Results: Dyslipidemia with medication was observed in 34 (24.8%) of the 137 HD patients. The therapeutic statins used for dyslipidemia were as follows: PS was used in the nine patients, ACH was used in 11 patients and PC was used in nine HD patients. The waist circumference and body mass index were more significantly increased in the patients treated with ACH (90.9 ± 10.5 cm [mean ± standard deviation], 24.8 ± 2.9 kg/m2) than in the patients treated with PS (79.9 ± 10.3 cm, 21.0 ± 2.9 kg/m2; P < 0.05). While the serum triglyceride levels in the PS group were 103 ± 36 mg/dl, those in the ACH group were 164 ± 75 mg/dl (P < 0.05). In addition, the serum whole parathyroid hormone levels were significantly higher in the ACH group (151 ± 102 pg/ml) than in the PS group (55 ± 32 pg/ml, P < 0.05). There were no differences between the PS and the PC groups in any of the laboratory data, except for the serum creatinine levels. Conclusion: Waist circumference, body mass index and the serum triglyceride levels were increased in the ACH HD patients. Interestingly, the serum whole PTH levels were found to be significant in the ESRD patients treated with ACH. Based on our results, PC may be an ideal statin for treating HD patients.

Effects of cinacalcet treatment on QT interval in hemodialysis patients.

Objective:Cinacalcet is a calcimimetic drug that acts via calcium-sensing receptors (CaSRs) and increases the sensitivity of CaSRs on the parathyroid gland; thus, it lowers calcium and phosphorus levels as well as parathormone levels. Prolongation of the QT interval is recognized as a risk factor for the development of ventricular arrhythmias and sudden death. Patients with end-stage renal disease (ESRD) are sensitive for QT prolongation and torsade de pointes more than the normal population. In this study, we aimed to evaluate the effects of cinacalcet on the electrocardiogram (ECG), particularly changes in the QT interval, in patients with ESRD.Methods:Thirty-seven patients (21 males and 16 females) undergoing maintenance hemodialysis for at least 12 months were included in this retrospective study. Patients receiving cardioactive and antiarrhythmic drugs and those having a history of any cardiac or cerebrovascular events, active malignancy, and infections were excluded. Baseline ECG measurements of patients were performed over the newest ECG measurements that were obtained within 1 month before initiating the cinacalcet treatment, and the ECG measurements of patients after the cinacalcet treatment were performed according to the most recent ECG that was taken within the last 1 week in the clinic. We recorded the heart rate and QT values of patients before and after treatment and then calculated the corrected QT values (QTc). The Statistical Package for the Social Sciences (SPSS) ver. 21.0 was used for statistical analysis.Results:The mean age of patients was 52.24±14.49 years. Prolongation of QTc was statistically significant compared with the baseline QTc value (baseline: 396.62±42.04 msec; after treatment: 404.97±43.47 msec; p=0.031). We found a positive correlation between the prolongation of QTc and treatment dose of cinacalcet (p<0.005, r=0.560).Conclusion:Clinicians should be very careful for life-threatening cardiac side effects while increasing the dose of cinacalcet treatment in hemodialysis patients who have a borderline or prolonged QTc interval.

Observation of the effect of urokinase thrombolysis combined the guide wire fragmentation and low molecular heparin anticoagulation for the treatment of arteriovenous fistula embolization

Objective To analyze the curative effect used the common urokinase thrombolysis combined with topo-guide-wire fragmentation and low molecular heparin in the treatment of hemodialysis patients with arteriovenous fistula embolization and explore the prospects of its application. Methods 30 hemodialysis patients with arteriovenous fistula embolization were divided into 15 cases of thrombolysis group and 15 cases of thrombectomy group according to the voluntary. The thrombolysis group was given simple urokinase thrombolysis, and the thrombectomy group was given thrombectomy combined with anticoagulant therapy. The curative effect and the difference in complication were compared. Results In curative effect, the recanalization rate,using time after recanalization, and dosage of urokinase of the thrombectomy group were better than those of the thrombolysis group[13cases vs.7cases,(22.13± 17.51)months vs.(11.05±10.55)months,(40.48±22.26)ten thousands IU vs.(60.29±15.81)ten thousands IU,χ2 =5.40,t=2.10,all P 0.05).For the thrombectomy group,there were fewer cases of re-embolization after recanalization(2 cases/13 cases vs.4 cases/7 cases,χ2=3.85,P<0.05),but more cases of organ embolism(4 cases vs.0 cases,χ2=4.62,P<0.05). Conclusion Compared with the traditional urokinase thrombolytic therapy, the guide wire fragmentation combined with low molecular weight heparin anticoagulant therapy has a higher fistula recanalization rate and a lower re-embolization rate.It does not increase the incidence of bleeding complications.Besides,it can extend the use of internal fistula.However,it may cause the serious organ embolism,so it is necessary to strictly grasp the indications,applying only to the patients who are in the poor efficiency of thrombolytic and unable to have another operation. Key words: Hemodiafiltration; Arteriovenous fistula; Thrombolytic therapy; Urokinase; Low molecular heparin

The effects of an individual, multistep intervention on adherence to treatment in hemodialysis patients

Purpose: The present study was conducted to investigate the effect of individual, multistep intervention on adherence to treatment in hemodialysis patients referred to a hemodialysis center in Shahrekord, Iran.Method: In this interventional study, hemodialysis patients referring the center of the study were randomly assigned into two control and intervention groups (each 33). The control group received routine treatment, recommended dietary and fluid restrictions. The intervention group participated in eight individual interventional sessions accompanied routine treatment. At the beginning and the end of the study, routine laboratory tests and end-stage renal disease-adherence questionnaire were filled out for patients in both groups. The data were analyzed using Mann–Whitney and Wilcoxon tests.Results: At the end of the study, the two groups showed a significant difference in all domains of adherence except adherence to diet and adherence was better in the intervention group (p < 0.05). In demographic characteristic, only age indicated a positive correlation with adherence to dialysis program (p = 0.04, r = 0.254). After intervention, serum phosphorus decreased significantly in the intervention group (p < 0.05).Conclusions: Adherence to treatment is one of the major problems in hemodialysis patients; however, comprehensive interventions are required in view of individual condition.Implications for RehabilitationAdherence to treatment means that all patients’ behaviors (diet, fluids and drugs intake) should be in line with the recommendations given by healthcare professionals.There is evidence on the association between adherence to treatment and decreased risk of hospitalization in dialysis patients.Individual structured programs are most likely to be successful in encouraging adherence to treatment.

Spironolactone is secure and reduces left ventricular hypertrophy in hemodialysis patients.

There is recent evidence that aldosterone play a role in the pathogenesis of cardiovascular disease in dialysis patients, which leads to the opportunity to block its actions for the benefit of these patients. In nondialytic chronic kidney disease, spironolactone was safe and effective in reducing left ventricular hypertrophy. However, routine use has been precluded in hemodialysis patients due to the risk of hyperkalemia. The aim of this study is to verify the safety and efficacy in regression of left ventricular hypertrophy with spironolactone in hemodialysis patients undergoing pharmacotherapeutic monitoring. We performed a controlled, randomized, double blind study evaluating 17 hemodialysis patients who received spironolactone at a dose of 12.5 mg titrated, in the second week, to 25 mg of spironolactone or placebo. The patients were treated for 6 months. The groups were composed of eight patients (intervention) and nine patients (control). These groups did not differ in their baseline characteristics. The group receiving spironolactone had a left ventricular mass index reduction from 77 ± 14.6 g/m(2.7) to 69 ± 10.5 g/m(2.7), p < 0.04, whereas in placebo group there was an increase from 71 ± 14.2 g/m(2.7) to 74 ± 17.4 g/m(2.7). Systolic or diastolic blood pressure did not change during the study. Potassium did not differ statistically between groups in all instances. Spironolactone treatment in hemodialysis patients was secure and effective in regression of left ventricular hypertrophy, a major risk factor for cardiovascular events in these patients. This effect occurred in spite of blood pressure stability. ClinicalTrials.gov identifier NCT01128101.

Hepatitis B virus reactivation after treatment for hepatitis C in hemodialysis patients with HBV/HCV coinfection

In coinfected HBV/HCV patients, HBV replication is usually suppressed by HCV over the time. No study to date has evaluated the HBV viremia in long-term follow-up after HCV treatment in hemodialysis patients with HBV/HCV coinfection. This study aimed to assess the evolution of HBV viremia after HCV treatment in this special population. Ten hemodialysis patients with HBV/HCV coinfection with dominant HCV infection (HBV lower than 2000IU/mL) and significant fibrosis were treated with interferon-alpha 3 MU 3×/week for 12 months and could be followed for at least 36 months after HCV treatment. Six cases of HBV reactivation (60%) during follow-up were observed and 5/6 had been successfully treated for HCV. Patients with HBV reactivation received anti-HBV therapy. Our preliminary findings indicate that treatment of hepatitis C in HBV/HCV coinfected hemodialysis patients may favor HBV reactivation. Thus, continued monitoring of HBV viremia must be recommended and prompt anti-HBV therapy should be implemented.

Prevalence of Vertebral Fractures, Vascular Calcifications, and Mortality in Warfarin Treated Hemodialysis Patients

Warfarin inhibits vitamin-K dependent proteins involved in bone mineralization and the prevention of vascular calcification (bone Gla protein BGP, matrix Gla protein MGP). In this multicenter, cross-sectional study with 3-year follow-up, data from 387 patients on hemodialysis for ≥1 year at 18 dialysis units were analyzed. Patients on warfarin treatment for > 1 year (11.9% of the population) were compared with the remaining cohort for vertebral fractures, vascular calcifications and mortality. Vertebral fractures and vascular calcifications were sought in L-L vertebral X-rays (D5 to L4). Compared with controls, warfarin-treated male patients had more vertebral fractures (77.8 vs. 57.7%, p<0.04), but not females (42.1% vs. 48.4%, p=0.6); total BGP was significantly reduced (82.35 vs. 202 µg/L, p<0.0001), with lower levels in treated men (69.5 vs. women 117.0 µg/L, p=0.03). In multivariate logistic regression analyses, the use of warfarin was associated with increased odds of aortic (OR 2.58, p<0.001) and iliac calcifications (OR 2.86, p<0.001); identified confounders were age, atrial fibrillation, angina, PPI use and total BGP. Seventy-seven patients died during a 2.7±0.5 year follow-up. In univariate Cox regression analysis, patients on warfarin had a higher risk of all-cause mortality (HR 2.42, 95% CI 1.42-4.16, p=0.001) when compared with those untreated and data adjustment for confounders attenuated but confirmed the significant warfarin-mortality link (HR: 1.97, 95% CI: 1.02-3.84, P=0.046). In hemodialysis patients, additional studies are warranted to verify the risk/benefit ratio of warfarin, which appears to be associated with significant morbidity and increased mortality.

TCTAP A-174 Optimal Treatment for Hemodialysis Patients with Critical Limb Ischemia; Comparison Surgical and Endovascular Revascularization for Infrainguinal Artery Disease

TCTAP A-174 Optimal Treatment for Hemodialysis Patients with Critical Limb Ischemia; Comparison Surgical and Endovascular Revascularization for Infrainguinal Artery Disease

The effect of two educational methods on knowledge and adherence to treatment in hemodialysis patients: clinical trial.

Patients with chronic renal disease (CRD) deal with many potential problems with hemodialysis for all their life. Regarding the importance of preventing dialysis adverse effects, which are in close connection with lack of knowledge and report on how to train the patients? This study aims at comparing the impact of two methods of face to face training and training pamphlet on complying and informing of hemodialysis treatments. This clinical trial study was conducted on 58 hemodialysis patients who visited Shahid Rahnemun Teaching hospital, Yazd, Iran, and had required conditions of the research. Data were collected through a questionnaire including personal-social information, several questions to assess the level of compliance and to inform the treatment method. The quantitative analysis of this study used the Statistical Package for Social Sciences SPSS version 13 and descriptive (frequency, mean, standard deviation) and inferential (Chi-square, paired t-test, ANOVA, ANCOVA) statistics were employed. The mean scores for informing both groups (face to face and training pamphlet) were significantly increased. The mean score for adherence to treatments was also significant. In this research, face to face training was found to be more effective than training pamphlet. It seemed to have more strong effect on increasing the level of information and adherence to treatment. To train these people, face to face training should be, thus, preferred.

Boceprevir-Based Triple Antiviral Therapy for Chronic Hepatitis C Virus Infection in Kidney-Transplant Candidates.

Background. There are few data on the combination of (pegylated-) interferon- (Peg-IFN-) α, ribavirin, and first-generation direct-acting antiviral agents (DAAs). Our aim was to describe the efficacy and safety of Peg-IFN-α, ribavirin, and boceprevir in hemodialysis patients. Patients. Six hemodialysis patients, chronically infected by genotype-1 HCV, were given Peg-IFN-α (135 µg/week), ribavirin (200 mg/d), and boceprevir (2400 mg/d) for 48 weeks. Results. At initiation of antiviral therapy, median viral concentration was 5.68 (3.78–6.55) log IU/mL. HCV RNA was undetectable in four of the six patients at week 4 and in all patients at week 24. A breakthrough was observed in two patients between weeks 24 and 48, and a third patient stopped antiviral therapy between weeks 24 and 48 because of severe peripheral neuropathy. At week 48, HCV RNA was undetectable in three patients. Of these, two patients relapsed within a month after antiviral therapy was stopped. Hence, only one patient had a sustained virological response; he was a previous partial responder. Overall, anemia was the main side effect. Conclusion. A triple antiviral therapy based on Peg-IFN-α, ribavirin, and boceprevir is not optimal at treating hemodialysis patients with chronic HCV infection. Studies using new-generation drugs are required in this setting.

Percutaneous transluminal angioplasty for central venous disease in dialysis patients: influence on cardiac function.

Increased vascular access flow after percutaneous transluminal angioplasty (PTA) for central venous stenosis and occlusion (central venous disease, CVD) can affect cardiac function in hemodialysis (HD) patients. We evaluated the cardiac function, etiology, and treatment in HD patients with CVD. HD patients with CVD treated by PTA between June 2006 and February 2013 were studied. Of the 26 patients, 22 had left arteriovenous fistulas (AVFs), 1 left arteriovenous graft (AVG), 2 right AVFs, and 1 right AVG. CVD sites were the left brachiocephalic vein (LBCV; n=13), left subclavian vein (LSCV; n=7), both LBCV and LSCV (n=3), right BCV (n=2), and right SCV (n=1). Computed tomography findings indicated a high extrinsic compression rate for the LBCV (91%) and LSCV (50%). The success rate of PTA was 96%. The primary patency rates at 3, 6, 9, and 12 months were 81%, 73%, 65%, and 57%, respectively. The post-PTA brachial artery flow volume was significantly increased compared with the pre-PTA volume (1306 vs. 957 ml/min; p=0.005). The post-PTA left ventricular ejection fraction and expiration inferior vena cava diameter were the same as the pre-PTA values (57% versus 60%, p=0.2 and 17 versus 17 mm, p=0.9, respectively). Our findings suggest that increased vascular access flow after PTA for CVD has no relation to cardiac function.

Optimization of anemia treatment in hemodialysis patients via reinforcement learning.

Anemia is a frequent comorbidity in hemodialysis patients that can be successfully treated by administering erythropoiesis-stimulating agents (ESAs). ESAs dosing is currently based on clinical protocols that often do not account for the high inter- and intra-individual variability in the patient's response. As a result, the hemoglobin level of some patients oscillates around the target range, which is associated with multiple risks and side-effects. This work proposes a methodology based on reinforcement learning (RL) to optimize ESA therapy. RL is a data-driven approach for solving sequential decision-making problems that are formulated as Markov decision processes (MDPs). Computing optimal drug administration strategies for chronic diseases is a sequential decision-making problem in which the goal is to find the best sequence of drug doses. MDPs are particularly suitable for modeling these problems due to their ability to capture the uncertainty associated with the outcome of the treatment and the stochastic nature of the underlying process. The RL algorithm employed in the proposed methodology is fitted Q iteration, which stands out for its ability to make an efficient use of data. The experiments reported here are based on a computational model that describes the effect of ESAs on the hemoglobin level. The performance of the proposed method is evaluated and compared with the well-known Q-learning algorithm and with a standard protocol. Simulation results show that the performance of Q-learning is substantially lower than FQI and the protocol. When comparing FQI and the protocol, FQI achieves an increment of 27.6% in the proportion of patients that are within the targeted range of hemoglobin during the period of treatment. In addition, the quantity of drug needed is reduced by 5.13%, which indicates a more efficient use of ESAs. Although prospective validation is required, promising results demonstrate the potential of RL to become an alternative to current protocols.

Angiotensin Blockade and Progressive Loss of Kidney Function in Hemodialysis Patients: A Randomized Controlled Trial

Glomerular filtration rate (GFR) declines during long-term dialysis treatment. In peritoneal dialysis, blockade of the renin-angiotensin-aldosterone system reduces GFR decline. Observational studies suggest that similar treatment may preserve kidney function in hemodialysis (HD). A multicenter, randomized, placebo-controlled, double-blinded trial, with 1-year follow-up. Adult HD patients with urine output >300mL/24h, HD vintage less than 1 year, and cardiac ejection fraction >30%. Patients were included from 6 HD centers. Patients were randomly assigned to placebo or the angiotensin II receptor blocker irbesartan, 300mg daily. Target systolic blood pressure (BP) was 140mm Hg. Primary outcomes were change in GFR measured as the mean of creatinine and urea renal clearance together with urine volume. Secondary outcomes were change in albuminuria, renin-angiotensin II-aldosterone hormone plasma levels, and time to anuria. Of 82 patients randomly assigned (41 patients in each group), 56 completed 1 year of treatment. The placebo and irbesartan groups were comparable at baseline in terms of sex balance (26 vs 30 men), mean age (62 vs 61 years), median HD vintage (137 vs 148 days), mean HD time (10 vs 11h/wk), median urine volume (1.19 vs 1.26L/d), and mean GFR (4.8 vs 5.7mL/min/1.73m(2)). The target BP level was reached in both groups and BP did not differ significantly between groups over time. Adverse-event rates were similar. GFR declined by a mean of 1.7 (95% CI, 1.2-2.3) and 1.8 (95% CI, 1.1-2.4) mL/min/1.73m(2) per year in the placebo and irbesartan groups, respectively. Mean difference (baseline values minus value at 12 months) between groups was-0.0 (95% CI,-0.8 to 0.8). In each group, 4 patients became anuric. GFR decline rates were lower than expected, reducing the power. At equal BP levels, we found that irbesartan treatment did not affect the decline in GFR or urine volume significantly during 1 year of treatment in HD patients. Irbesartan treatment was used safely in the studied population.

Troponin I and NT-proBNP and the Association of Systolic Blood Pressure With Outcomes in Incident Hemodialysis Patients: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study

There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. National prospective cohort study. 446 incident hemodialysis patients. Predialysis systolic BP. Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Participants with cTnI level ≥0.1 ng/mL or NT-proBNP level ≥9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Participants in the high-biomarker group (n=138 [31%]) were older (61 vs. 57 years) and had a higher prevalence of CVD (67% vs. 23%), but similar baseline BPs (152 vs. 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction=0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. BP measurements not standardized. The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.

Cost-Utility Analysis of Erythropoietin for Anemia Treatment in Thai End-Stage Renal Disease Patients with Hemodialysis

ObjectiveTo compare the cost utility of using erythropoietin (EPO) to maintain different hemoglobin (Hb) target levels in hemodialysis patients from a societal perspective. MethodsA Markov model was used to estimate the incremental cost and quality-adjusted life-year of five Hb levels: 9 or less, more than 9 to 10, more than 10 to 11, more than 11 to 12, and more than 12 g/dl. A systematic review of EPO treatment in hemodialysis patients was conducted to estimate transitional probabilities. Cost data were estimated on the basis of the reference price of Siriraj Hospital, the largest university hospital in Thailand. Utility scores were derived from the six-dimensional health state short form (derived from short-form 36 health survey), which were collected from 152 hemodialysis patients receiving EPO at Siriraj hospital. Probabilistic sensitivity analysis was conducted to investigate the effect of uncertain parameters. All future costs and outcomes were discounted at the rate of 3% per annum. ResultsThe incremental cost-effectiveness ratios of Hb levels more than 9 to 10, more than 10 to 11, more than 11 to 12, and more than 12 g/dl compared with the least costly option (Hb ≤ 9 g/dl) were US $24,128.03, US $18,789.07, US $22,427.36, and US $28,022.33 per quality-adjusted life-year, respectively. From probabilistic sensitivity analysis, the hemoglobin level of more than 10 to 11 g/dl was appropriate when the willingness to pay was US $15,523.88 to US $46,610.17 and the probability of cost-effective was 29.32% to 95.94%. ConclusionsProviding EPO for a hemoglobin level of more than 10 to 11 g/dl had a cost-effectiveness higher than that of doing so for other hemoglobin levels. This finding will be put forward to the policy level to set up the EPO treatment guideline of the hospital for hemodialysis patients.

Oral paricalcitol for the treatment of secondary hyperparathyroidism in hemodialysis patients

Secondary hyperparathyroidism is common amongst dialysis patients and is associated with increased morbidity and mortality. Vitamin D analogues are effective treatments, but the adverse effects of traditional vitamin D preparations, especially hypercalcemia, are often dose-limiting. We studied the efficacy and safety of paricalcitol for the treatment of secondary hyperparathyroidism in hemodialysis patients. We reviewed 13 adult hemodialysis patients treated with oral paricalcitol. The dosage of paricalcitol was adjusted according to the clinical response. Serum parathyroid hormone (PTH) level decreased by 47.3 ± 34.3% at 3 months and 74.7 ± 36.8 % by 3 years. Eight patients (62%) responded and had reduction in PTH levels by at least 30%; seven of them (87.5%) responded within the first 3 months. Responders had a significantly lower baseline PTH level than the nonresponders (64.3 ± 32.2 vs. 138.5 ± 64.0 pmol/L, p = 0.02). None of the patients developed hypercalcemia, but hyperphosphatemia was present in all patients. There is a substantial improvement in PTH levels by paricalcitol treatment in hemodialysis patients with secondary hyperparathyroidism, and paricalcitol is generally well tolerated. Our results suggest that patients with more advanced secondary hyperparathyroidism tend to have a less favorable response. 在血液透析患者間，次發性甲狀旁腺功能亢進是常見的疾病，會明顯增加患者的死亡與患病率。維生素 D 類似物通常是有效的療法，但傳統製劑的臨床應用常受限於不良作用如高鈣血症的出現。本研究以患有次發性甲狀旁腺功能亢進的血液透析患者為對象，調查了 paricalcitol 在這方面的功效與安全性。 本研究回顧了 13 位成年血液透析患者，正在接受口服 paricalcitol 治療，其劑量根據臨床反應作出調整。 經過 3 個月及 3 年後，血清副甲狀腺素 (PTH) 水平分別下降 47.3 ± 34.3% 及 74.7 ± 36.8%。其中，8 人 (62%) 反應良好，PTH 降幅達至少 30%；他們之中有 7 人 (87.5%) 在首 3 個月呈現反應。相比於不反應者，反應者的基線 PTH 明顯較低 (64.3 ± 32.2 vs 138.5 ± 64.0 pmol/L， p = 0.02)。治療期間，無任何人出現高鈣血症，但所有病人均有高磷酸血症的現象。 對於患有次發性甲狀旁腺功能亢進的血液透析患者，paricalcitol 可有效降低 PTH，且耐受性良好。本研究的結果亦顯示，較晚期的次發性甲狀旁腺功能亢進患者，其療效反應可能較為不明顯。

Cost of managing anemia in end-stage renal disease: the experience of five French dialysis centers

The aim of this retrospective study was to evaluate the direct cost of anemia treatment in hemodialysis patients and to evidence factors predictive of 1-year cost. Retrospective study which included hemodialyzed patients during year 2009 in five centers. Patients were evaluable if they had at least one hemoglobin (Hb) assay per month and were monitored for at least 4 months. Patients were classified in different "annual Hb category" according to their monthly mean Hb [Hb categories: Ideal (10 ≤ Hb ≤ 12 g/dL); High (Hb > 12 g/dL) and Low (Hb < 10 g/dL) if >75% of time in respective category, otherwise classified in the Fluctuating category]. We analyzed 636 patients (male, 59.4%) with a mean age of 67 years who underwent 144 hemodialysis sessions (median number per patient) in 2009. The cost of anemia treatment was largely driven by erythropoiesis-stimulating agents (ESA) (68% of total cost for Low Hb category and approximately 90% for the other Hb categories). Adjusted predictive factors for 1-year direct cost of anemia treatment (p < 0.0001) were dialysis center (<euro>2,518-<euro>5,617), death (<euro>6,091 vs. <euro>4,911), age (<euro>4,911 for ≤55 years and <euro>5,378 for 65-75 years), female gender (<euro>4,911 vs. <euro>4,398 for male), Low Hb category (<euro>13,005 vs. <euro>5,034 for Ideal, <euro>4,911 for Fluctuating and <euro>2,418 for High), serum ferritin level (<euro>5,102 for 200-500 μg/mL and <euro>4,646 for ≥500 μg/mL) and duration of dialysis (<euro>4,911 if ≤2 years and <euro>2,952 if 4-6 years). Retrospective study, and low number of patients in the Low Hb category. The main factors that were predictive of 1-year cost of anemia treatment in hemodialysis patients were centers, patients in the Low Hb category, and dialysis duration of less than 2 years.

Statut d’hydratation extracellulaire et natriurèse résiduelle en hémodialyse chronique : une étude transversale multicentrique

BackgroundIn dialysis patients, a misevaluation of dry weight may lead to an increased morbidity and mortality. The aim of this cross-sectional multicenter study was to evaluate the association between residual urinary sodium excretion and extracellular volume status in chronically treated hemodialysis patients. Patients and methodsDry weight was determined clinically and by whole-body bioimpedance spectroscopy (Body Composition Monitor, Fresenius Medical Care) prior to a mid-week session in 40 chronic hemodialysis patients with significant residual diuresis (more than 250 mL per day) and receiving treatment in four dialysis centers. Regarding their hydration status assessed by the Body Composition Monitor and in comparison to a healthy reference population, patients were assigned to 1 of the 3 categories: overhydrated, normohydrated and dehydrated. Urine output, urinary sodium excretion and residual renal function were measured for all patients within 30 days before dry weight assessment. ResultsThe median post-HD session FO was of−0.40 L (IQR: from−1.95 to+0.90) and the median residual urinary sodium excretion was of 64 mmol/L (IQR: 46–79). Among these patients, 16 were normohydated, 16 were dehydrated and 8 were overhydrated. There was a linear relationship between the hydration status after HD session and the urinary sodium excretion (estimate: 5.6±1.5; p<0.001). Compared with normohydrated patients, overhydrated patients had a higher residual urinary sodium excretion (estimate: 26±10; p<0.01). ConclusionIn this study, urinary sodium excretion is associated with the hydration status evaluated by whole-body bioimpedance spectroscopy.

Intolerance to Sunitinib Treatment in Hemodialysis Patients With Metastatic Renal Cell Carcinoma

Sunitinib is a multiple tyrosine kinase receptor inhibitor that is approved for the treatment of metastatic renal cell carcinoma (RCC). However, neither an appropriate dose nor dosing schedule of sunitinib has yet been established for patients with metastatic RCC who are on hemodialysis. Here, we report on two hemodialysis patients who received sunitinib to treat metastatic RCC. Sunitinib was planned to be administered at a dosage of 25 mg/d for 4 of every 6 weeks. Although sunitinib toxicity was manageable in one patient, disease progression occurred after 4 months of treatment. In the second patient, acute pulmonary edema, caused by uncontrolled hypertension, developed on the 15th day of sunitinib therapy and the drug had to be discontinued. Sunitinib is thus not well tolerated in a hemodialysis setting. Close monitoring of toxicity and dose manipulation may be required if such therapy is attempted.

Effect of long intermittent hemodialysis on improving dialysis adequacy of maintenance hemodialysis patients

Background With the increase in hemodialysis (HD) patients, the blood dialysis patient’s quality of life (QoL) and long-term survival are still a challenge for clinicians. Recent studies have found that most of the HD patients have sleep disorders, which have a certain correlation with long-term survival and QoL. But there are few studies of Chinese in this field. This study aimed to investigate whether increasing the dialysis dose can improve sleep quality, so we treated HD patients on long intermittent hemodialysis (LIHD). Methods Forty patients who were treated by conventional HD at the Beijing Friendship Hospital Blood Purification Center were offered the option of LIHD. The patients’ laboratory data, medication use, and questionnaire answers were analyzed. Conventional HD was delivered thrice weekly with 4 hours per treatment, and LIHD was delivered thrice weekly with 8 hours per treatment. The study lasted 6 months. Questionnaires included sleep quality survey and QoL SF-36; the former includes the Athens Insomnia Scale, Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS). Results After conversion to LIHD the dialysis efficiency (K t/V) significantly increased than before (P &lt;0.05) and clearance rate of urea nitrogen also increased from 67 to 78% (P &lt;0.01). After conversion, median values for Hb increased from 108.95 to 126.55 g/L (P &lt;0.01); albumin increased from 38.85 to 40.05 g/L (P &lt;0.01). Phosphorus decreased from 2.69 to 1.54 mmol/L (P &lt;0.01), but there was no alteration in blood calcium; phosphorus and calcium-phosphate product levels were under more control, but parathyroid hormone (iPTH) level did not change after conversion to LIHD. After conversion, blood pressure (BP) was better controlled than before and the mean number of antihypertensive drugs prescribed declined from 2.9 to 0.5 (P &lt;0.01). There was a significant reduction in the use of erythropoietin-stimulating agent of 5250 U/w (P &lt;0.01). Sleep quality significantly improved in the 2 months after conversion to LIHD, and the PSQI score decreased from 10.80 to 5.45 and the ESS score decreased from 12.05 to 5.30 (P &lt;0.01). However, sleep quality started to decline after 2 months on LIHD. QoL SF-36 score increased from 410.92 to 592.53 (P &lt;0.01). Conclusion LIHD offers an effective improvement in dialysis adequacy for Chinese maintenance HD patients, but it improves sleep quality only briefly which may be related to loss of serum calcium and parathyroid dysfunction.