High Dialysis Research Articles

Withdrawal

One of the cardinal features of any liver replacement therapy is the ability to remove accumulated metabolites. The removal of water-soluble substances by dialysis procedures is well established. However, an unsolved problem is the low dialyzability of lipophilic toxins. This study aimed to explore whether bilirubin and bile acids removal can be increased by free fatty acid (FFA) displacement and its combination with albumin dialysis. First, we found that the protein binding of both bilirubin and bile acids decreased significantly with increasing FFA concentrations when co-incubated directly. Then, in vitro dialysis showed that fatty acid mixtures ([linoleic acid] / [oleic acid] = 2) infusion pre-filter effectively increased the fractional removal of bilirubin and bile acids from 1.43 ± 0.07% and 2.50 ± 0.12%, to 10.04 ± 0.29% and 6.12 ± 0.07%, respectively, which were significantly higher than albumin-based hemodialysis (HD); in vivo dialysis showed that lipid emulsion administration resulted in higher reduction ratios and more total solute removals for bilirubin and bile acids after 4 h HD compared with control, which was also superior to albumin-based HD. Finally, the highest dialysis efficacy was always observed by their combination whether in vitro or in vivo. These findings highlight that FFA displacement-based HD could efficiently improve the dialytic removal of bilirubin and bile acids, whilst its dialysis efficacy might even be superior to albumin-based HD. The concept of their combination may open up new avenues and possibilities in the field of dialysis to further enhance lipophilic toxins removal in liver failure.

FC 098MESENCHYMAL STEM CELL EXOSOMES AMELIORATE MICE PERITONEAL FIBROSIS INDUCED BY HUMAN PERITONITIS DIALYSIS EFFLUENT

Abstract Background and Aims Peritoneal fibrosis is a severe complication of peritoneal dialysis, but there are few effective therapies for it. The purpose of this study was to investigate the protective effect of exosomes secreted by mouse bone marrow mesenchymal stem cells on peritoneal fibrosis and to reveal the mechanism. Method Forty-two male C57BL/6 mice were randomly divided into a normal group, a control group (2.5% glucose dialysate), a peritonitis-effluent group (The overnight 2.5% glucose dialysate of patients with peritonitis), a high glucose dialysate group (4.25% glucose concentration), a peritonitis-dialysate + exosome group, and a high glucose dialysate + exosome group. The mouse model of peritoneal fibrosis was constructed by intraperitoneal injection of human peritonitis effusion continuously for 42 days. The mice in the exosome treatment group received intraperitoneal injection of mesenchymal stem cell (MSC)-exosomes twice. The level of peritoneal structural and functional damage, inflammation, fibrosis and mesothelial cell damage of peritoneum were detected. Furthermore, the effect of MSC-exosomes was validated in vitro. Results Peritoneal transport was significantly impaired and peritoneal thickness was significantly increased in the peritonitis-effluent group and the high glucose dialysate group after 42 days. The degree of peritoneal inflammation and fibrosis in the two groups was significantly higher than the control group. The results suggested that human peritonitis dialysis effluent could be used to construct a mouse model of peritoneal fibrosis. Masson staining results showed that the fibrosis degree of peritonitis - effluent + exosome group was significantly less than the peritonitis - effluent group. Immunohistochemical analysis showed that the expression levels of mesothelial markers E-cadherin and ZO-1, neutrophil granulocytes (MPO) and macrophages (F4/80), and fibrosis markers collagen I and a-SMA in the peritonitis - effluent + exosome group were significantly lower than those in the peritonitis - effluent group. Similarly, the high glucose dialysate + exosome group mice showed significantly lower levels of peritoneal inflammation and fibrosis than the high glucose dialysate group mice. In vitro experiments showed that exosomes could down-regulate the secretion of IL-1, IL-6 and TGF- by renal tubular cells stimulated by high glucose dialysate, maintain the expression of mesenchymal cell marker (E-cadherin), and inhibit the mesenchymal marker (-SMA), suggesting that exosomes could inhibit the transdifferentiation of peritoneal mesenchymal cell-mesenchymal cells (MMT). Conclusion MSC-exosomes can alleviate peritoneal fibrosis by inhibiting peritoneal mesothelial cell-mesenchymal cell transdifferentiation.

MO563HIGH DIALYSATE MAGNESIUM AND CORONARY ARTERY CALCIFICATION IN MAINTENANCE HEMODIALYSIS PATIENTS*

Abstract Background and Aims Cardiovascular calcification is highly prevalent among patients with end-stage renal disease (ESRD). Low normal serum magnesium has been linked to a more severe degree of vascular calcification and a decrease in patient survival. An inhibitory effect of extracellular magnesium on osteogenic transformation of vascular smooth muscle cells and the upregulation of anti-calcification protein have been confirmed in vitro. Increased dialysate magnesium concentration has also been shown to lower calcification propensity of the serum of maintenance hemodialysis (HD) patients. Method This study is an investigator initiated, single-blinded, parallel-group, matched case-control clinical trial that investigated the effect of high dialysate magnesium concentration for 24 weeks on the progression of coronary artery calcification (CAC) in maintenance HD patients. The changes in laboratory data and bone mineral density (BMD) were also examined. Seventy-six ESRD patients underwent CAC screening by multi-slice computed tomography and BMD measurement by dual-x-ray absorptiometry. Only patients with Agatston score>300 were included. They were matched according to the initial CAC score that fell within 20% of one another. Twenty patients were assigned to high dialysate magnesium concentration of 1.75 mEq/L and the matched controls were kept on standard dialysate magnesium concentration of 0.7 mEq/L. CAC and BMD measurements were repeated after 24 weeks. Laboratory data were obtained prior to dialysis at study entry, 8-week intervals during the study and 2 weeks after the study ended. Results There were no significant differences in age, sex, BMI, underlying diseases, dialysis vintage, medications, baseline CAC scores and BMD. The median baseline CAC Agatston score (Volume score) were 1923 (720) and 1672 (785) in the standard and high dialysate groups, respectively. At the end of the study, a significant increase in the CAC score was observed in both groups. Because majority of the included patients had severe calcification burden at baseline, patients were categorized into 2 subgroups using the median baseline CAC Agatston (1600) and Volume scores (700) as cut-offs. Among patients with CAC Agatston score <=1600, CAC score increased significantly in the standard dialysate magnesium group (P<0.01) but was stable in the high dialysate magnesium group (P=0.33). Among patients with CAC Agatston score >1600, the severity of CAC worsened in both groups. The progression of CAC was analyzed by the difference between the follow-up and the baseline square root transformed Agatston and Volume scores. In subgroup of patients with less severe calcification, more patients in the standard dialysate magnesium group progressed compared to the high dialysate magnesium group (P=0.03). In subgroup of patients with more severe calcification, the number of progressors were comparable among the 2 groups. Serum and ionized magnesium levels increased substantially during the study and returned to baseline after the return to standard dialysate magnesium concentration. The highest predialysis serum magnesium was 3.8 mg/dL. Most patients who received high dialysate magnesium reported the disappearance of symptoms of muscle cramps (P=0.01) and requested the high dialysate magnesium be continued after the end of the study. There were no significant changes in serum calcium, phosphate or PTH levels. The decline in BMD was observed in both groups but the difference did not reach statistical significance. Conclusion High dialysate magnesium was well tolerated and could ameliorate the progression of CAC in maintenance HD patients with mild to moderate vascular calcification.

MO657RANDOMIZED CONTROL TRIAL OF INTERMITTENT HEMODIALYSIS WITH REGIONAL CITRATE VS PRIMING HEPARIN WITH PREDILUTION IN PATIENTS AT RISK OF BLEEDING

Abstract Background and Aims Standard intermittent haemodialysis (SIHD) includes anticoagulation to avoid clotting of the dialysis system. In patients at high risk for bleeding, alternativ methods have been developed to avoid systemic anticoagulation. Regional citrate anticoagulation (RCA) is usually used with continuous renal replacement therapy and low blood flow but the Promotheus® device (Freseinus Medical care-Germany) allow RCA for liver support therapy with dialysis system 4008H® and blood flow over 200ml/min. The aim of this study was to compare the IHD with RCA (IHD-RCA) to SIHD without systemic anticoagulation in patients at high risk for bleeding. Method We conducted a randomized control trial study evaluating the superiority of IHD-RCA with Prometheus® device compared to SIHD with 5008H® dialysis monitor using priming heparin (5000UI unfractionated heparin) with predilution (25 ml/min) in a 4 hour IHD strategy in patients with high risk for bleeding. Randomization was stratified on vascular access. Sixty adult patients were randomly allocated to one IHD-RCA session or SIHD in a one ICU unit university center from 2019 to 2020. Bleeding risk was defined by nephrologist and inclusion need well-functioning fistula or double-lumen catheters with a protocol blood flow higher than 200 ml/min. The primary end point was the percentage of successful study period, defined as no premature interruption of a 4 hour hemodialysis session. Secondary end points included dialysis adequacy (KT/V), dialysis circuit bubble trap status and dialyzer membrane status by visual inspection. The study was declared in ClinicalTrial NCT03562754. Results Two patients from IHD-RCA were excluded of analysis because of early vascular access failure. Causes of bleeding risk were activ bleeding in 25(43%), recent surgery or organ biopsy in 31(53%) and Stroke in 2 sessions. 10(17%) patients were treated by IHD for AKI3 and other for chronic hemodialysis. 24(41%) patients have fistula, and the mean blood flow was significantly higher in SIDH group vs IHD-RCA (294 vs 263 ml/min, p<0.001). All sessions were performed with FX800 dialyzer (Polysulfone, hollow-filter 1.8M2, FMC). No statistically significant difference was observed for primary end point between group with 96% (27/28) of success for IHD-RCA and 83% (23/28) for SIHD (p=0.09). For secondary end point, no statistically significant difference was observed for KT/V delivery between group (1.69 vs 1.61, p=0.27) but score was statistically significant different between groups for visual inspection of fiber bundles (p<0.01) and dialysis circuit bubble traps aspect ( p<0.01 ) with higher score for SIHD. Conclusion No statitically significant difference was observed between 2 groups for 4-hour heparin-free hemodialysis sessions but we observed lower session failure with IHD-RCA. We confirm efficacy of Prometheus device for IHD-RCA in this population. Moreover, we report a low risk of 4-hour heparin-free session failure with SIHD without systemic anticoagulation using double lumen access, priming heparin, high blood flow, predilution and Polysulfone High-flux dialyser in comparison with other studies.

FC 118DIALYSIS WITHDRAWAL IN THE NETHERLANDS BETWEEN 2000-2020: TIME TRENDS AND CENTRE VARIATION

Abstract Background and Aims Treatment withdrawal is an important cause of death among dialysis-dependent patients. Widely variable withdrawal rates were reported in studies using varying designs and definitions in culturally different regions of the world, limiting comparability of individual studies. Cessation of life-prolonging treatment is a well-accepted option in the Netherlands, however it is unclear if these premises result in higher dialysis withdrawal rates and if this effect is generalisable. This study aims to describe dialysis withdrawal practice in the Netherlands, focussing on time trends and practice variation between centres. Method Patient data was retrieved from RENINE, the Dutch national registration which includes nearly all patients requiring dialysis for at least 28 days. All patients who initiated maintenance dialysis from January 1, 2000, to December 31, 2020, and died within this period were included for analysis. Since the primary aim of this study concerned cause of death on dialysis, data of patients in whom dialysis was stopped due to kidney transplantation or recovery of kidney function, were excluded. Main outcome was death by dialysis withdrawal, as registered by the treating physician using ERA-EDTA codes. Other causes of death were used as comparison. Time trends for dialysis withdrawal were first analysed as unadjusted data (proportion per year). Univariable logistic regression analyses were then used to identify factors associated with dialysis withdrawal, including year of death in five-year strata. A multivariable model was subsequently used to determine risks, adjusting for factors associated with dialysis withdrawal. Centre variation was compared visually by using funnel plots. Results A total of 34.692 patients commenced maintenance dialysis of which 20.389 died. After applying exclusion criteria, a cohort of 18.412 patients was used for analysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 13.5% in 2000 to 31.2% in 2019 (22.1% overall). In multivariable analysis, increasing age, female sex, increasing dialysis vintage, haemodialysis as treatment modality, and year of death were independent factors associated with death by dialysis withdrawal. Centre variation was large, even after correction for confounding factors (36.6% outside 95% control limits). Conclusion Treatment withdrawal has become the main cause of death in the Netherlands among dialysis-dependent patients during 2000-2020. Large practice variations were observed between centres, even after correction for confounding factors. These findings emphasize the need for timely advance care planning and urge treating health care professionals to better inform their patients when choosing to start dialysis or not.

MO843PREVALENCE AND MANAGEMENT OF HYPERTENSION IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Hypertension (HTN) is common in hemodialysis (HD) patients & diagnosed by pre-dialysis BP >140/90 mmHg. Causes include high salt intake, volume overload, & loss of residual kidney function. Therapy includes achieving correct dry weight with each session, restricting interdialytic sodium & fluid intake & medications. We review its prevalence, factors associated with it & its management in our patients. Method Demographics, HD prescription & medications data collected for patients from 5 dialysis centers. Results A total of 1585 files reviewed. Males were 51.8% & mean age was 59. Mean age significantly higher for females (61 vs 57). ESKD cause was DM in 51% & HTN in 35%. However, of files reviewed, adequate data on comorbidities in 1390 patients (table 1), 69% had DM, 92% had HTN, 47% had CVD & 31% had BMI > 25 (which was significantly more frequent in females). HTN was more likely in older patients, diabetics & females with odds of HTN in females nearly twice the odds of HTN in males & odds of HTN with DM is 2.27 times odds of HTN without DM & one-year increase in age would increase odds of HTN by nearly 4%. Mean pre-HD BP for those with HTN was 143/76 mmHg & for those without HTN was 136/75 mmHg. HD frequency was thrice weekly in 94% & HD duration was > 3.5 hours in only 77% of patients. HDF used in 81.5%. Mean interdialytic weight gain (IDWG) was 2.8 kg, with no difference according to gender or presence of DM or HTN (Table 2). Higher IDWG associated with age < 65, Calcium bath of 1.75 & Sodium bath > 138 with 0.638 kg higher IDWG with calcium of 1.75 compared to calcium of 1.25. Higher IDWG was associated with higher BP. Mean volume of fluid removed per session was 2.74, which was less than mean IDWG, with no difference according to gender or DM, however, it was higher in the higher dialysate sodium group, & lower in the shorter session group (with trend towards statistical significance). CCB used to treat HTN in 62% followed by βB in 52%. Number of patients with HTN on 1 drug 21%, 2 drugs 27%, 3 drugs 23%, ≥ 4 drugs 20% & 9% missing data. Number of antihypertensives did not correlate with IDWG. Conclusion Interdialytic weight gain in our HD patients is excessive & contributing to HTN. Patients must restrict salt & fluid intake & dialysis centers must regularly & frequently assess dry weight, ensure thrice weekly schedule & 4 hours per session are met, so excess fluid is completely removed. Also, high sodium & high calcium baths need to be avoided.

Hemodialysis and hemodiafiltration-induced transient hypercalcemia: an unrecognized phenomenon with potential for calcium-loss and vascular calcification

Uremic vascular calcification is prevalent in 70-80% of end-stage kidney disease (ESRD) patients and is an independent predictor of cardiovascular morbidity and mortality. In this study we report our experience with significant transient hypercalcemia during maintenance hemodialysis (HD) in 105 patients and hemodiafiltration (HDF) in another 44 ones. The studied patients had controlled predialysis levels of calcium, phosphorus, 1, 25 vitamin D and parathyroid hormone. Treatment was associated with high dialysate calcium and low serum phosphorus without significant changes in parathyroid hormone levels. Pre-treatment with a single dose of Fosamax; resulted in amelioration of hypercalcemia indicating its bone etiology. In conclusion; maintenance HD and HDF are associated with inherent hypercalcemia which may contribute to osteomalacia and uremic vascular calcification in ESRD patients. 
 Keywords: Bisphosphonates, HD, HDF, hypercalcemia, hypophosphatemia, osteomalacia, vascular calcification, uremia.

Serum sodium variation is a major determinant of peridialytic blood pressure trends in haemodialysis outpatients

Intradialytic hypotension (IDH) and peridialytic blood pressure (BP) trends are associated with morbidity and mortality in haemodialysis (HD) patients. We aimed to characterise the respective influence of volume status and small solutes variation on peridialytic systolic BP (SBP) trends during HD. We retrospectively analysed the relative peridialytic SBP decrease in 647 prevalent outpatients attending for their mid-week session with corresponding pre- and post-HD bioelectrical impedance analysis. Mean SBP decreased by 10.5 ± 23.6 mmHg. Factors positively associated with the relative decrease in SBP were: serum sodium (Na) decrease, body mass index, serum albumin, dialysis vintage, ultrafiltration rate and urea Kt/V (p < 0.05 for all). Antihypertensive medications and higher dialysate calcium were negatively associated with the relative decrease in SBP (p < 0.05 for both). Age had a quadratic relationship with SBP trends (p < 0.05). Pre-HD volume status measured by extracellular to total body water ratio was not associated with SBP variation (p = 0.216). Peridialytic SBP trends represent a continuum with serum Na variation being a major determinant while volume status has negligible influence. Middle-aged and overweight patients are particularly prone to SBP decline. Tailoring Na and calcium dialysate concentrations could influence haemodynamic stability during HD and improve patient experience and outcomes.

Influencia del flujo del líquido de diálisis en los parámetros de calidad de la hemodiafiltración en línea post-dilucional

Introducción: La hemodiafiltración en línea post-dilucional es una variante de hemodiálisis que, según diferentes estudios puede aumentar la supervivencia de los pacientes. Inicialmente, y a diferencia de la hemodiálisis convencional, se utilizaban flujos de dializado muy elevados (hasta 700-800 ml/min); nuevos estudios cuestionaron la utilidad de elevar tanto este flujo en cuanto a eficacia depurativa. Objetivo: Analizar las diferencias producidas en Kt, Kt/V y volumen de infusión en esta técnica utilizando flujo de baño de diálisis a 600 ml/min y a 500 ml/min, así como evaluar la repercusión en el consumo de agua durante la sesión. Método: Se incluyeron 22 pacientes crónicos dializados con hemodiafiltración en línea post-dilucional en monitores Artis®. Se estudiaron 440 sesiones, 220 con cada flujo. Las variables estudiadas fueron edad, tiempo de permanencia en técnica, Kt, Kt/V y volumen de infusión. Resultados: De los 22 pacientes 7 son mujeres, la mediana de edad es de 79,5 años (rango 40-86) y la media de permanencia: 25,13±10,51 meses. Las medias con flujo de diálisis a 600 ml/min y a 500 ml/min fueron respectivamente: Kt:45,5±9,4 y 45,2±9,2 litros, Kt/V:1,52±0,33 y 1,51±0,33 y volumen de infusión: 21,84±4,50 y 21,94±4,51 litros. Influencia del flujo del líquido de diálisis en los parámetros de calidad de la hemodiafiltración en línea post-dilucional. Conclusión: Según nuestros resultados se puede dializar en hemodiafiltración en línea post-dilucional con flujos de dializado de 500 ml/min sin menoscabo de los parámetros de calidad de hemodiálisis.

Effect of low dialysate sodium in the management of intradialytic hypertension in maintenance hemodialysis patients: A single-center Indian experience.

High dialysate sodium is a significant contributor to intradialytic hypertension (IDH) in maintenance hemodialysis patients. In this study, we aimed to study the effect of low dialysate sodium on IDH in Indian hemodialysis patients. Fifty patients on maintenance hemodialysis for atleast 3 months with episodes of IDH were enrolled in this study. The study was performed in two different stages. In the first phase, patients were dialyzed with standard dialysate sodium (140 mEq/L) for eight consecutive sessions and in the second phase, they were dialyzed with low sodium dialysate (136 mEq/L) for eight consecutive sessions. Differences in pre, intradialytic, and post-HD blood pressure, interdialytic weight gain, mean serum sodium, intradialytic adverse events, and number of IDH episodes requiring intervention between the two phases were assessed. The mean age of the study population was 52 years (36 males,14 females). The mean post-HD systolic and diastolic BP was 163.26 ± 9.58 mmHg and 88.60 ± 5.27 mmHg in the standard dialysate phase and 142.38 ± 14.09 mmHg and 84.58 ± 4.276 mmHg, respectively, in the low dialysate phase (p < 0.01). Interdialytic weight gain was 3.34 ± 0.9 and 3.11 ± 0.86 in the standard and low sodium dialysate phases, respectively (p = 0.19).The mean pre-HD plasma sodium level was 138.48 ± 3.69 and 135.80 ± 1.35 mEq/dl, respectively, in standard and low dialysate phases (p = 0.01). There was significant reduction in number of IDH episodes requiring intervention. There was no difference in hypotensive episodes, adverse events between the two phases. In patients with intradialytic hypertension, low dialysate sodium significantly reduces the post-HD blood pressure and intradialytic hypertensive episodes, when compared with standard sodium dialysate.

Myoglobin clearance with continuous veno-venous hemodialysis using high cutoff dialyzer versus continuous veno-venous hemodiafiltration using high-flux dialyzer: a prospective randomized controlled trial

BackgroundMyoglobin clearance in acute kidney injury requiring renal replacement therapy is important because myoglobin has direct renal toxic effects. Clinical data comparing different modalities of renal replacement therapy addressing myoglobin clearance are limited. This study aimed to compare two renal replacement modalities regarding myoglobin clearance.MethodsIn this prospective, randomized, single-blinded, single-center trial, 70 critically ill patients requiring renal replacement therapy were randomized 1:1 into an intervention arm using continuous veno-venous hemodialysis with high cutoff dialyzer and a control arm using continuous veno-venous hemodiafiltration postdilution with high-flux dialyzer. Regional citrate anticoagulation was used in both groups to maintain the extracorporeal circuit. The concentrations of myoglobin, urea, creatinine, β2-microglobulin, interleukin-6 and albumin were measured before and after the dialyzer at 1 h, 6 h, 12 h, 24 h and 48 h after initiating continuous renal replacement therapy.ResultsThirty-three patients were allocated to the control arm (CVVHDF with high-flux dialyzer) and 35 patients to the intervention arm (CVVHD with high cutoff dialyzer). Myoglobin clearance, as a primary endpoint, was significantly better in the intervention arm than in the control arm throughout the whole study period. The clearance values for urea and creatinine were higher in the control arm. There was no measurable albumin clearance in both arms. The clearance data for β2-microglobulin and interleukin-6 were non-inferior in the intervention arm compared to those for the control arm. Dialyzer lifespan was 57.0 [38.0, 72.0] hours in the control arm and 70.0 [56.75, 72.0] hours in the intervention arm (p = 0.029).ConclusionsMyoglobin clearance using continuous veno-venous hemodialysis with high cutoff dialyzer and regional citrate anticoagulation is better than that with continuous veno-venous hemodiafiltration with regional citrate anticoagulation.Trial registrationGerman Clinical Trials Registry (DRKS00012407); date of registration 23/05/2017. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012407.

High magnesium dialysate does not improve intradialytic hemodynamics or abrogate myocardial stunning.

Hemodialysis (HD) induces myocardial stunning and is associated with adverse cardiovascular outcomes. Intradialytic hypotension is a modifiable determinant of myocardial stunning. Magnesium (Mg) is reported to be valuable in maintaining intradialytic blood pressure, which potentially would protect against demand myocardial ischemia. This study aimed to compare high vs. low dialysate Mg effects on intradialytic hemodynamics and HD-induced myocardial stunning. Twenty stable prevalent HD patients entered a randomized cross-over trial of low (0.5 mmol/L) vs. high (1.0 mmol/L) dialysate Mg. Patients were studied after 2 weeks of standard HD with each Mg concentration. Serial echocardiography assessed myocardial stunning, measured by left ventricular regional wall motion abnormalities (RWMAs). Continuous intradialytic hemodynamics were measured noninvasively using thoracic bioimpedance. Median predialysis serum Mg was higher with high dialysate Mg (1.45[1.29-1.55] vs. 1.03[0.98-1.1] mmol/L, P < 0.0001). There was no significant difference in maximum intradialytic reduction in systolic BP. There was no significant difference in stroke volume, total peripheral resistance, and cardiac output. Overall ventricular global longitudinal strain (GLS) (as a sensitive marker of contractile function) was higher before dialysis in high Mg group, but there was no difference in GLS at peak stress. However, we showed a significant correlation between Mg changes and GLS changes, r = -0.47, P = 0.02. There was no difference in mean number of peak stress RWMAs per patient (4.0 ± 2.2 vs. 4.3 ± 2.9, P = 0.5). Ultrafiltration volume, a critical determinant of stunning, was not different between high and low dialysate Mg studies (1.35[0-3.3] vs. 1.5[0-2.8], P = 0.49). Manipulation of magnesium by altering dialysate magnesium concentration does not influence intradialytic hemodynamic response or HD-induced myocardial stunning in the short term. However, decreasing Mg changes appears to decrease GLS changes.

P0635MYOGLOBIN CLEARANCE IN CVVHD USING HIGH CUT-OFF FILTER VERSUS CVVHDF WITH REGIONAL CITRAT ANTICOAGULATION: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Abstract Background and Aims Acute kidney injury (AKI) is frequent among critically ill patients and it is associated with high mortality. Rhabdomyolysis is a distinct cause of AKI. As myoglobin has renal toxic effects, clearance via continuous renal replacement therapy (CRRT) may be favourable. Current international guidelines recommend regional citrate anticoagulation (RCA). Clinical data comparing different modalities of CRRT addressing myoglobin clearance are lacking. Hemofiltration is recommended to eliminate myoglobin, which requires systemic anticoagulation. RCA would be impractical due to the high citrate load as a result of the higher blood flow. Continuous veno-venous hemodiafiltration (CVVHDF) is one opportunity to realize lower citrate load and maintain middle molecule clearance. Another approach may be the application of hemodialysis with high cut-off (HCO) membranes with a pore size larger than 0.01 μm in CVVHD (CVVHD-HCO). We have previously shown that CVVHD-HCO is superior to conventional high-flux dialyser regarding the clearance of β2-microglobulin. Based on this finding, we analyzed of various etiologiesre Filter lilifespan mit dem efonnummer der Virologie zum Befunderfragenmyoglobin clearance with CVVHDF compared to CVVHD-HCO with RCA. Method The present study is a prospective, randomized, single-blinded, monocentric trial. We enrolled patients from May 2017 to September 2018 in our 28-bed medical ICU at the University Hospital Leipzig. We screened 430 patients with AKI and indication for RRT for eligibility. A total of 70 patients underwent randomisation 1:1 into the intervention (CVVHD-HCO, high cut-off dialyzer Ultraflux EMiC2) and control group (CVVHDF, high-flux dialyzer Ultraflux AV1000S). The concentrations of myoglobin (17053 Dalton (Da), urea (60 Da), creatinine (113 Da), β2-microglobulin 11800 Da), interleukin 6 (IL-6, 26000 Da) and albumin (66470 Da) were measured before (pre) and after (post) the dialyzer 1, 6, 12, 24 and 48 h after initiating CRRT. We hypothesized non-inferiority of CVVHD-HCO versus CVVHDF regarding myoglobin clearance (primary end-point). Results Myoglobin clearance showed non-inferiority in the intervention group for all time points. The dialyzer in the intervention group resulted in even a better myoglobin clearance during the whole study period. (Table 1). Clearance values for urea and creatinine were equal and there was no albumin loss in both groups.β2-microglobulin clearance was significantly better in the intervention group than in the control group at all time points. The clearance of IL-6 was also better at T0 in the intervention group. The filter lifespan was 51.5 hours (CI: 44.24; 58.76) in the control group and 62.3 hours (CI 56.83; 67.7) in the intervention group (log-rank, p=0,029). Conclusion Myoglobin can be reliably cleared using both CVVHD-HCO and CVVHDF. Nevertheless, the plasma specific clearance rate of myoglobin was higher with CVVHD-HCO. High myoglobin levels are associated with AKI and higher mortality rates and on this account clearance of myoglobin represents a relevant clinical issue.

P0160HOW TO MANAGE INTRADIALYTIC HYPERTENSION?

Abstract Background and Aims Hypertension in subjects on long term dialysis is frequent. Intradialytic hypertension affects up to 20% of hemodialysis patients and occurs more frequently in patients who are older, have lower dry weights, are prescribed more antihypertensive medications. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Method We realized a cross sectional study in two hemodialysis center patients during october 2019. We compared two groups of patients: group 1 with HTA (HTA+) and the second without (HTA-). Prevalence of hypertension intra dialysis (increase in systolic BP &amp;gt; 15mmHg during dialysis) was determined by blood pressure recordings every thirty minutes during hemodialysis. We collect information about prescription patients (bolus dose of IV nicardipine or administration of captopril orally) after HTA inicident. We collected and analyzed datas of 1476 hemodialysis sessions for 123 patients. Results The mean age of your patients was 46 ± 26,3 years with a female predominance. The mean duration of hemodialysis was 9,8 years. The initial nephropathy was hypertensive in 14,6%. 44,7% (n=55) patients used at least one antihypertensive treatment (HTA+ group), in 72,7% calcic inhibitor. Hypertension crisis in HTA+ group was higher than HTA- group, respectively 37,9% and 4,7% (p=0,0002). Concerning HTA+ group, in 9,35% of cases patients receveid IV bolus of nicardipine, 7,9% captopril and 17,9% of cases have not receveid any antihypertensive medication. In HTA- group they receveid IV nicardipine on only 2,5% cases and no drugs in half of all cases. Patients who were older and receive erythropoietin-stimulating agents were more likely to exhibit an increase in SPB despite similar amounts of ultrafiltration in each groups. It appears HTA- group had better control of hypertension crisis in 77,5% versus 65,5% in HTA+ group, at 20minutes of crisis (p= 0,004). Administration of captopril in the both group allowed better control of hypertension 90% (HTA+ group) and 84,2%(HTA- group). Hypertension crisis was more controlled in group with high ultrafiltration rate with administration of captopril . Conclusion Use of ACE inhibitors during dialysis to manage hypertension crisis appears a great solution and confirm hypothesis of activation of the renin–angiotensin–aldosterone system. Treatment of intradialytic hypertension may include careful attention to dry weight, avoidance of dialyzable antihypertensive medications, limiting the use of high calcium dialysate, achieving adequate sodium solute removal during hemodialysis, and using medications which inhibit the rennin-angiotensin-aldosterone system or which lower endothelin 1.

P0005TIME-VARYING DIALYSATE BICARBONATE CONCENTRATIONS CAN REDUCE PEAK INTRADIALTIC SERUM BICARBONATE CONCENTRATIONS

Abstract Background and Aims Hemodialysis (HD) treatments using bicarbonate-containing dialysis solutions can result in large intradialytic increases in serum bicarbonate concentration, potentially inducing intradialytic alkalemia. It has been suggested that a time-varying, compared with a constant, dialysate bicarbonate concentration may limit the intradialytic increase in serum bicarbonate concentration (Tobvin &amp; Sherman, Semin Dial 2016). We tested this hypothesis using a mathematical model of bicarbonate transport during HD. Method We used the H+ mobilization model describing bicarbonate transport during HD (Sargent et al, Semin Dial 2018) to compare intradialytic serum bicarbonate concentrations when using constant or time-varying dialysate bicarbonate concentrations that deliver the same total amount of buffer base to the patient during the HD treatment. We employed this model to evaluate different time-varying dialysate bicarbonate concentration profiles that started at a high value and then decreased as a step function with a 10-minute timing resolution. Dialysis time was 210 minutes, dialysis solutions were assumed to contain acetate at 3 mEq/L, and all kinetic parameters were assumed to be identical to those reported by Sargent et al (Semin Dial 2018). All results with time-varying dialysate bicarbonate concentrations were compared to a constant dialysate concentration of 32 mEq/L. Results Example results comparing time-varying (36.0 mEq/L for the initial 40 min, 31.2 mEq/L thereafter) and constant (32 mEq/L) dialysate bicarbonate concentrations are shown in the figure. The time-varying dialysate bicarbonate concentration lowered the peak intradialytic serum bicarbonate by 0.4 mEq/L for approximately one-half of the treatment. Similar reductions in the peak intradialytic serum bicarbonate concentration could be achieved if the initial high dialysate bicarbonate concentration was 37.6 mEq/L for 30 min or 40.8 for 20 min. The optimal initial high dialysate bicarbonate concentrations and the reduction in the peak intradialytic serum bicarbonate concentrations were somewhat dependent on the assumed patient-dependent H+ mobilization coefficient. Conclusion We conclude that a time-varying dialysate bicarbonate concentration can lower the peak intradialytic serum bicarbonate concentrations while delivering the same total amount of buffer base to the patient. Whether this approach will yield improved patient outcomes requires further evaluation.

P1568EFFECTS OF VOLUME STATUS ON BODY COMPOSITION IN INCIDENT PERITONEAL DIALYSIS PATIENTS

Abstract Background and Aims Volume control is the most important issue in peritoneal dialysis (PD). Inadequate fluid removal or high water intake leads to overhydration, which result in malnutrition. Sarcopenia (SP) as a result of malnutrition is more prevalent in PD than in the general population, and is associated with high mortality and low quality of life in PD patients. The aim of the present study was to evaluate the effects of volume status on body composition in incident PD patients. Method This retrospective study was performed at a tertiary medical center from January 2001 to March 2015. All incident PD patients who survived ≥1 year after PD initiation were considered eligible. 366 incident PD patients were finally included and divided into 3 tertiles according to the time-averaged-edema index (TA-EI). Edema index was calculated by dividing extracellular water values by total body water values. The mean of the EI values at 1 month and 1 year was defined as TA-EI. The body composition parameters measured using bioimpedance analysis included the EI, fat mass index (FMI, kg/m2), and appendicular muscle mass index (AMMI, kg/m2). dFMI and dAMMI were defined as delta values for each variable. The cutoff value for sarcopenia (SP) was defined as previously reported (The cutoff value for SP was defined as AMMI ≤ 7.0 kg/m2 in men and ≤ 5.7 kg/m2 in women). Patients with AMMI below the cut-off values were defined as having SP. Results The number of participants in the low, middle, and high tertiles was 126, 100, and 140, respectively. The TA-EI in the low, middle, and high tertiles was 0.384 ± 0.006, 0.398 ± 0.003, and 0.413 ± 0.009, respectively (P &amp;lt; 0.001). A high volume status was associated with high solute clearance, peritoneal albumin loss, and glucose absorption through the peritoneal membrane, which led to high dialysate glucose. In addition, volume status was inversely associated with increases in AMMI, but was not associated with changes in FMI. SP as a categorical variable was positively associated with a high volume status. On subgroup analyses, TA-EI had the greatest negative correlation coefficients for dAMMI. Conclusion Overhydration in PD patients was associated with decrease in muscle mass indices and the development of SP.

SO074VASCULAR CALCIFICATION IN PREVALENT PERITONEAL DIALYSIS PATIENTS AND ITS RELATIONSHIP WITH CLINICAL AND BONE HISTOMORFOMETRIC PARAMETERS

Abstract Background and Aims Vascular calcification (VC) is associated to morbidity and mortality in chronic kidney patients. However, it remains to clarify the relationship between VC and renal osteodystrophy (ROD) evaluated by bone biopsy in peritoneal dialysis (PD) patients. Method In order to characterize the relationship between VC and ROD in prevalent PD population, we performed tetracycline-labelled bone biopsies with histomorphometric analysis according KDIGO guidelines. Hands and pelvis x-ray were performed to evaluate VC and to calculate Adragão Score. Exclusion criteria: previous kidney transplant, hemodialysis, treatment with agents interfering in bone metabolism (for example bisphosphonates). All patients were treated with biocompatible PD solutions, with calcium concentration of 1.25 mmol/L. Results Thirty-one patients participated in the study. Mean age was 52.32±11.09 years, 16 male, 6 with diabetes mellitus (DM), 22 on manual PD, median time on PD was 12 (3-61) months. Mean calcium, phosphate and PTH were 9.2±0.5 mg/dL, 4.9±1.0 mg/dL and 486.0±230.5 pg/mL, respectively. Most frequent diagnosed ROD pattern was adynamic bone disease (44.4%) followed by hiperparathyroid bone disease (33.3%) and normal bone (14.8%). VC was detected in 29% of patients and mean Adragão score was 1.13. However, 100% of diabetics had VC on x-ray compared to 12% of non-diabetics. Clinical, analytical and histomorphometric essential data is represented in table 1: Also no significant differences were observed between the patients with or without VC in ROD patterns on bone biopsy, glucose load in PD solutions, prescribed phosphate binders namely calcium-based binders, active vitamin D or calcimimetics. In diabetic patients, bone volume tended to be lower (17.26% vs 22.54%; p=0.072) comparing to non-diabetics. Bone formation rate was similar in diabetics and non-diabetics (25.39 vs 27.71µm3/µm2/y) as mineralization lag time (18.7 vs 20.1 days). Conclusion ROD evaluated by bone biopsy and the proportion of PD patients with VC on x-ray were similar to previous reports. However, in the present study a striking difference in VC was detected in diabetics – all diabetic patients had VC demonstrated radiographically. This finding was not explained by differences in calcium, phosphate, PTH levels or other studied factors. So DM could be a strong risk factor to VC in this population. Also, patients with VC were older, with higher sedimentation rate and lower total KT/V. It is possible that diabetic patients represent a different subgroup, particularly prone to lower bone volume and specially VC. They might benefit from higher dialysis dose and aggressive approaches to prevent or retard VC. This remains to be proved in properly designed prospective studies. In conclusion, age, sedimentation rate, total KT/V and presence of diabetes were associated to VC in prevalent PD patients. Diabetics may be a subgroup of PD patients with very high risk of VC.

P1548THE VALUE OF BEING A NETWORK: CLINICAL GOVERNANCE AND DIALYSIS CLINIC PERFORMANCE MANAGEMENT IS ASSOCIATED WITH IMPROVED PATIENTS SURVIVAL

Abstract Introduction. In order to help facilitate the uptake of best clinical practices, improve outcomes, enhance efficiency and reduce costs, few healthcare organizations have introduced Continuous Quality Improvement (CQI) programs. Since September 2014, dialysis centers belonging to the EMEA Fresenius Medical Care (FME) network have introduced a CQI policy called Medical Peer Review (MPR) based on key performance indicators (KPI) related to patient’s clinical status. We exploit the quasi-experimental setting generated by the introduction of FMC CQI policy, to evaluate the association between improvement in intermediate outcomes (key performance indicators) and prolonged survival among dialysis patients registered in the EMEA FME network. Methods. We conducted a historical cohort study. We included adult patients on chronic dialysis with less than 90 days between renal replacement therapy (RRT) initiation date and first treatment date in FME clinics. We compared KPI target achievement (P-BSC score) and 2-year mortality for patients enrolled prior to MPR-CQI policy onset (Cohort A) and a cohort of patients enrolled after MPR-CQI policy onset (Cohort B). Structural Equation model was adopted to estimate the association of MPR-CQI policy on patients’ survival through changes in intermediate outcomes (P-BSC score). Results. The Cohort A and Cohort B consisted of 2397 and 1873 patients, respectively. We observed no difference across groups concerning the distribution of age (63.1 vs 62.8 years), gender (59% vs 60% males) and body mass index (27.6 vs 26.4 kg/m2); Cohort A showed lower Charlson’s comorbidity index (3.3±1.5 vs 3.8±1.9, p&amp;lt;0.01) and higher dialysis vintage (32.9±27.0 vs 21.3±22.2 days, p-value&amp;lt;0.01) compared to Cohort B. P-BSC scores over the 6-month ascertainment period was 5.25±1.47 in the pre CQI-MPR policy cohort, while it was significantly higher (6.67±1.63) in the post CQI-MPR policy cohort. Mediation analysis demonstrated a strong indirect effect of CQI-MPR implementation on mortality trough improvement of P-BSC rating score occurring in the post-implementation era (OR=0.70, p&amp;lt;0.001) Conclusion. We showed that, after discounting for potential unmodifiable confounding factors and potential unmeasured selection/chronological bias, improvement of intermediate outcomes and performance indicators occurred after MPR-CQI policy implementation, was associated to a strong improvement in survival. Figure:

MO078HEMODIAFILTRATION MAINTAINS A SUSTAINED IMPROVEMENT IN BP COMPARED TO CONVENTIONAL HEMODIALYSIS IN CHILDREN - THE HDF, HEART AND HEIGHT (3H) STUDY

Abstract Background and Aims Hypertension is prevalent in children on dialysis and associated with left ventricular hypertrophy, cardiovascular disease and mortality. We studied the effect of different dialysis modalities (conventional hemodialysis [HD] vs hemodiafiltration [HDF]) on BP and risk factors affecting the evolution of BP over a one-year follow-up. Method This is a post-hoc analysis of the “3H - HDF-Hearts-Height” dataset, a multicenter, non-randomized, parallel-arm intervention study. The time–averaged 24-h mean arterial pressure (MAP) was used for the analyses and hypertension defined as 24-h MAP standard deviation score exceeding the 95th percentile. Results All 133 children who completed 12 months follow-up in the 3H study were included in this post - hoc analysis. 78 (74%) were on HD and 55 (77%) on HDF. At baseline MAP-SDS was &amp;gt; 95th percentile in 64 (82%) of children on HD and 23 (41.8%) patients on HDF, but these data are skewed by a high percentage of prevalent dialysis patients in the study. 43 (55%) of HD patients and 23 (42%) of HDF patients were on antihypertensive medications, and uncontrolled hypertension (BP&amp;gt;95th centile on medications) was present in 38 (88%) of HD patients and 6 (25%) of HDF patients. In the stepwise logistic regression at baseline, independent risk factors for hypertension were gender (OR 2.29; 95%CI 1.06–4.96; p=0.04) and inter-dialytic weight gain at baseline (OR 1.3; 95%CI 1.1–1.55; p=0.004). Over the one-year study period, MAP-SDS increased by 39% in HD patients and 12% in HDF patients (p&amp;lt; 0.001) (Figure). Significant risk factors for hypertension over time were dialysis modality (OR for HD compared to HDF 7.65; 95% CI 3.23 – 18.12; p&amp;lt; 0.001), inter-dialytic weight gain (OR 1.21; 95% CI 1.05 – 1.39; p=0.007), and dialysate sodium (for 1 mmol/L increase in dialysate sodium MAP-SDS increased by 1.1mmHg ; 95% CI 1.01 – 1.21; p=0.04). Conclusion Children on HD compared to HDF had a 7.6-fold higher 24-hr MAP-SDS and a sustained increase in BP over the one-year study period. Higher inter-dialytic weight gain and higher dialysate sodium levels were associated with a higher MAP-SDS in both groups.

P1212PREDICTORS OF QUALITY OF LIFE IN PERITONEAL DIALYSIS: A SINGLE-CENTER EXPERIENCE

Abstract Background and Aims Quality of life (QoL) is an important indicator of quality of healthcare. Measuring QoL and its correlates for peritoneal dialysis (PD) patients is very important for intervention and clinical decision-making. Being a technique performed by the patients themselves, their perspective of health related QoL is extremely important. The EuroQol questionnaire evaluates 5 QoL dimensions (mobility, self-care, usual activities, pain/ discomfort and anxiety/ depression) and includes a visual analogue scale (VAS) rated 0-100% that provides a quantitative measure of the patients’ perception of their overall health. Method Data from 69 patients on peritoneal dialysis at our center were collected using EQ-5D-5L EuroQol questionnaire. Health state index (HSI) scores were calculated from individual health profiles using the Spanish value set (maximum score 1). Additional clinical and laboratory data was collected from the patient’s medical files. Results Mean age of the population studied was 55,2 ± 14,0 years, and 66,7% (n=46) were male. Most patients were on PD &amp;gt; 1 year (62,3%, n=43) and performing automated peritoneal dialysis (APD) (52,2%, n=36). Mean HSI was 0,88 ± 0,15 and mean VAS score was 75,1 ± 18,7. Patients with weekly Kt/V ≥ 1,7 scored on average 0,09 points higher on the HSI (p=0,070) and 13,34 points higher in VAS (p=0,019), compared to patients with weekly Kt/V &amp;lt; 1,7. Patients on PD &amp;gt; 1 year scored on average 0,09 points lower on the HSI (p=0,017), mainly due to higher levels of anxiety/depression, and 11,9 points lower in VAS (p=0,005) than those &amp;lt; 1 year. Age did not significantly influence QoL, even when comparing patients &amp;gt; 70 years with those &amp;lt; 70 years old (HSI 73.0 ± 15.5 vs 75.4 ± 19.3, p=0.710 / VAS 0.82 ± 0.3 vs 0.89 ± 0.1, p=0.175). Likewise, when comparing continuous ambulatory peritoneal dialysis (CAPD) to APD, there was no significant difference in the scores of QoL. Gender, diabetes mellitus, arterial hypertension, cancer and infectious events related to PD in the last year did not influence QoL. Residual diuresis as an isolated factor did not significantly influence QoL scores. However, as it is a fundamental contributor to Kt/V, it may be indirectly associated with better QoL. A more detailed analysis was not possible as the number of patients with Kt/V ≥ 1.7 and no residual diuresis was, as expected, very low (n=4). Conclusion Perceived QoL in the elderly when compared to younger patients in PD was not inferior in our study, showing this option should be discussed individually with each patient. Our results revealed time in PD negatively influences patients’ perception of their own health, which may be due to patient’s burden and exhaustion, and eventually lead to technique related complications. Kt/V ≥ 1,7 was related to better QoL, either because higher dialysis adequacy leads to better QoL, or because patients who feel better have less tendency to neglect the technique. Finally, we also found type of PD (CAPD vs APD) to have no significant influence on QoL, reinforcing the idea that it should be discussed and adapted to each individual patient.