Post Hemodialysis Research Articles

Changes in Intracellular Water Following Hemodialysis Treatment Lead to Changes in Estimates of Lean Tissue Using Bioimpedance Spectroscopy.

Bioelectrical impedance (BIA) devices are being introduced into hemodialysis (HD) centers to aid determining normohydrated weight and also provide body composition assessment by estimating lean tissue mass index (LTMI) and fat mass index (FMI). BIA devices differ, with most using a 2-body compartmental model, which can be affected by hydration status, and as such for reliable measurements, these should be made postdialysis when patients are not overhydrated, which is inconvenient for both patients and staff. The development of BIA devices using a 3-compartmental body model, separately estimating normohydrated LTMI potentially, now offers the advantage of making reliable measurements of body composition prior to dialysis. We measured body composition predialysis and postdialysis in 50 HD patients using a 3-body compartment model BIA device. Although there were no statistically significant differences for the whole cohort in LTMI and FMI (pre and post HD-13.5 ± 4.2 vs 13.9 ± 4.7 kg/m(2), and 10.5 ± 5.5 vs 10.6 ± 5.4 kg/m(2) respectively), the correlation (r(2)) between pre and post HD was only 0.27 and 0.37 kg/m(2) respectively, with a mean ± SD bias on Bland-Altman analysis, -0.67 ± 4.25 and 0.33 ± 4.77 kg/m(2) respectively. Changes in intracellular water were associated with changes in LTMI (r(2) = 0.99, P < .001). Similarly, a fall in LTMI was associated with a corresponding increase in FMI (r(2) = -0.86, P < .001). In clinical practice, predialysis bioimpedance measurements are more convenient. However, for more reliable and reproducible assessments of nutrition status, we suggest that measurements of body composition should be made when patients are not overhydrated.

Serum Thiamine Values in End-Stage Renal Disease Patients under Maintenance Hemodialysis.

Hemodialysis patients are prone to malnutrition because of diet or many uremic complications. The objective of this study is to determine whether thiamine deficiency is associated with regular dialysis patients. To determine whether thiamine deficiency is associated with regular dialysis patients, we measured thiamine in 100 patients undergoing consecutive dialysis. Average thiamine levels were not low in both pre-hemodialysis (50.1 ± 75.9 ng/mL; normal range 24 - 66 ng/mL) and post-hemodialysis (56.4 ± 61.7 ng/mL). In 18 patients, post-hemodialysis levels of thiamine were lower than pre-hemodialysis levels. We divided the patients into two groups, the decrease (Δthiamine/pre thiamine < 0; - 0.13 ± 0.11) group (n = 18) and the increase (Δthiamine/pre thiamine> 0; 0.32 ± 0.21)) group (n = 82). However, there was no significance between the two groups in Kt/V or type of dialyzer. Patients were dichotomized according to median serum thiamine level in pre-hemodialysis into a high-thiamine group (≥ 35.5 ng/mL) and a low-thiamine group (< 35.4 ng/mL), and clinical characteristics were compared between the two groups. The low-thiamine value group (< 35.4 ng/ml; 26.8 ± 5.3 ng/ml) exhibited lower levels of serum aspartate aminotransferase and alanine aminotransferase than the high-thiamine value group (≥ 35.4 ng/ml; 73.5 ± 102.5 ng/ml) although there was no significance in nutritional marker, Alb, geriatric nutritional risk index , protein catabolic rate and creatinine generation rate. In our regular dialysis patients, excluding a few patients, we did not recognize thiamine deficiency and no significant difference in thiamine value between pre and post hemodialysis.

Efficacy of Intravenous Vitamin-D Selective Receptor Activator ( Paricalcitol ) in Management of Secondary Hyperparathyroidism in Hemodialysis Patients : Single Center Experience

Background: secondary hyperparathyroidism (SHPT), a complication of chronic kidney disease (CKD) and is characterized by not only increased serum levels of intact parathyroid hormone (iPTH), but also may cause skeletal and cardiovascular complications. Deficiency of calcitriol (1, 25-hydroxy vitamin D) caused by impaired renal function, a main factor in the pathogenesis and pathophysiology of secondary hyperparathyroidism (SHPT) is associated with poor outcomes in hemodialysis patients. Therapy with vitamin D receptor (VDR) activators, including calcitriol or the selective VDR activator paricalcitol, has been associated with improved survival in patients with CKD on hemodialysis. PATIENTS AND METHODS: single center cross over observational study of 28 patients on regular Hemodialysis in nephrology unit in Dubai hospital, the patient stopped all vitamin-D supplementations and calcium containing phosphate binder for 2 weeks prior to initiation and for the whole study period, non calcium based phosphate binder was continued. Initial dose of selective VDRA (PARICALCITOL) is 0.04 to 0.1 mcg/kg body weight (average total dose 2.8 – 7 mcg) administered as a bolus dose post hemodialysis twice to three times per week according to initial parathyroid hormone level Titration weekly dose (micrograms) calculated by dividing most recent i-PTH level (pg/ml)/80. RESULTS : analyzing the data at start and end of trial period 48 weeks showed that there was significant reduction of serum I-PTH from (491.210±144.690 pg/dl ) at start of the trial to (142.610 ±41.519pg/dl) at 48 weeks with P- value (<0.001) . Serum calcium increased from ( 8.343± 0.654mg/dl ) at the start of the study to (8.629±0.534mg/dl ) at 48 weeks but without statistical significance P- value (0.006), same occurred with serum phosphatewhich showed insignificant rise with phosphate level at start of the test( 7.264±1.695mg/dl) and at 48 weeks (7.279±1.800mg/dl) with P-value( 0.975). CONCLUSION: It could be concluded that use of intravenous vitamin D selective receptor activator (Paricalcitol) is effective in reducing serum I-PTH level in hemodialysis patients. Serum Ca++ and phosphorus levels were statistically insignificant.

355 B-Lines on Lung Ultrasound in End Stage Renal Disease Patients Post Hemodialysis: Accuracy and Precision-Interim Analysis

Studies have shown that B-lines on lung ultrasound are an objective method for the evaluation of extravascular fluid and volume overload. The availability, feasibility and sensitivity of ultrasound renders it an important tool for initial bedside evaluation in the emergency department. Training residents to take advantage of this exam can lead to a more precise and rapid assessment of a patient’s volume status. To evaluate the precision and reliability of measuring volume overload through quantitating B-lines on lung ultrasound by residents following a short training course. Secondary objective was to evaluate the correlation between the B-line scores obtained and the NYHA CHF scores in end stage renal disease (ESRD) patients post hemodialysis (HD). Internal medicine and emergency medicine residents were trained by ultrasound-fellowship trained emergency physicians to use ultrasound (Sonosite Edge) to identify B-lines on lung ultrasound in a 3-hour course. This course included a didactics and simulation training portion. All resident investigators had to pass an objective structured clinical examination (OSCE) and 10 question multiple choice exam for eligibility in enrolling patients in the study. Residents then performed lung ultrasound looking specifically for B-lines in patients post HD to assess for volume overload. Patients on HD have a high prevalence of moderate to severe pulmonary congestion, even after achieving dry weight. As validated in a study by Zoccali et al, a total of 28 lung windows were scanned: 16 in the right hemithorax (parasternal, mid-clavicular, anterior axillary and mid-axillary in the 2nd through 5th intercostal space (ICS)) and 12 in the left hemithorax in the 2nd through the 4th ICS at the same positions. For each scanned window, a 6-second video clip was recorded. A B-line score was calculated and categorized as minimal (0-5 B-lines present), mild (6-13), moderate (14-30) and severe (>30 B) for pulmonary congestion. This score was recorded in real time by the study investigators who were blinded to the patients’ clinical data. Each video clip was reviewed at a later time by two emergency physician, who were also blinded to the patients’ clinical data. The B-line scores obtained by the emergency physician were compared with the results obtained by the study investigators. A total of 41 ESRD patients on HD were scanned. Sixty-eight percent were males; mean age 60.83 ± 16.175, mean BMI 28.17 ± 5.347; mean test duration was 15 minutes. The mean number of B-lines found by the study investigators and EPs was 18.24 and 19.33, respectively. The mean and standard deviation for difference was 5.13 and 11.98, respectively. When categorized, there was no significant difference in classification between the study investigators and emergency physicians (significance 0.982). NYHA score correlated with B-lines (P = .003) even after adjusting for other variables. B-lines on bedside lung ultrasound can provide a reliable indicator for a patient’s volume status assessment in comparison to other validated measures, including the NYHA CHF score. Our study also shows that a short training course can render novice users of ultrasound capable of performing this quick evaluation, This can aid in objectively assessing volume overload in patients presenting to the ED, especially in HD patients who present a unique clinical challenge.

Effects of intradialytic exercise on systemic cytokine in patients with chronic kidney disease

Background: Immunological dysfunctions and a pro-inflammatory environment are associated with higher risk of cardiovascular diseases in chronic kidney disease (CKD). Physical exercise can be an important anti-inflammatory strategy, but the effects in CKD remain poorly investigated. Objective: Evaluate the acute inflammatory response to intradialytic exercise in the peripheral blood of individuals with CKD. Methods: Nine patients, of both genders, with CKD and allocated in the ambulatory of hemodialysis of Hospital Ernesto Dornelles (Brazil), performed two sessions of hemodialysis (HD) in random form: aerobic intradialytic exercise sessions (EX, 20 min of moderate exercise in cycle-ergometer) and a control hemodialysis session (CON). Peripheral blood collection was made at the baseline, during and immediately after HD to evaluate the cytokine profile: interleukin-6, interleukin-10 (IL-10), interleukin-17a (IL-17a), interferon-gamma (INF-γ) and tumoral necrosis factor-alpha (TNF-α). Results: INF-γ decreased during HD when compared with the pre moment in both sessions, while an increase in post HD was only found in the CON session. IL-17 was higher in post when compared with during HD in both sessions. In addition to the time effect, IL-10 presented a time × group interaction and the relative changes were significantly higher in EX when compared with the CON session. The relative changes in TNF-α tended to be higher in CON when compared with EX immediately post HD session. Conclusions: These data indicate that 20 min of intradialytic exercise have modest effect in systemic inflammation. However, the significant increase in IL-10 may indicate an immunoregulatory effect of physical exercise.

Changes in muscle and fat mass with haemodialysis detected by multi-frequency bioelectrical impedance analysis.

Multi-frequency bioelectrical impedance analysis (MFBIA) is becoming more widely used to assess hydration status and body composition in haemodialysis patients. Most centres only measure MFBIA pre dialysis when patients are overhydrated. We wished to determine whether body composition assessments change post dialysis following fluid removal. Lean body and fat mass were measured by MFBIA pre and post haemodialysis in 676 stable outpatients. Weight fell post dialysis from 72.9 ± 17.8 to 70.9 ± 19.9 kg, P<0.001, soft lean mass from 48.2 ± 12.1 to 45.4 ± 11.0 kg and fat-free mass from 51.8 ± 19.2 to 48.1 ± 11.8 kg, P<0.001, whereas percentage body fat (PBF) increased from 28.8 ± 11.9 to 30.8 ± 12.1% post dialysis, P<0.001, with a mean increase post dialysis of 2.0% (95% confidence limits 1.55 to 2.45). There were correlations between the fall in total body water and extracellular water and skeletal muscle mass (r=0.826, P<0.001 and r=0.711, P<0.001, respectively), and negative correlation between the fall in total body water and ICW and the increase in PBF (r=-0.72, P<0.001, and -0.72, P<0.001, respectively). The relative changes were greater for the arms compared with the legs. Although more convenient for both patients and staff to undertake bioimpedance measurements pre dialysis, overhydration over estimates muscle mass and under estimates fat. For more reliable and reproducible assessments of nutritional status, we suggest that bioimpedance measurements of body composition should be made when patients are closer to their target weight than when overhydrated.

Research Priorities in CKD: Report of a National Workshop Conducted in Australia

Research aims to improve health outcomes for patients. However, the setting of research priorities is usually performed by clinicians, academics, and funders, with little involvement of patients or caregivers and using processes that lack transparency. A national workshop was convened in Australia to generate and prioritize research questions in chronic kidney disease (CKD) among diverse stakeholder groups. Patients with CKD (n=23), nephrologists/surgeons (n=16), nurses (n=8), caregivers (n=7), and allied health professionals and researchers (n=4) generated and voted on intervention questions across 4 treatment categories: CKD stages 1 to 5 (non-dialysis dependent), peritoneal dialysis, hemodialysis, and kidney transplantation. The 5 highest ranking questions (in descending order) were as follows: How effective are lifestyle programs for preventing deteriorating kidney function in early CKD? What strategies will improve family consent for deceased donor kidney donation, taking different cultural groups into account? What interventions can improve long-term post-transplant outcomes? What are effective interventions for post hemodialysis fatigue? How can we improve and individualize drug therapy to control post-transplant side effects? Priority questions were focused on prevention, lifestyle, quality of life, and long-term impact. These prioritized research questions can inform funding agencies, patient/consumer organizations, policy makers, and researchers in developing a CKD research agenda that is relevant to key stakeholders.

Does the presence of an arteriovenous fistula alter changes in body water following hemodialysis as determined by multifrequency bioelectrical impedance assessment?

Multifrequency bioelectrical impedance assessments (MFBIAs) aid clinical assessment of hydration status for hemodialysis (HD) patients. Many MFBIA devices are restricted to whole body measurements and as many patients dialyze using arteriovenous fistulas (AVFs), we wished to determine whether AVFs affected body water measurements. We reviewed pre- and post-HD segmental MFBIA measurements in 229 patients attending for midweek HD sessions. Up to 144 were dialyzed with a left arm AVF (L-AVF), 42 with a right arm AVF (R-AVF), and 43 by central venous access catheter (CVC). Water content and lean tissue were greater in the left compared to right arm in those patients with L-AVFs both pre and post dialysis (pre 2.1 ± 0.7 vs. 2.0 ± 0.7 L, and post 1.9 ± 0.6 vs. 1.8 ± 0.6 L and pre 2.65 ± 0.9 vs. 2.56 ± 0.8 kg, and post 2.34 ± 0.8 vs. 2.48 ± 0.8 vs. 2.34 ± 0.8 kg, respectively) and were also greater in the right compared to left arm for those patients dialyzing with R-AVFs (pre-HD 1.92 ± 0.5 vs. 1.86 ± 0.6 L and post-HD 1.79 ± 0.5 vs. 1.7 ± 0.5 L, and pre-HD 2.47 ± 0.6 vs. 2.38 ± 0.7 kg and post-HD 2.3 ± 0.74 vs. 1.28 ± 0.7 kg, respectively), all Ps < 0.05. There were no significant differences in arm volumes or composition pre or post dialysis in those dialyzing with CVCs. Segmental MFBIA detects differences in arm water and lean mass in patients with AVFs. The presence on an AVF increases the water content in the ipsilateral arm both pre and post HD. This increased water content of the fistula arm will not be detected by whole body bioimpedance devices.

Estimation of Body Composition and Normal Fluid Status Using a Calf Bioimpedance Technique

The aims of this study in hemodialysis (HD) patients were: 1. To evaluate the relationship of calf bioimpedance with total body composition and fluid status as measured by gold standard methods. 2. To investigate the ability of calf normalized resistivity (CNR) to predict the normal fluid status (dry weight: DW) in a prospective study. In the body composition study (n = 41), fluid status (ECV_Br/FFM_MRI), muscle mass (MM_MRI), and total adipose tissue (TAT_MRI) were measured by dilution (D₂O and Br) and MRI methods three hours prior to HD treatment. Calf extracellular and intracellular resistance, resistivity, and CNR were measured with a multi-frequency bioimpedance device (Hydra 4200). In the fluid status study (n = 32 with 429 measurements), a nonlinear model based on the differences in CNR between patients and healthy subjects was established to predict DW_cBIS previously determined by a separate continuous calf bioimpedance spectroscopy (cBIS) method. CNR significantly correlated with a gold standard hydration marker (ECV_Br/FFM_MRI). Calf body composition models were highly correlated with MM_MRI (R² = 0.85) and TAT_MRI (R² = 0.85). DW_cBIS prediction was validated with a CNR model in the degree of differences of 0.94 ± 0.18, 0.39 ± 0.7 and -0.02 ± 0.8 kg from DW_cBIS when post HD fluid overload was 1.8 ± 1.2, 1.15 ± 0.8 and 0.54 ± 0.5 kg, respectively. These differences are not considered to be clinically significant. Conclusion: This practical method of calf bioimpedance is useful to predict body composition and normal fluid status in dialysis patients.

Haemodynamics during dialysis and cognitive performance.

Persons receiving haemodialysis (HD) are at increased risk of cognitive impairment (CI). Since blood pressure (BP) fluctuations during HD may affect cerebral perfusion - and subsequently cognitive function - we examined the relationship between dialytic BP fluctuation and cognitive outcomes. We included HD patients without diagnosed dementia who were 50 years or older. Using established methods, we classified participants' in CI categories (none to mild and moderate to severe) based on results of a neurocognitive battery. We collected demographic and laboratory data from dialysis unit records, as well as all BP measurements from 12 dialysis sessions. We tested the association between CI and BP fluctuation, adjusting for demographic and laboratory variables. Our study enrolled 39 patients; 25 had moderate to severe CI. The normal to mild CI group and the moderate to severe patients had similar degrees of BP fluctuation (average minimum systolic BP (SBP): 107.6 ± 18.7 vs 110.2 ± 18.6 mmHg, maximum drop in SBP: 32.6 ± 10.2 vs 35.4 ± 15.0 mmHg; proportion of sessions with SBP < 90 mmHg: 0.2 ± 0.3 vs 0.2 ± 0.3; average change in SBP, pre to post HD: 10.2 ± 12.4 vs 11.8 ± 16.4 mmHg, all P > 0.55). There was no association between BP variables and performance on individual cognitive tests. Multivariable analysis showed that older age and non-Caucasian race were associated with a reduction in cognitive scores. There was no cross-sectional association between dialytic BP changes and cognitive performance.

A computational design of a magnetic field applied to control magnetic adsorbent used in liquid/gas adsorption processes

Recently in our research studies, ferroferric oxide magnetic micro particles were used as seeds combined with chitosan and activated carbon respectively in a nutrition recovery process for post hemodialysis (HD) and in a mixed-gas adsorbate analysis. Initially, these magnetic adsorbents used in the experiments were all sealed inside a cylinder vessel by molecular sieve filters. However, this design led to a very slow liquid or gas flow rate during adsorption. To increase the flow rate, a novel design applying a nonlinear gradient magnetic field in the reverse direction of liquid or gas flow was proposed in this paper. The objective of the design was to retain the magnetic adsorbent inside the vessel maintaining a high flow rate. The magnetic field inside an infinite solenoid coil was derived using Ampere Circuit Law and the Langevin equation. An equation, showing the relationship between the ampere-turns of the magnetic field and their positions, was outlined in this paper. We finally proved that this equation is suitable for the practical design of a magnetic field with finite length. Thus, this mathematic model could help the development of adsorption device utilizing magnetic particles.

Effect of Extracorporeal Unfractionated Heparin on Hematological and Electrolyte Markers in Hemodialyzed Patients

End-Stage renal disease is the final stage of chronic kidney disease (CKD), which can be managed by hemodialysis (HD), peritoneal dialysis, or renal transplantation. This study was conducted to investigate the changes in hematological and electrolyte markers that occur pre and post hemodialysis using unfractionated heparin (UFH) to prevent extracorporeal circuit clotting. Fifty patients with end stage renal failure (22 males, 28 females), aged between 15-78 years, maintained on long-term hemodialysis at the hemodialysis center in Sulaimani city during the period between February 20 th 2013 and July 15 th 2013 were enrolled in the present study. All patients provided written informed consent. The results of the hematological and electrolyte parameters measured pre and post hemodialysis were not significantly changed. No significant reduction in Hb level has been reported after dialysis compared to the pre-dialysis level. There were non-significant change in PTT, PT, and platelets count values in post-dialysis, which were not affected by the extracorporeal UFH. Although serum calcium and sodium levels were not significantly affected, serum potassium was significantly decreased in post hemodialysis states compared with pre-dialysis levels. This study revealed that extracorporeal use of UFH did not affect the hematological and electrolyte parameters post-dialysis in chronic renal failure patients maintained on hemodialysis. Only serum potassium was significantly decreased in post hemodialysis states, but still predictable fluctuations may limit the benefits of the procedure.

Arteriovenous fistula (AVF) monitoring and surveillance

Abstract An arteriovenous fistula (AVF) is created by direct anastomosis between an artery and adjacent vein which leads to flow of blood from artery directly into the vein. A well functioning and patent AVF is essential for optimum delivery of hemodialysis and hence it is important to assess the AVF for any signs of loss of patency (stenosis/thrombosis) on a regular basis. Methods of AVF monitoring include physical examination and other features like difficulty in AVF cannulation due to poor blood flow, clot aspiration or prolonged bleeding from the AVF site post hemodialysis. Methods of AVF surveillance include access blood flow, venous pressure and Doppler ultrasound etc. Both physical examination and investigations have complimentary role in this field and it is necessary that adequate stress is given on monitoring on a continuous basis. Access blood flow and intra-access pressures have role in confirming any abnormal physical examination finding.

Clinical outcomes of end stage renal disease and adequacy of adult maintenance hemodialysis patients

Background &amp; AimEnd stage renal disease (ESRD) is an irreversible loss of kidney function caused by various risk factors and affected persons of lives mainly depending on the technology of renal replacement therapy (RRT) or renal transplantation (RT) to sustain the life. Aim of this study is to overview the clinical outcomes of ESRD and adequacy of maintenance hemodialysis among the patients.Materials &amp; MethodsCurrently, there are sixty two end stage renal disease patient's clinical data's were collected and included in the study. For all patients, pre and post hemodialysis samples were collected and processed through biochemical and hematology auto analyzer. The hemodialysis modalities 4008 H/S and high-flux &amp; low flux ultra filter dialyzers had utilized to three dialysis sessions per week, 4 hrs per session for each individuals. Blood flow rates differed from 150 to 350ml min-¹ depending on conditions and standard dialysate flow was 500ml/min-¹.ResultsOf total sixty two patients, 51.62% females and 48.38% males with mean age of 47.76 (18–72) years; gradually increased at the ages of 55 to 72 years then adult age. Concerning overall risk factors in ESRD, 61.30% of hypertension as a leading risk factor followed by 21% NIDDM, 11.30% other kidney diseases and 6.40% cardiac related diseases. Although, there are others clinical signs such as hypothyroidisms; extra-pulmonary infection, retinitis pigmentosa and infertility have been diagnosed. In addition, nearly 33.87%% of HCV, 6.45% HBV and 3.22% of co-infection have been prevalence in ESRD hemodialysis population. Relating to hepatitis C, B and co-infection during dialysis exposure were 29.41%, 2.94% and 2.94% in that order. In relation to overall adequacy of maintenance hemodialysis in this study nearly 75.80% (≥ 1.3 to 2.5 Kt/V) and 24.20% (1.05 to 1.3 Kt/V) were been analyzed through Kt/V formula for wastage clearance.The present study highlighted that the co morbidity of ESRD, current adequacy of adult maintenance hemodialysis, and suggesting to boost better by 90% (≥1.2Kt/V) of adequacy in all dialysis patients. In addition to that, exposure of hepatitis B and C virus during dialysis and advocating to implement current medical strategic to prevent ongoing clinical phenomenon within the patients.

Effects of Azilsartan in Ambulatory Patients on Maintenance Hemodialysis: Monitoring at Night and at Home

Background: Recently, a newly developed Angiotensin Receptor Blocker (ARB), azilsartan, has been shown to have a persistent depressor action throughout the day in hypertensive patients. However, there have been few reports discussing the efficacy of azilsartan in patients on Hemodialysis (HD). Methods: Blood Pressure (BP) measurements in the HD center, and at home and ambulatory monitoring during the night were carried out before and after the change from other ARBs to azilsartan. All patients who were persistently hypertensive despite the treatment with antihypertensive drugs including ARB were considered as candidates. All patients were on antihypertensive treatment (12 on calcium channel blockers (CCBs), 6 on alpha blockers, and 2 on beta blockers and 4 on centrally acting antihypertensive drugs). Initially, azilsartan was started at 20 mg once daily in the evening, and increased up to 40 mg once daily in the evening. Results: Pre-dialytic systolic BP (SBP), SBP in the morning at home and during night were all significantly reduced by 3 months’ administration of azilsartan: (167.3 ± 10.3 to 145.3 ± 9.6 (pre-dialytic); 167.1 ± 11.0 to 151.8 ± 10.4 (at home); 150.5 ± 13.1 to 134.0 ± 10.3 (during night); mmHg). Conclusion: The present study demonstrated that azilsartan reduced SBP of pre-and post HD session measured at a dialysis center, on the morning of HD days and at the night time after HD. In addition to reduction of SBPs, azilsartan stabilized BP during the night. Furthermore, azilsartan significantly attenuated reduction of SBP from the start to the end of HD session.

Evaluation of oxidative stress and antioxidant activity in pre and post hemodialysis in chronic renal failure patients from Western region of Nepal

Objective: To evaluate the oxidative stress and antioxidant activity in pre and post hemodialysis in chronic renal failure patients using a diacetate cellulose membrane. Background: Chronic Renal Failure is a gradual, progressive and irreversible loss of normal functioning of kidneys. This is associated with increased formation of reactive oxygen species and increased oxidative stress. No studies have been undertaken in this area in Nepal. Method: The study groups were devided into chronic renal failure patients undergoing hemodialysis (n=52) and healthy controls (n=52). Diacetate cellulose was used as dialyzer membrane for chronic renal failure patients. Blood samples were collected in EDTAbottles and plasma was used for the estimation of oxidative stress marker, total antioxidant activity, vitamin C, ?-tocopherol, urea and creatinine. Results: There was significant reduction in the levels of vitamin C,? -tocopherol and total antioxidant activity in post dialysis patients compared to predialysis and control groups (p&lt;0.001). Plasma urea and creatinine levels were high in predialysis patients compared to controls and was significantly reduced after dialysis. Significantly elevated malondialdehyde levels were found in chronic renal failure patients before and after dialysis when compared with controls. Conclusion: The results of our study indicate that there are reduced levels antioxidants in chronic renal patients in pre and post dialysis condition and also more loss of antioxidants after dialysis. All these condition leads to increased oxidative stress in these patients. DOI: http://dx.doi.org/10.3329/bjms.v13i1.14741 Bangladesh Journal of Medical Science Vol. 13 No. 01 January2014: 40-44

Prognostic Factors Including Clinical Manifestation and Paraclinic Finding in Sever Methanol Toxicity

Objective: Ingested methanol (a toxic alcohol) undergoes enzymatic oxidation to toxic formic acid, resulting in acidosis and formaldehyde which resulted in neurotoxicity specifically optic neuritis and blindness and death in severe poisoning. According to Iranian law, selling, buying and consumption of alcoholic beverages is a punishable crime and people who wish to drink alcohol use industrial or homemade ethanol. Due to depressant effects of methanol on the central nervous system, the objective of this study was to assess the pathologic findings on brain CT scan in methanol poisoned patients beside of their clinical information. Material and method: This prospective study was from Jan 2013 to May 2013. All 20 methanol poisoned patients examined and questionnaires were filled by physician. Brain CT scans without contrast medium were obtained. Results: All of cases were male; their mean age was 33.1 ± 9.2 years. The mortality rate was 15%. Hemodialysis was performed in 85% cases. Mean primary Methanol Level was 22.4 ± 10.5 mg/dL and after hemodialysis was 7.3 ± 6.1. Totally serum methanol levels pre and post hemodialysis were 22.4 and 7.3, respectively. Brain death was recorded in 2 patients. The most common findings at admission were loss of consciousness (n=11) and blurred vision (n=9). The early pathologic brain CT findings were bilateral hypo density lesion in putamen, low attenuation in sub cortical, white matter bilateral hemorrhagic necrosis in putamen and bilateral hypo density in globuspallidus, respectively. Conclusion: In conclusion, it seems CT finding are important as Methanol concentration before any other Para clinic findings and even clinical manifestations.

Estudio comparativo de biocompatibilidad entre la hemodiafiltración en línea y la hemodiafiltración con reinfusión endógena

Objetivo: Comparar la biocompatibilidad entre la hemodiafiltración en línea (HDF) y la hemodiafiltración con reinfusión endógena (HFR). Material y método: Estudio comparativo observacional en una población de 15 pacientes en hemodiálisis crónica elegidos al azar entre los pacientes de nuestra unidad. Se compararon cambios en el perfil hematológico, nivel de PCR y constantes vitales, pre y post hemodiálisis, tras someterse a ambas técnicas de hemodiafiltración. Se comparó las diferencias entre los parámetros estudiados pre y post hemodiálisis en cada técnica. Resultados: Los niveles de plaquetas descendieron más en la HDF (HDF -1,33 vs HFR -19,73 x103/mm3, p=0,005). El nivel de leucocitos disminuyó en la HDF y aumentó en la HFR (HDF -0,46 vs HFR +0,8 x103/mm3; p=0,006). Respecto a la fórmula leucocitaria hubo resultados dispares: segmentados HDF -1,7 vs HFR +5,4%, p

Endotoxaemia in Haemodialysis: A Novel Factor in Erythropoetin Resistance?

Background/ObjectivesTranslocated endotoxin derived from intestinal bacteria is a driver of systemic inflammation and oxidative stress. Severe endotoxaemia is an underappreciated, but characteristic finding in haemodialysis (HD) patients, and appears to be driven by acute repetitive dialysis induced circulatory stress. Resistance to erythropoietin (EPO) has been identified as a predictor of mortality risk, and associated with inflammation and malnutrition. This study aims to explore the potential link between previously unrecognised endotoxaemia and EPO Resistance Index (ERI) in HD patients.Methodology/Principal Findings50 established HD patients were studied at a routine dialysis session. Data collection included weight, BMI, ultrafiltration volume, weekly EPO dose, and blood sampling pre and post HD. ERI was calculated as ratio of total weekly EPO dose to body weight (U/kg) to haemoglobin level (g/dL). Mean haemoglobin (Hb) was 11.3±1.3 g/dL with a median EPO dose of 10,000 [IQR 7,500–20,000] u/wk and ERI of 13.7 [IQR 6.9–23.3] ((U/Kg)/(g/dL)). Mean pre-HD serum ET levels were significantly elevated at 0.69±0.30 EU/ml. Natural logarithm (Ln) of ERI correlated to predialysis ET levels (r = 0.324, p = 0.03) with a trend towards association with hsCRP (r = 0.280, p = 0.07). Ln ERI correlated with ultrafiltration volume, a driver of circulatory stress (r = 0.295, p = 0.046), previously identified to be associated with increased intradialytic endotoxin translocation. Both serum ET and ultrafiltration volume corrected for body weight were independently associated with Ln ERI in multivariable analysis.ConclusionsThis study suggests that endotoxaemia is a significant factor in setting levels of EPO requirement. It raises the possibility that elevated EPO doses may in part merely be identifying patients subjected to significant circulatory stress and suffering the myriad of negative biological consequences arising from sustained systemic exposure to endotoxin.

Taste Disorder As A Common Cause Of Enhanced Salt Intake In Dialysis Patients

Salt intake is a key, but hard-to achieve target of nutrition guidance in chronic hemodialysis (HD) patients. In this study, we examined the influence of hypogeusia on oral salt intake in 34 HD patients (mean age: 59 years old) with dialysis vintage over 15 years. Their salt intake was calculated by Kimura’s formula (Int J Artif Organs, 1988) with pre- and post HD serum sodium concentrations and body weight gain between dialysis sessions. Hypogeusia was evaluated by gustatory tests by filter-paper disc. Average estimated salt intake was 9.5+/−2.7 g/day (160% of recommended salt intake by Japanese CKD guideline). HD patients showed lower sensitivity for salt than normal populations. Scores for salty taste were lower in patients taking less than 10 g of salt (Group L) than those taking more than 10 g (Group H). There was no difference in BMI or protein intake between these two groups. More prevalent use of spices in cooking was confirmed by dietary survey in Group L than Group H. In conclusion, enhanced salt intake in HD patients is partly due to taste disorder (less sensitive to salty taste). It may be possible to decrease enhanced salt intake by appropriate use of spices.