Urea Reduction Ratio Research Articles

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

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

Using a generic definition of cachexia in patients with kidney disease receiving haemodialysis: a longitudinal (pilot) study.

Research indicates that cachexia is common among persons with chronic illnesses and is associated with increased morbidity and mortality. However, there continues to be an absence of a uniformed disease-specific definition for cachexia in chronic kidney disease (CKD) patient populations. The primary objective was to identify cachexia in patients receiving haemodialysis (HD) using a generic definition and then follow up on these patients for 12 months. This was a longitudinal study of adult chronic HD patients attending two hospital HD units in the UK. Multiple measures relevant to cachexia, including body mass index (BMI), muscle mass [mid-upper arm muscle circumference (MUAMC)], handgrip strength (HGS), fatigue [Functional Assessment of Chronic Illness Therapy (FACIT)], appetite [Functional Assessment of Anorexia/Cachexia Therapy (FAACT)] and biomarkers [C-reactive protein (CRP), serum albumin, haemoglobin and erythropoietin resistance index (ERI)] were recorded. Baseline analysis included group differences analysed using an independent t-test, dichotomized values using the χ2 test and prevalence were reported using the Statistical Package for the Social Sciences 24 (IBM, Armonk, NY, USA). Longitudinal analysis was conducted using repeated measures analysis. A total of 106 patients (30 females and 76 males) were recruited with a mean age of 67.6 years [standard deviation (SD) 13.18] and dialysis vintage of 4.92 years (SD 6.12). At baseline, 17 patients were identified as cachectic, having had reported weight loss (e.g. >5% for >6 months) or BMI <20 kg/m2 and three or more clinical characteristics of cachexia. Seventy patients were available for analysis at 12 months (11 cachectic versus 59 not cachectic). FAACT and urea reduction ratio statistically distinguished cachectic patients (P = 0.001). However, measures of weight, BMI, MUAMC, HGS, CRP, ERI and FACIT tended to worsen in cachectic patients. Globally, cachexia is a severe but frequently underrecognized problem. This is the first study to apply the defined characteristics of cachexia to a representative sample of patients receiving HD. Further, more extensive studies are required to establish a phenotype of cachexia in advanced CKD.

Hemodialysis With the Quanta SC+: Efficacy and Safety of a Self-care Hemodialysis Machine

Rationale & ObjectiveMost patients with kidney failure receive hemodialysis 3 times per week in a facility. More frequent and longer duration dialysis prescriptions improve a number of key outcome measures. These prescriptions are best suited to self-care and home regimens. The Quanta SC+ hemodialysis system is a novel device with demonstrated ease of use for patients and health care practitioners through human factors testing. The primary objective of this study is to report the efficacy and safety of the SC+ system using conventional hemodialysis prescriptions.Study DesignNonrandomized observational study.Setting & ParticipantsPrevalent hemodialysis patients in 4 sites in the United Kingdom were recruited to switch from their current device to the SC+ system with no other changes to their prescription.InterventionsSC+ hemodialysis system.OutcomesEfficacy data were collected in terms of dialysis adequacy, urea reduction ratios, and net fluid removal accuracy.Results60 patients were enrolled in the study, resulting in 1,333 evaluable treatments. The threshold single-pool Kt/V of 1.2 was exceeded in 96.6% of treatments in patients receiving 3-times-weekly regimens, whereas the threshold standard Kt/V of 2.1 was exceeded in 94% of treatments and 97.6% of treatments in patients without significant residual kidney function. Ultrafiltration accuracy was determined by measuring net fluid removal and validated to be within acceptable limits. The adverse event profile during treatment was typical of hemodialysis. There were no serious adverse events.LimitationsFew patients on high-frequency treatment regimens were enrolled.ConclusionsThe SC+ system delivers safe and effective hemodialysis across a range of patients and dialysis prescriptions. It is one of the smallest systems available and has validated usability for patients to perform self-care safely with minimal training. This device may encourage patients to feel empowered to take on home hemodialysis, unlocking beneficial clinical and patient-reported outcomes associated with these modalities.

Effect of Omega-3 supplements on quality of life among children on dialysis: A prospective cohort study.

Children with end stage renal disease (ESRD) are liable to various health disorders that possibly impair their quality of life (QoL). Low dietary intake of Omega-3 fatty acids also called marine n-3 fatty acid (n-3 FA) may be associated with health problems which are among the leading causes of impaired QoL.The objective of this study was to assess the effect of omega-3 Fatty acid (n-3 FA) supplements on quality of life among children on dialysis and to evaluate its use regarding adequacy of dialysis and inflammatory markers.A prospective cohort study was conducted on 31 hemodialysis children. Quality of life was measured for patients and an equal number of matched controls using the PedsQL Inventory where the higher the score the poorer is the quality of life. n-3FA supplementation had been given to the patients for 3 months to study its effects on QoL. Laboratory investigations like hemoglobin, lipid profile, inflammatory markers, and tests for adequacy of dialysis had been carried out.Patients had significantly higher QoL scores (42.22 ± 13.31) than controls (22.70 ± 1.31) (P < .001). Young ages showed higher score of physical functioning (18.23 ± 4.22) than older ones (13.92 ± 6.84) (P = .049). Females had significantly higher total QoL score (25.53 ± 6.61) than males (20.06 ± 7.09) (P = .010). The total QoL score was significantly lower post than pre administration of n-3FA (35.41 ± 10.36 vs 42.22 ± 13.31) (P < .001). Triglycerides and CRP were significantly lower post than pre n-3FA supplementation (160.64 ± 32.55 vs 169.35 ± 31.82) (P < .001) and (10.29 ± 4.39 vs 11.19 ± 4.83) (P = .006) respectively. Means of Kt/V and urea reduction ratio (URR) were significantly higher post (1.37 ± 0.09, 70.0 ± 5.99 respectively) than pre n-3FA (1.31 ± 0.07 and 65.25 ± 6.06 respectively) (P = .005, .001 respectively).Quality of life and adequacy of dialysis get improved after n-3FA supplementation among children on dialysis which encourages its testing for more patients to evaluate its long term effects and support its routine use.

Factors Affecting Employment in Maintenance Hemodialysis Patients in Egypt

Background: Most of hemodialysis patients are unemployed and the few who are working are at risk of losing their jobs. Therefore, factors affecting employment need to be studied. Objective: Our aim was to access factors affecting employment among working-age patients on hemodialysis all over Egypt as it was not assessed before. Patients and Methods: This study was conducted between October 2012 and April 2015 in multiple hemodialysis centers by direct interview of the patients and collecting the data from the medical record in a special data collection sheet. Results: The study was conducted on 16280 hemodialysis patients in 19 Egyptian governorates. 21.2% of the patients were employed, 81.6% of the employed patients were men, and their mean age was 47.25+11.31. Hypertension was the most common etiology of end-stage renal disease (ESRD) and was the commonest comorbidity in employed patients. Employment was affected by age, gender, ESRD etiology and most comorbid conditions apart from comorbid chronic liver disease and chronic obstructive pulmonary disease. Factors affecting employment was dialysis frequency, duration, complications, dialyzer type, material, and surface area, dialysate type, dialysate Na, K and vascular access, haemoglobin (Hb) level, Ca/PO4 ratio, parathormone (PTH), iron injection, blood transfusion, erythropoietin intake, vitamin B complex intake, L carnitine intake, phosphate binders, cinacalcet and folic acid intake while Kt/v and urea reduction ratio and vitamin D supplements did not affect employment. Conclusion: Similar to the other studies we found that employment was not common among hemodialysis patients, which was affected by age, gender, ESRD etiology and comorbidities apart from chronic obstructive pulmonary disease (COPD) and chronic liver disease (CLD) which differed from other studies.

Factors Affecting Employment in Maintenance Hemodialysis Patients in Egypt

Background: Most of hemodialysis patients are unemployed and the few who are working are at risk of losing their jobs. Therefore, factors affecting employment need to be studied. Objective: Our aim was to access factors affecting employment among working-age patients on hemodialysis all over Egypt as it was not assessed before. Patients and Methods: This study was conducted between October 2012 and April 2015 in multiple hemodialysis centers by direct interview of the patients and collecting the data from the medical record in a special data collection sheet. Results: The study was conducted on 16280 hemodialysis patients in 19 Egyptian governorates. 21.2% of the patients were employed, 81.6% of the employed patients were men, and their mean age was 47.25+11.31. Hypertension was the most common etiology of end-stage renal disease (ESRD) and was the commonest comorbidity in employed patients. Employment was affected by age, gender, ESRD etiology and most comorbid conditions apart from comorbid chronic liver disease and chronic obstructive pulmonary disease. Factors affecting employment was dialysis frequency, duration, complications, dialyzer type, material, and surface area, dialysate type, dialysate Na, K and vascular access, haemoglobin (Hb) level, Ca/PO4 ratio, parathormone (PTH), iron injection, blood transfusion, erythropoietin intake, vitamin B complex intake, L carnitine intake, phosphate binders, cinacalcet and folic acid intake while Kt/v and urea reduction ratio and vitamin D supplements did not affect employment. Conclusion: Similar to the other studies we found that employment was not common among hemodialysis patients, which was affected by age, gender, ESRD etiology and comorbidities apart from chronic obstructive pulmonary disease (COPD) and chronic liver disease (CLD) which differed from other studies.

Effect of High Flux Hemodialysis versus Hemodiafiltration on Metabolic Status in Hemodialysis Patients

Background: Hemodiafiltration (HDF) is a newly developed renal replacement therapy blood purification technology with more advantageous effects on hemodynamic stability and better removal of B2 microglobulin and phosphorous Objective: The aim of this study is to compare effect of high flux (HF), low flux (LF) dialysis membranes and hemodiafiltration (HDF) on the metabolic status in hemodialysis patients and quality of life of those patients. Patients and Methods: This study included 60 patients more than18 years old, clinically stable with end stage renal disease on regular HD for at least three years (3 yrs), selected from HD unit in (Kobry El Kobba Military Nephrology Hospital) in the period from March 2018 to September 2018. The patients were divided into three groups equally. Group I: 20 patients on low flux dialyzer, Group II: 20 patients on high flux dialyzer, Group III: 20 patients on hemodiafiltration. Results: There was a highly significant decrease in iPTH, B2 microglobulin and Phosphorous in patients received HDF (363.80±149.04, 8.79±7.22 and 4.31±0.74 respectively in comparison with patients received HF hemodialysis (540.10±242.55, 20.47±3.97and 4.58±1.07 respectively) and patients received LF hemodialysis (725.95±270.01, 36.60±7.22 and 5.73±1.34 respectively).Also, there were a highly significant increase in urea reduction ratio in HDF group compared to HF and LF groups (80.43±7.46, 76.03±9.55 and 65.81±7.42 respectively. Conclusion: Hemodiafiltration is the most effective dialysis technique than high flux and low flux dialysis membrane in removal of medium sized molecule and improvement of quality of life.

Patient characteristics according to rehabilitation and employment status in Korean hemodialysis patients.

BackgroundWhile the final goal of renal replacement therapy is to achieve normal social adaptation and employment, many studies to date have focused on the analysis of complications and causes of death. In contrast, the analysis of dialysis patients with normal job employment and exhibiting a good medical status can be important for clinical treatment policy. This study assessed various clinical parameters according to rehabilitation and employment status to elucidate characteristics correlated with better rehabilitation status among hemodialysis patients.MethodsA total of 29,865 hemodialysis patients who were registered with rehabilitation status information in the Korean Society of Nephrology end-stage renal disease registration program from January 2017 to April 2019 were included and divided into five groups according to their rehabilitation status.ResultsAbout half (47%) of enrolled patients belonged to the “independent but without a job” group and 21% of patients belonged to the “employed with a full-time job” group. Analysis revealed significantly younger mean age, longer mean hemodialysis duration, a higher proportion of male sex, and a lower proportion of diabetic nephropathy cases in the full-time job group than in the other hemodialysis patient groups. Also, hemoglobin, albumin, and phosphorus levels were higher but the urea reduction ratio was lower in the full-time job group.ConclusionA better rehabilitation and employment state of hemodialysis patients was associated with younger age, male sex, and underlying chronic glomerulonephritis. Patients with full-time jobs generally have better laboratory data but lower dialysis efficacy.

Intermittent hemodiafiltration as a down-step transition therapy in patients with acute kidney injury admitted to intensive care unit who initially underwent continuous venovenous hemodiafiltration.

Continuous renal replacement therapies (CRRT) are initially employed in patients with acute kidney injury (AKI) in ICU setting. After the period of serious illness, hemodialysis is usually used as a mode of transition from CRRT. Intermittent hemodiafiltration (HDF) is not commonly applied in this scenario. To evaluate the feasibility of using HDF as transition therapy after CVVHDF in critically patients with AKI. An observational and prospective pilot study was conducted in ICU patients with dialysis-requiring AKI. Patients were initially treated with CVVHDF and, after medical improvement, those who still needed renal replacement therapy were switched to HDF treatment. Ten Patients underwent 53 HDF sessions (mean of 5.3 sessions/patient). The main cause of renal dysfunction was sepsis (N = 7; 70%). The APACHE II mean score was 27.6 ± 6.9. During HDF treatment, the urea reduction ratio was 64.5 ± 7.5%, for β-2 microglobulin serum levels the percentage of decrease was 42.0 ± 7.8%, and for Cystatin C was 36.2 ± 6.9%. Five episodes of arterial hypotension occurred (9.4% of sessions). There were 20 episodes of electrolytic disturbance (37.7% of sessions), mainly hypophosphatemia. No pyrogenic or suggestive episode of bacteremia was observed. Hemodiafiltration was safe and efficient to treat critically ill patients with acute kidney injury during the transition phase from continuous to intermittent dialysis modality. Special attention should be paid regarding the occurrence of electrolytic disturbance, mainly hypophosphatemia.

Prolonged Bleeding Following Removal of Arterio-Venous Fistula Needles after Hemodialysis Therapy

Background: Bleeding at fistula sites in patients with end stage renal disease (ESRD) is a common and potentially serious complication that contributes to blood loss (anemia). This study aimed to determine the factors that influence prolonged bleeding at fistula puncture sites following removal of fistula needles.Methods: This was a descriptive cross-sectional study. We consecutively enrolled patients who underwent maintenance hemodialysis between May and October 2017 at Muhimbili National Hospital and Access Dialysis Centre in Dar es Salaam, Tanzania. A case report form (CRF) was used for data collection.Prolonged bleeding was assessed by measuring activated partial thromboplastin time (aPTT) and compression time (CT). Descriptive statistics and regression analysis were used to assess the association between factors and tease out the independent factors associated with prolonged bleeding at fistula puncture site. A two-tailed p-value &lt;0.05 was used as a cut-off for statistical significance.Results: One hundred and fifteen patients were recruited for the study whereby 81(70.4%) of participants had elevated aPTT (&gt; 31 seconds) and 4 (3.5%) had prolonged compression time (&gt; 15 minutes). The mean aPTT and compression time of the participants were 42 ± 17.6 seconds and 5 ± 2.9 minutes respectively. Over half of participants 67(58.2%) had normal compression time (≤ 15 minutes). Elevated serum urea levels (&gt; 7.4mmol/L) was the only factor significantly associated with elevated aPTT (OR=4.143 95% C.I (1.021-16.810), p=0.047).Conclusion: The findings have demonstrated that elevated serum urea levels are significantly associated with prolonged bleeding time following removal of Arterio-Venous fistula needles after completion of a hemodialysis therapy session. This study suggests that, in hemodialysis procedure where a fixed dose of heparin is generalized to all patients there is a chance of exceeding the individual’s requirements.Recommendations: Serum urea levels should be factored in when gauging the individual risk of arterio-venous fistula site bleeding for patients using heparin for anticoagulation during hemodialysis. Further studies with large sample sizes are recommended to elucidate how other predisposing factors may affect A-V fistula bleeding.&#x0D; Keywords: Hemodialysis, heparin, prolonged bleeding, urea reduction ratio, A-V Fistula, aPTT, Compression time, blood urea.

1-8DIAGNOSTIC VALUE OF HEMOGLOBIN LEVELS, UREA REDUCTION RATIO AND Kt/V IN DETECTING INTRADIALYTIC HYPERTENSION IN CHRONIC KIDNEY DISEASE PATIENTS UNDERGOING HEMODIALYSIS AT SANGLAH HOSPITAL DENPASAR

Background: Intradialytic hypertension is the most common complication in hemodialysis patients, with a prevalence of 38%. It is also one of the causes of death in hemodialysis patients. Aim: To determine the diagnostic value of haemoglobin (Hb) levels, Urea Reduction Ratio (URR) and Kt/V in detecting intradialytic hypertension in chronic kidney disease (CKD) patients undergoing hemodialysis Method: A cross-sectional study was conducted on 222 CKD patients undergoing hemodialysis at Sanglah Hospital, Denpasar, from 1 January 2018 to 30 June 2019. Intradialytic hypertension is defined as an increase in mean arterial blood pressure (MAP) ≥15 mmHg from baseline at the end of the hemodialysis session. Results: The AUC values of Hb levels, URR, and Kt/V were 75.5% (95% CI 60.5% - 90.4%, p 0.05), 92.4% (95% CI 87% – 97,9%, p 0.004), and 90.4% (95% CI 84.5% – 96.4%, p 0.006) respectively, with cut-off values of 6.66 g/dL (sensitivity 97.1%, specificity 80%), 83.17% (sensitivity 80%, specificity 85.7%), and 2.16 (sensitivity 80%, specificity 86.4%). Conclusion: Haemoglobin levels, URR and Kt/V, have good sensitivity and specificity in predicting intradialytic hypertension in CKD patients undergoing hemodialysis.

Comparison of Clinical Performance of VectorFlow and Palindrome Symmetric-Tip Dialysis Catheters: A Multicenter, Randomized Trial

PurposeTo compare clinical performance of 2 widely used symmetric-tip hemodialysis catheters. Materials and MethodsPatients with end-stage renal disease initiating or resuming hemodialysis were randomized to receive an Arrow–Clark VectorFlow (n = 50) or Palindrome catheter (n = 50). Primary outcome was 90-d primary unassisted catheter patency. Secondary outcomes were Kt/V ([dialyzer urea clearance × total treatment time]/total volume of urea distribution), urea reduction ratio (URR), and effective blood flow (QB). ResultsPrimary unassisted patency rates with the VectorFlow catheter at 30, 60, and 90 d were 95.5% ± 3.3, 87.2% ± 7.3, and 80.6% ± 9.8, respectively, compared with 89.1% ± 6.2, 79.4% ± 10.0, and 71.5% ± 12.6 with the Palindrome catheter (P = .20). Patients with VectorFlow catheters had a mean Kt/V of 1.5 at 30-, 60-, and 90-day time points, significantly higher than the mean Kt/V of 1.3 among those with Palindrome catheters (P = .0003). URRs were not significantly different between catheters. Catheter QB rates exceeded National Kidney Foundation–recommended thresholds of 300 mL/min at all time points for both catheters and were similar for both catheters (median, 373 mL/min). Catheter failure, ie, poor flow rate requiring guide-wire exchange or removal, within the 90-day primary outcome occurred in 3 VectorFlow subjects and 5 Palindrome subjects (P = .72). Infection rates were similar, with 0.98 infections per 1,000 catheter days for VectorFlow catheters compared with 2.62 per 1,000 catheter days for Palindrome catheters (P = .44). ConclusionsThe 90-day primary patency rates of Palindrome and VectorFlow catheters were not significantly different, and both achieved sustained high QB through 90 day follow-up. However, dialysis adequacy based on Kt/V was consistently better with the VectorFlow catheter versus the Palindrome.

P0927THE IMPACT OF NUTRITIONAL EDUCATION ON PHOSPHORUS CONTROL IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Hyperphosphatemia is frequently encountered in hemodialysis patients and is an important risk factor of cardiovascular diseases. It is usually difficult to be managed by phosphate binders and hemodialysis. This study was carried out to assess the effect of nutritional education (NE) on the control of serum phosphorus level in hemodialysis patients. Method An open label, single center randomized controlled trial was conducted in the nephrology department, New Mansoura General Hospital, Egypt. One hundred hemodialysis patients were randomized into two groups; intervention Group (IG) (n=50) subjected to NE program for 3 months and Control group (CG) (n=50) received the usual care. Nutritional education was applied for the intervention group, by a trained renal dietitian, in the form of educational sessions, booklets, procures, audio visual teaching aids and patient-tailored counselling. Nutritional evaluation was done for all patients using dietary history, 24 hour diet recall sheet and malnutrition inflammation score (MIS) in addition to assessment of anthropometrics measurements and routine laboratory tests before randomization and at the end of the study. Results Three months after randomization, body mass index, waist circumference and midarm muscle circumference (MAMC) were significantly lower among IG versus the CG (p=0.04, 0.04 and 0.004 respectively). MIS score was significantly lower among the IG compared to the CG (p=0.02). Regarding laboratory tests, serum phosphorus level and calcium X phosphorus product were significantly lower among IG compared to the CG at the end of the study (p&amp;lt;0.001 and =0.04 respectively) with a percent change of serum phosphorus of -13.8 ± 21.41 after NE. The percentage of patients with hyperphosphatemia (&amp;gt; 5.5 mg/dl) were significantly lower in the IG at the end of study (p=0.04). Other laboratory tests including serum albumin, hemoglobin level, iron status and urea reduction ratio did not show any significant difference between both groups. Conclusion NE applied to dialysis patients added to the control of hyperphosphaemia without exposing the patients to the risk of malnutrition, resulting from injudicious dietary restrictions.

P0637SAFETY, EFFICACY AND OUTCOMES OF SLOW LOW EFFICIENCY DIALYSIS (SLED) IN CRITICALLY ILL PATIENTS WITH ACUTE KIDNEY INJURY (AKI) IN MEDICAL INTENSIVE CARE UNITS (ICU)- A PROSPECTIVE STUDY IN A TERTIARY CARE HOSPITAL IN INDIA

Abstract Background and Aims Slow low efficiency dialysis (SLED) is increasingly being used as a renal replacement therapy in hemodynamically unstable, critically ill patients with acute kidney injury (AKI). SLED may reduce intradialytic hemodynamic instability as compared with conventional intermittent haemodialysis, while reducing resource demands of continuous renal replacement therapies (CRRT). There are very few studies which have evaluated its safety, efficacy and outcome despite its increasing use, especially in Indian subcontinent. Method We conducted a single centre, prospective study to demonstrate safety, efficacy and outcome of SLED.. Net fluid removal and duration of SLED were based on need and hemodynamic status of the individual patient as decided by treating nephrologist. SOFA score was used as severity illness score. Efficacy of SLED was studied in terms of ability to achieve ultrafiltration goal, correction of acidosis and urea reduction ratio. Safety was studied in terms of hemodynamic and cardiovascular stability and complications during and after SLED. Outcomes were noted at time of discharge and six months later in terms of dialysis dependence, renal parameters (if dialysis independent) and mortality (In hospital and 6 months following discharge). We included hemodynamically unstable patients with AKI from medical ICUs with age &amp;gt;18 years of either gender. We excluded patients with AKI who could tolerate conventional haemodialysis or ESRD on maintenance haemodialysis. Results We analysed 228 patients with AKI in medical ICUs who underwent 576 SLED sessions over period of six months. Mean age was 57.48 ± 15.67 years and 74% (n=169) were male. Comorbidities were hypertension (56%), diabetes mellitus (43%), CKD (33%) and cardiovascular diseases (28%). Sepsis (93%) and hypoperfusion (68%) were most common causes for AKI. Refractory fluid overload (91%) and refractory metabolic acidosis (79%) were most common indications for SLED. Mean SOFA score was 12.2 ± 7.75 with 61 % patients had SOFA score more than 11. 66% were on mechanical ventilator. Out of 576 sessions, 555 sessions (96%) completed the planned duration without any adverse event. Planned ultrafiltration goal was achieved in 94%. SLED was able to correct metabolic acidosis in majority (86.1%). 68% SLED sessions required a vasopressor support and 34.8 % of SLED sessions were associated with hemodynamic instability. Total 14(6.2 %) patients died during SLED session. No documented arrhythmias developed after starting SLED. In-hospital mortality occurred in 61% patients. At 6 months follow up, another 13% patients died. In subgroup analysis, mortality was significantly higher in patients with SOFA score more than 11 (P&amp;lt;0.0001). Ventilatory requirement was also significantly high in non-survivors(P&amp;lt;0.0001). Univariate logistic regression analysis showed that inotropic requirement, higher SOFA severity score, acidosis with pH &amp;lt;7.25 and presence of underlying CKD were associated with significant mortality. Conclusion Our study demonstrated efficacy and safety of SLED in critically ill AKI patients in medical ICU. SLED was able to achieve planned ultrafiltration goal and correct metabolic acidosis in majority of patients. SLED had good hemodynamic tolerability. Mortality was noted in 61 % of patients (not attributable to SLED per se). High SOFA score, underlying co morbidities, vasopressor requirement and severe acidosis (pH &amp;lt;7.25) were associated with high mortality. SLED is a reasonable cost-effective option of RRT in hemodynamically unstable patients with AKI especially in developing countries.

P1299SODIUM ZIRCONIUM CYCLOSILICATE FOR THE TREATMENT OF PERSISTENT HYPERKALAEMIA IN PREVALENT HAEMODIALYSIS PATIENTS: EXPERIENCE FROM CLINICAL PRACTICE

Abstract Background and Aims Sodium zirconium cyclosilicate (SZC) (Lokelma®) is a new oral potassium binder. In September 2019 the UK National Institute for Health and Care Excellence (NICE) did not recommend SZC for dialysis patients due to a lack of evidence. The recent DIALIZE phase 3b randomised controlled trial concluded that SZC is an effective and well-tolerated treatment for hyperkalemia in haemodialysis (HD) patients. We offer an insight into SZC treatment in HD patients with persistent hyperkalaemia in clinical practice. Method Adult prevalent HD patients prescribed SZC for persistent hyperkalaemia were included for analysis. The highest pre-dialysis serum potassium (sK+) values were recorded each month before (M-6 to M-1) and after (M1 to M5) SZC initiation. The primary efficacy measure was a reduction in sK+ with SZC treatment. Results Sixteen patients (mean age 53.5 years, 56.3% male) were included for analysis. 43.8% (n=7) were diabetic. At the time of SZC initiation 43.8% (n=7) received HD via arteriovenous fistula, 12.4% (n=2) via arteriovenous graft and 43.8% (n=7) via tunnelled central venous catheter. The mean Urea Reduction Ratio [SD] was 68.5% [10.8] and the mean [SD] pre-HD bicarbonate was 22.8mmol/L [2.7]. The dialysate potassium prescription was 2mmol/L for 93.8% of patients (n=15) and 1mmol/L for 6.2% of patients (n=1). The mean [SD] achievement of prescribed dialysis hours over the previous 4 weeks was 93.5% [12.2]. 68.8% (n=11) had previous treatment with calcium polystyrene sulfonate and 12.5% (n=2) with patiromer. 18.8% (n=3) were currently prescribed a renin-angiotensin-aldosterone system inhibitor. 93.8% (n=15) had received dietetic advice. SZC starting doses ranged from 5g four times a week on non-dialysis days to 10g three times a day. Mean [SD] sK+ at month-1 (M-1) (immediate pre-treatment period) was 7.38mmol/L [0.31]. Mean [SD] sK+ at month 1 (M1) was 6.37mmol/L [1.21]. The statistical difference between these groups was p=0.0023 (paired two-tailed T-test). Figure 1 includes mean maximum monthly pre-dialysis sK+ from M-6 to M5. SZC was stopped in two patients (after M1 with sK+ 5.0mmol/L and after M4 with sK+ 4.3mmol/L) as it was no longer clinically indicated. Two patients became non-compliant (clinician-suspected or confirmed by patient) with SZC after M2 (sK+ 6.7mmol/L and sK+ 6.4mmol/L). Subsequent sK+ values would not reflect treatment with SZC in these patients. Figure 2 includes mean maximum monthly sK+ for the 12 patients on SZC from M-3 to M5. ANOVA and post-hoc Dunnett’s tests were undertaken to compare SZC treatment months (M1, 2, 3, 4 and 5) to the immediate pre-treatment period (M-1). ANOVA was close to significance (p=0.058), with post-hoc corrected for multiple comparisons finding the data to be significant for M1 vs. M-1 (p=0.045) and M5 vs. M-1 (p=0.018). The same tests across M1 through M5 revealed no significant difference (p=0.968 ANOVA and p=0.555 Dunnett’s), demonstrating that continued treatment with SZC to M5 did not result in a further decline in sK+. Conclusion Sodium zirconium cyclosilicate is effective in reducing pre-dialysis sK+ in patients with moderate and severe hyperkalaemia undergoing haemodialysis in clinical practice.

Usefulness of prolonged renal replacement therapy in patients with acute kidney injury requiring dialysis

Acute kidney injury (AKI) requiring dialysis is becoming more common. Several types of renal replacement therapies have been used, including continuous, intermittent, and prolonged intermittent renal replacement therapy (PIRRT). There is no clear difference between those therapies in terms of patient survival. The aim of this study was to describe a form of PIRRT (shift continuous veno-venous hemodialysis [CVVHD]) and the results of this technique in a population of patients with AKI requiring dialysis in a tertiary care center. We studied 302 patients with AKI requiring dialysis over a 3-year period. All patients were treated in the intensive care unit. There were 1709 treatments in the study. Shift CVVHD was done for 8 h daily using NxStage machines, with a bicarbonate base dialysate at a rate of 5 L/h. Demographics and laboratory data were obtained from the electronic medical record. Dialysis data were obtained from the dialysis run sheets. Patient mortality was 51.3%.The dialysis time was close to 8 h and the blood flow was 310 (± 43) mL/min. The mean arterial pressure was stable before and after the dialysis. The total ultrafiltration averaged 2934 mL per treatment; the ultrafiltration rate was 4.1 (± 3.1) mL/kg/h, and the ultrafiltration per hour was 359 (± 257.8) mL/h. The average dialysate potassium used was 2.9 mEq/L. The dose of dialysis was 57 (± 19) mL/kg/h. The urea reduction ratio was 48% (± 15%), the standardized KT/V (a measure of dialysis dose obtained by urea kinetic modeling) was 3.5 (± 0.9), and the equivalent renal urea clearance (EKR) was 9.8 (± 4.1) mL/min. The method produced a consistent reduction in the levels of blood urea nitrogen, creatinine, potassium, and phosphorous. The delivered dose of dialysis was stable during the observation period. In conclusion, shift CVVHD is effective in treating patients with AKI requiring dialysis and has a survival similar to that of continuous therapies with less intensive use of resources.

Use of the esa resistance index to guide dosing for anaemia management.

Identifying erythropoiesis-stimulating agent (ESA) resistance is important for treating reversible causes, reaching target haemoglobin levels with minimal dosing, avoiding adverse effects and reducing costs. The resistance index (RI, dose/kg weight/g haemoglobin/dl) is reportedly superior to absolute or weight-based dosing. With the growing number of ESA classes and medications, our goal was to develop methodology to establish RI ranges in otherwise healthy haemodialysis patients as a structured approach to identify remediable causes of anaemia. We retrospectively studied anaemia management with darbepoetin in 100 chronic haemodialysis patients and a subgroup of 48 without identifiable conditions that impair erythropoiesis. Data included inflammatory and bone marrow conditions, medications with hematologic effects, catheter use, iron, parathyroid and dialysis measures. The haematologically healthy group was aged 57.1 ± 1.9 SEM years, 33% diabetic, with haemoglobin 10.4 ± 0.2 g/dl. The darbepoetin RI (DRI) values were 0.05 ± 0.01, absolute dose 38.5 ± 3.5 mcg/week and weight-based 0.50 ± 0.05 mcg/kg. Regression analyses included iron saturation, ferritin, parathyroid hormone and urea reduction ratio. DRI was superior to other dosing approaches based on the distribution of results (kurtosis) and discordance between the measures that occurred in 17% of patients at haemoglobin target. We demonstrate the value of determining the RI for use with expanding ESA choices, using as an example how DRI values can be established for healthy haemodialysis patients so as to guide dosing. When elevated, the RI can trigger evaluation for remediable factors causing hyporesponsiveness even when haemoglobin goals have been reached.

Routine Kt/V and Normalized Protein Nitrogen Appearance Rate Determined From Conductivity Access Clearance With Infrequent Postdialysis Serum Urea Nitrogen Measurements

Conventional monitoring of hemodialysis dose is implemented using urea kinetic modeling based on single-pool Kt/V, which requires both pre- and postdialysis serum urea nitrogen (SUN) measurements. We compared this conventional approach to one in which Kt/V is calculated using conductivity clearance, thereby reducing the need for regular postdialysis SUN measurements. Comparative study of 2 diagnostic tests. Prevalent patients receiving maintenance hemodialysis for at least 2 years for whom both urea reduction ratio (URR) and average conductivity clearance (Kecn) were measured. During the initial 8 months (baseline interval), average Kecn and URR were used to calculate a median patient-specific, modeled, calibration solute distribution volume (Vcal). During months 9 to 16 (period 1) and 17 to 24 (period 2), Kt/V was conventionally computed using URR and also by a new method using Vcal and Kecn without postdialysis SUN values. We examined the percentage error between these 2 methods of calculating Kt/V. Concordance between the 2 methods of calculating Kt/V. Among 1,093 patients, mean individual-level median single-pool Kt/V values derived using the conventional method during the baseline interval, period 1, and period 2 were 1.62±0.24 (SD), 1.66±0.24, and 1.67±0.24, respectively. During periods 1 and 2, patient-level median Kt/V values derived using Kecn were 1.64±0.24 and 1.65±0.24, respectively. Percent differences between patient-level median values of Kt/V (conductivity minus conventional URR methods) were-0.63%±7.7% and-0.75%±8.4% for periods 1 and 2. Normalized protein nitrogen appearance were comparable between the 2 methods. Data were collected over 2 years. Study was limited to in-center hemodialysis patients dialyzed 3 times per week. Dialysis session length was not adjusted for treatment interruptions. A new method of calculating Kt/V based on Kecn that requires fewer postdialysis SUN measurements provided diagnostic data comparable to those from conventional use of URR and has the potential to avoid errors related to postdialysis blood sampling and measurement.

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

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

Accelerated Venovenous Hemofiltration as a Transitional Renal Replacement Therapy in the Intensive Care Unit

Background: Continuous renal replacement therapy (CRRT) is commonly employed in the intensive care unit (ICU), though there are no guidelines around the transition between CRRT and intermittent hemodialysis (iHD). Accelerated venovenous hemofiltration (AVVH) is a modality utilizing higher hemofiltration rates (4–5 L/h) with shorter session durations (8–10 h) to “accelerate” the clearance and volume removal that normally is spread out over a 24-h period in CRRT. We examined AVVH as a transition therapy between CRRT and iHD, with the aim of decreasing time on CRRT and providing a more graduated transition for hemodynamically unstable patients requiring RRT. Methods: Retrospective cohort study describing the clinical outcomes and quality initiative experience of the integration of AVVH into the CRRT program at an academic tertiary care center. Outcomes of interest included mortality, ICU length of stay and readmission rates, and technical characteristics of treatments. Results: In total, 97 patients received a total of 298 AVVH treatments (3.1 ± 3.3 treatments per patient). Totally, 271/298 (91%) treatments were completed successfully. During an average treatment time of 9.5 ± 1.6 h with 4.2 ± 0.5 L/h ­replacement fluid rate, urea reduction ratio was 23 ± 26% per 10-h treatment, and net ultrafiltration volume was 2.4 ± 1.3 L/treatment. Inpatient mortality was 32%, mean total hospital length of stay was 54 ± 47 days. Sixty-four out of 97 (66%) patients recovered renal function by discharge. Among those who transferred out of the ICU, 7/62 (11%) patients required readmission to the ICU after developing hypotension on iHD. Conclusion: AVVH can serve as a transition therapy between CRRT and iHD in the ICU and has the potential to decrease total time on CRRT, improve patient mobility, and sustain low ICU readmission rates. Future study is needed to analyze the implications on resource use and cost of this modality.