Hemodialysis Vascular Access Creation in Patients Switching From Peritoneal Dialysis to Hemodialysis: A Population-Based Retrospective Cohort (original) (raw)
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Revisiting the hemodialysis dose
Seminars in dialysis
An adequate dose of hemodialysis is currently defined by the Kidney Disease Outcomes Quality Initiative (K/DOQI) and European guidelines as a delivered single-pool urea Kt/V (spKt/V) of 1.2 and 1.4, respectively. Results from several studies, in particular the Hemodialysis (HEMO) study, have largely supported the legitimacy of these guidelines, although they may need to be altered or amended for certain patient subgroups. This review discusses several potential changes to current guidelines based on recent clinical outcome studies. The following questions are addressed: 1) Should the dialysis dose for low molecular weight water-soluble solutes (i.e., urea) be normalized by the body distribution volume for urea? 2) Should spKt/V or equilibrated Kt/V (eKt/V) be used for routine monitoring of the hemodialysis dose? 3) Should the dialysis dose for small solutes be dependent on gender? 4) Should the dialysis dose for middle molecules be used in clinical practice? 5) What should be the di...
Dialysis. Pathophysiology and Clinical Studies
Nephrology Dialysis Transplantation, 2014
Introduction and Aims: A high level of fibroblast growth factor 23 (FGF23) is a risk factor for mortality, and recent studies have linked FGF23 to parameters of volume homeostasis and an increased risk of heart failure. In hemodialysis (HD), a large ultrafiltration volume (UFV) is also associated with an increased mortality risk. We aimed to investigate whether circulating FGF23 levels and ultrafiltration volume are related in a cohort of stable HD patients. Methods: Post-hoc analysis on a prospective cohort study of 104 HD patients, median age 66 (interquartile range 51-75) years, dialysis vintage 25.0 (8.5-51.2) months, who underwent a standard four-hour HD session at the first session of the week. Blood samples were drawn at onset of HD. Plasma C-terminal FGF23 was determined by ELISA. Residual renal function (RRF) and Kt/V were extracted from patient records. We used uni-and multivariate linear regression to assess the association between UFV and FGF23. Natural log (Ln)-transformation was applied when appropriate. Results: At start of the HD session the median FGF23 level was 7535 [interquartile range 3276-13433] RU/mL. Mean UFV throughout the HD session was 2561 (standard deviation ±771) mL. In univariate analysis, natural log-transformed (Ln) FGF23 levels correlated with UFV (Figure 1), and also with serum phosphate (R=0.587, P<0.001), age (R=-0.384 P<0.001), and Ln Kt/V (R=-0.252 P=0.01), but not significantly with calcium (R=0.167 P=0.09). Multivariate linear regression analysis revealed a consistent strong association between Ln FGF23 AND UFV (St. β 0.385, P<0.001), in a model adjusted for serum phosphate (Standardized β 0.451, P<0.001) and serum calcium (St. β 0.222, P=0.002; model R2 52%). Age, gender, dialysis vintage, Kt/V, systolic and diastolic blood pressure did not contribute to this model. The association between FGF23 and UFV was independent of serum phosphate (Figures 1, 2). Patients with relevant residual renal function had a trend for lower FGF23 levels (Mann-Whitney P=0.04, Spearman's Rho-0.230 P=0.04), however RRF was no correlate of FGF23 in multivariate analysis (St. β-0.111, P=0.16).
The Clinical Impact of Increasing the Hemodialysis Dose
Hemodialysis International, 2001
The Clinical Impact of Increasing the Hemodialysis Dose G ood evidence suggests that improvements in dialysis efficiency reduce morbidity and mortality of hemodialysis (HD) patients. Dialysis efficiency has also been related to better control of arterial blood pressure (BP), anemia, and serum phosphorus levels, and to improvement in patients' nutritional status. Over a 2-year period, the present self-controlled study of 34 HD patients (23 men, 11 women; age, 52.6 ± 14.5 years; HD duration, 55.9 ± 61.2 months) looked at the effect on clinical and laboratory parameters of increasing the delivered dialysis dose under a strict dry-weight policy. Dialysis dose was increased without increasing dialysis time and frequency. A statistically significant increase was seen in delivered HD dose: the urea reduction ratio (URR) increased to 60% ± 10% from 52% ± 8%, and then to 71% ± 7% (p < 0.001); Kt/V urea increased to 1.22 ± 0.28 from 0.93 ± 0.19, and then to 1.55 ± 0.29 (p < 0.001). A statistically significant increase in hemoglobin concentration also occurred-to 10.8 ± 1.9 g/dL from 10.4 ± 1.7 g/dL, and then to 11.0 ± 1.3 g/dL (p < 0.05 as compared to baseline)-with no significant difference in weekly erythropoietin dose. Statistically significant decreases occurred in the systolic and diastolic blood pressures during the first year; they then remained unchanged. Systolic blood pressure decreased to 131 ± 23 mmHg from 147 ± 24 mmHg (p < 0.001); diastolic blood pressure decreased to 65 ± 11 mmHg from 73 ± 12 mmHg (p < 0.001). Serum albumin increased insignificantly to 4.4 ± 0.4 g/dL from 4.3 ± 0.4 g/dL, and then significantly to 4.6 ± 0.3 g/dL (p = 0.002 as compared to both previous values). Normalized protein catabolic rate increased significantly to 1.16 ± 0.15 g/kg/day from 0.93 ± 0.16 g/kg/ day (p < 0.001), and then to 1.20 ± 0.17 g/kg/day (p < 0.001 as compared to baseline). We conclude that the increases achieved in average Kt/V urea per hemodialysis session by increasing dialyzer membrane area, and blood and dialysate flows, without increasing dialysis time above 4 hours, in patients hemodialyzed thrice weekly, coupled with strict dry-weight policy, resulted in improvements in hypertension, nutritional status, and anemia.
Lessons from the hemodialysis (HEMO) Study: An improved measure of the actual hemodialysis dose
American Journal of Kidney Diseases, 1999
The Hemodialysis (HEMO) Study is a multicenter, prospective, randomized, 2 ؋ 2 factorial clinical trial designed to evaluate the efficacy of the dose of dialysis delivered (''standard'' v ''high'') and dialysis membrane flux (''low'' v ''high'') in reducing the morbidity and mortality of patients. The study is nearly half complete. Although both patients and investigators are blinded to the overall findings, which will not be available for another 3 years, important data have been generated from which a more accurate expression has been derived for the dose of dialysis received by each patient in the trial. This new expression of the effectiveness of dialysis, eKt/V, is a two-pool approximation derived from the traditional single-pool Kt/V (spKt/V) and time on dialysis. The dialysis prescription for the HEMO Study subjects is individualized to achieve the target dose for each patient and is closely monitored by measuring the more accurate and validated expression of eKt/V. Comparisons of the HEMO Study dose of dialysis with other studies have been confused by this unique expression (eKt/V) of the dialysis dose and adequacy adopted for the HEMO Study. The target eKt/V dose in the ''standard'' arm of the Study is 1.05 and in the ''high'' arm is 1.45 per dialysis thrice weekly. Based on data available from 426 subjects randomized to each arm, the target of 1.05 in the ''standard'' dose of the HEMO Study is equivalent to an spKt/V of 1.32, and that of the ''high'' dose, 1.67. Thus, volunteers in the ''standard'' arm of the Study are receiving a tightly controlled and closely monitored dose, which is above the current national mean spKt/V, and above that of the accepted minimum standard spKt/V of 1.2. When completed, the HEMO Study will show whether there are merits of a tightly controlled hemodialysis dose that is consistently delivered over a prolonged period and whether a high dose is beneficial and safe to prescribe.
Nephrology Dialysis Transplantation, 2005
Background. Cardiovascular disease (CVD) is a frequent complication in chronic haemodialysis (HD) patients. Endothelial dysfunction, as measured by soluble cellular adhesion molecules (sCAM) and von Willebrand factor (vWf ) in plasma, is an early manifestation of CVD. Today, it is unknown if, and to what extent, their levels are influenced by the type of dialyser. Methods. Four dialysers, low-flux cuprammonium (CU); high-flux and low-flux polysulfone and superflux polyethersulfone, were compared in 15 chronic HD patients in a randomized cross-over fashion. sCAM and vWf were measured at baseline as well as after 4 weeks, and both intra-dialytical and after 24 h (t24 h). Twenty healthy subjects served as controls.