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Impact of using two dialyzers in parallel on phosphate clearance in hemodialysis patients: a randomized trial.
Thompson, S, Manns, B, Lloyd, A, Hemmelgarn, B, MacRae, J, Klarenbach, S, Unsworth, L, Courtney, M, Tonelli, M
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2017;(5):855-861
Abstract
BACKGROUND Dietary restriction and phosphate binders are the main interventions used to manage hyperphosphatemia in people on hemodialysis, but have limited efficacy. Modifying conventional dialysis regimens to enhance phosphate clearance as an alternative approach remains relatively unstudied. METHODS This was a 10-week, 2-arm, randomized crossover study. Participants were prevalent dialysis patients ( n = 32) with consecutive serum phosphate levels >1.6 mmol/L and on stable doses of a phosphate binder. Following a 2-week run-in period, participants were randomized to initiate dialysis using two high flux dialyzers in parallel (blood flow ≥350 mL/min, dialysate flow 800 mL/min) or standard dialysis using one high flux dialyzer (blood flow ≥350 mL/min, dialysate flow of 800 mL/min). Each regimen was 3 weeks in duration. After a 2-week washout period, participants received the alternate regimen. The primary outcome was the mean difference in phosphate clearance by dialyzer strategy. Secondary outcomes were phosphate removal and pre-dialysis serum phosphate. RESULTS Phosphate clearance for the double dialyzer strategy did not differ significantly from the single dialyzer strategy [mean difference 7.5 mL/min (95% confidence interval, 95% CI, -6.1, 21.0), P = 0.28]. There was no difference in total phosphate removal and pre-dialysis phosphate between the double and single dialyzer strategies [total phosphate removal mean difference -0.2 mmol (95% CI -4.1, 3.7), P = 0.93; pre-dialysis mean difference 0.01 mmol/L (95% CI -0.18, 0.21), P = 0.88]. There was no difference in the proportion of participants who experienced at least one episode of intradialytic hypotension (32 versus 47%, P = 0.13). A limitation of the study was frequent protocol deviations in the dialysis prescription. CONCLUSIONS In this study, the use of two dialyzers in parallel did not increase phosphate clearance, phosphate removal or pre-dialysis serum phosphorus when compared with a standard dialysis treatment strategy. Future studies should continue to evaluate novel methods of phosphate removal using conventional hemodialysis.
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[Low flux dialysate daily home hemodialysis: A result for the 62 first French and Belgian patients].
Benabed, A, Henri, P, Lobbedez, T, Goffin, E, Baluta, S, Benziane, A, Rachi, A, van der Pijl, JW, Bechade, C, Ficheux, M
Nephrologie & therapeutique. 2017;(1):18-25
Abstract
Since 2011, a new device is available for low flux dialysate quotidian home hemodialysis in France and Belgium. This study aims to evaluate the characteristics and dialysis prescriptions for Nx Stage System One™ users. We retrospectively included patients trained between 2011 and 2013 in France and Belgium. We collected data concerning their clinical features, their dialysis prescriptions, their laboratory parameters until 6 months of dialysis and, reason for dropping in case of cessation. Sixty-two patients from 31 centers, aged 48±18 years old, with a sex ratio 46/16 (M/F) are included with a median Charlson comorbidity index of 1 [0-3]. Of these patients, 71% are anuric and have been on dialysis for a mean time of 136.6±125 months. Previously, most of them had been taken care of in satellite units of dialysis (45%) and 14% are incident patients. In total, A total of 60% have an arterio-veinous fistula (AVF), with 18 patients using the Buttonhole system and 2 patients have a tunneled catheter. Median time for training was 26.5 days (17-45). Among the patients, 69% are dialyzed 6 days a week, during a mean time of 142.5±20 minutes with a volume of 20.9±3 liters of dialysate and without anticoagulant (63%). Predialytic levels of hemoglobin, creatinin, urea, phosphorus and β2microglobulin remain stable. On the contrary, there is a significant improvement of albumin and bicarbonate levels. Technique survival was 75% at 1 year, and major reason for cessation was kidney transplant. It seems that this device fits for young patients, with few comorbidities and a long past in renal chronic failure. These results suggest that dialysis adequacy is acceptable despite low dialysate volumes but need confirmation with a longer follow up and a larger cohort.
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Effects of citrate dialysate in chronic dialysis: a multicentre randomized crossover study.
Schmitz, M, Loke, O, Fach, B, Kalb, K, Heering, PJ, Meinke, D, Rawer, P, Galle, J, Kozik-Jaromin, J
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2016;(8):1327-34
Abstract
BACKGROUND Although citrate dialysate (CiDi) is regarded to be safe, dialysis modalities using higher dialysate volumes, like haemodiafiltration (HDF), may expose patients to higher citrate load and thus increase the risk of complications. We investigated the residual risk of CiDi compared with standard dialysate (StDi) in patients on different dialysis modalities and its effect on dialysis dose. METHODS In a multicentre randomized crossover study, 92 dialysis patients (HDF post-dilution: n = 44, HDF pre-dilution: n = 26, haemodialysis: n = 25) were treated for 4 weeks with each dialysate (StDi and CiDi). Hypocalcaemia (ionized calcium ≤0.9 mmol/L), alkalosis (pH ≥7.55), post-treatment bicarbonate ≥32 mmol/L, pre-treatment bicarbonate ≥27 mmol/L, intra-dialytic events (IEs) and adverse events (AEs) between dialysis sessions were investigated as primary end points. The secondary objective was dialysis efficacy, i.e. dose and removal ratios of urea, creatinine, phosphate and β-2-microglobulin. RESULTS Post-dialysis overcorrection of bicarbonate (>32 mmol/L) was less frequent with CiDi (P = 0.008). Other predefined calcium and acid-base disturbances did not vary. There was no significant difference in IE. However, more patients developed AEs such as fatigue, muscle spasms or pain using CiDi (StDi: 41 versus CiDi: 55 patients, P = 0.02), particularly in the first 2 weeks of exposure. Dialysis efficacy was comparable with both dialysates. CONCLUSIONS It can be confirmed that CiDi is not associated with the development of severe calcium and acid-base disorders, even when dialysis modalities with higher citrate loads are used. However, a refinement of the CiDi composition to minimize AEs is necessary.
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Icodextrin reduces insulin resistance in non-diabetic patients undergoing automated peritoneal dialysis: results of a randomized controlled trial (STARCH).
de Moraes, TP, Andreoli, MC, Canziani, ME, da Silva, DR, Caramori, JC, Ponce, D, Cassi, HV, de Andrade Bastos, K, Rio, DR, Pinto, SW, et al
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2015;(11):1905-11
Abstract
BACKGROUND Insulin resistance is a common risk factor in chronic kidney disease patients contributing to the high cardiovascular burden, even in the absence of diabetes. Glucose-based peritoneal dialysis (PD) solutions are thought to intensify insulin resistance due to the continuous glucose absorption from the peritoneal cavity. The aim of our study was to analyse the effect of the substitution of glucose for icodextrin on insulin resistance in non-diabetic PD patients in a multicentric randomized clinical trial. METHODS This was a multicenter, open-label study with balanced randomization (1:1) and two parallel-groups. Inclusion criteria were non-diabetic adult patients on automated peritoneal dialysis (APD) for at least 3 months on therapy prior to randomization. Patients assigned to the intervention group were treated with 2L of icodextrin 7.5%, and the control group with glucose 2.5% during the long dwell and, at night in the cycler, with a prescription of standard glucose-based PD solution only in both groups. The primary end-point was the change in insulin resistance measured by homeostatic model assessment (HOMA) index at 90 days. RESULTS Sixty patients were included in the intervention (n = 33) or the control (n = 27) groups. There was no difference between groups at baseline. After adjustment for pre-intervention HOMA index levels, the group treated with icodextrin had the lower post-intervention levels at 90 days in both intention to treat [1.49 (95% CI: 1.23-1.74) versus 1.89 (95% CI: 1.62-2.17)], (F = 4.643, P = 0.03, partial η(2) = 0.078); and the treated analysis [1.47 (95% CI: 1.01-1.84) versus 2.18 (95% CI: 1.81-2.55)], (F = 7.488, P = 0.01, partial η(2) = 0.195). CONCLUSIONS The substitution of glucose for icodextrin for the long dwell improved insulin resistance measured by HOMA index in non-diabetic APD patients.
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[Clinical and laboratory evaluation of the efficiency of chronic hemodialysis treatment using acidosuccinate in patients with terminal renal failure].
Smirnov, AV, Nesterova, OB, Suglobova, ED, Golubev, RV, Vasil'ev, AN, Vasil'eva, IA, Verbitskaia, EV, Korosteleva, NIu, Kostereva, EM, Lebedeva, EB, et al
Terapevticheskii arkhiv. 2013;(1):69-75
Abstract
AIM: To evaluate the efficiency of using a succinate-containing dialysis solution (SCDS) in terminal renal failure patients treated with chronic hemodialysis (CHD). SUBJECTS AND METHODS Ninety patients from two hemodialysis units took part in the crossover study and were allocated to 2 groups. For 6 months, study group patients received CHD using SCDS and control group patients had CHD with a standard bicarbonate dialysis solution after 3-month washout period followed by decussation. The time course of changes in blood biochemical parameters, 24-hour ECG monitoring data, and quality of life indicators were estimated in the patients. RESULTS After using acidosuccinate during hemodialysis, there was a significant reduction in the predialysis serum level of inorganic phosphate, a calcium phosphate product, gamma-glutamyl transpeptidase, urea, and aldosterone as compared to the control group. The blood concentration of total protein was also increased. After 6-month administration of acidosuccinate, the patients showed reductions in systolic blood pressure, heart rate, and the frequency and duration of ST-segment depression episodes. There were positive changes in the quality of life of patients according to the KDQOL-SF questionnaire. CONCLUSION The use of SCDS in patients with CHD causes positive changes in a number of laboratory parameters and improves the physical and general status, and quality of life of patients.
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Post-dilution on line haemodiafiltration with citrate dialysate: first clinical experience in chronic dialysis patients.
Panichi, V, Fiaccadori, E, Rosati, A, Fanelli, R, Bernabini, G, Scatena, A, Pizzarelli, F
TheScientificWorldJournal. 2013;:703612
Abstract
BACKGROUND Citrate has anticoagulative properties and favorable effects on inflammation, but it has the potential hazards of inducing hypocalcemia. Bicarbonate dialysate (BHD) replacing citrate for acetate is now used in chronic haemodialysis but has never been tested in postdilution online haemodiafiltration (OL-HDF). METHODS Thirteen chronic stable dialysis patients were enrolled in a pilot, short-term study. Patients underwent one week (3 dialysis sessions) of BHD with 0.8 mmol/L citrate dialysate, followed by one week of postdilution high volume OL-HDF with standard bicarbonate dialysate, and one week of high volume OL-HDF with 0.8 mmol/L citrate dialysate. RESULTS In citrate OL-HDF pretreatment plasma levels of C-reactive protein and β 2-microglobulin were significantly reduced; intra-treatment plasma acetate levels increased in the former technique and decreased in the latter. During both citrate techniques (OL-HDF and HD) ionized calcium levels remained stable within the normal range. CONCLUSIONS Should our promising results be confirmed in a long-term study on a wider population, then OL-HDF with citrate dialysate may represent a further step in improving dialysis biocompatibility.
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The effect of different dialysate magnesium concentrations on QTc dispersion in hemodialysis patients.
Afshinnia, F, Doshi, H, Rao, PS
Renal failure. 2012;(4):408-12
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Abstract
BACKGROUND Electrolyte changes during dialysis affect corrected QT (QTc) and QTc dispersion (QTcd), a surrogate marker of arrhythmogenicity. The impact of magnesium on QTcd is not clear. METHODS Twenty-two stable patients on maintenance hemodialysis were enrolled in this study. Each underwent two consecutive hemodialysis sessions at least 2 days apart, the first against normal magnesium dialysate (with magnesium at 1.8 mg/dL) followed by a low magnesium dialysate (with magnesium at 0.6 mg/dL). Pre- and post-dialysis weights, blood pressure, electrolytes, and 12-lead surface EKG were recorded. The QT interval and the QTcd were calculated before and after dialysis in both sessions. RESULTS Of 22 patients, 16 were female. The mean age ± SD was 53.7 ± 18.0 years. The mean change of QTcd (pre- vs. post-dialysis) was 9.5 ms (p = 0.120) and 9.3 ms (p = 0.145) in low and normal magnesium groups, respectively. Using univariate analysis, there was a statistically significant decrease in the mean blood pressure, weight, potassium, magnesium, and QTc interval post-dialysis (compared to pre-dialysis) in both groups (p ≤ 0.049). Post-dialysis concentrations of sodium and calcium were unchanged (compared to pre-dialysis) but bicarbonate increased with both dialysate groups (p < 0.001). The mean change of QTcd was not significant pre- versus post-dialysis by univariate analysis in either group. Multiple linear regression analysis adjusting for pertinent factors did not change the results in either of the two groups. CONCLUSION Using a low magnesium dialysate bath in hemodynamically stable hemodialysis patients without preexisting advanced cardiac disease does not significantly impact QTcd.
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The beneficial influence on the effectiveness of automated peritoneal dialysis of varying the dwell time (short/long) and fill volume (small/large): a randomized controlled trial.
Fischbach, M, Issad, B, Dubois, V, Taamma, R
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis. 2011;(4):450-8
Abstract
BACKGROUND It is well known that the efficiency of peritoneal dialysis (PD) varies with the duration of the dwell and with the prescribed fill volume. Automated PD (APD) is classically given as a series of recurrent exchanges, each having the same dwell time and fill volume-that is, conventional APD (APD-C). We propose a new way of giving PD, using a modified version of APD-C. This method first uses a short dwell time with a small fill volume to promote ultrafiltration (UF) and subsequently uses a longer dwell time and a larger fill volume to promote removal of uremic toxins from the blood. We use the term "adapted APD" (APD-A) to describe this modified form of PD. METHODS We designed a multicenter prospective randomized crossover trial to assess the impact of APD-A in comparison with APD-C on the efficacy of dialysis. The parameters investigated were overnight UF; weekly peritoneal Kt/V(urea); weekly peritoneal creatinine clearance corrected to 1.73 m(2) body surface area (K(creat)); and phosphate (PDR) and sodium dialytic removal (SDR) in millimoles per session, corrected for glucose absorption, which provides an estimate of metabolic cost. Blood pressure was also regularly monitored. Initially, 25 patients were identified for inclusion in the study. There were 6 withdrawals in total: 2 at enrolment, 1 at day 75 (transplantation), 2 at day 30 (catheter dysfunction), and 1 for drainage alarms. All patients received the same duration of overnight APD, using the same total volume of dialysate, with the same 1.5% glucose, lactate-buffered dialysate (Balance: Fresenius Medical Care, Bad Homburg, Germany). RESULTS Tolerance was good. Compared with APD-C, APD-A resulted in a significant enhancement of Kt/V(urea), K(creat), and PDR. The metabolic cost, in terms of glucose absorption, required to achieve dialytic capacity for urea, creatinine, and phosphate blood purification was significantly lower for APD-A than for APD-C, and UF increased during APD-A. With APD-A, each gram of glucose absorbed contributed to 18.25 ± 15.82 mL UF; in APD-C, each gram of glucose absorbed contributed to 15.79 ± 11.24 mL UF. However, that difference was not found to be significant (p=0.1218). The SDR was significantly higher with APD-A than with APD-C: 35.23 ± 52.00 mmol and 18.35 ± 48.68 mmol per session respectively (p<0.01). The mean blood pressure recorded at the end of each PD period (on day 45) was significantly lower when patients received APD-A than when they received APD-C. CONCLUSIONS Our study provides evidence that, compared with the uniform dwell times and fill volumes used throughout an APD-C dialysis session, the varying dwell times and fill volumes as described for an APD-A dialysis session result in improved dialysis efficiency in terms of UF, Kt/V(urea), K(creat), PDR, and SDR. Those results were achieved without incurring any extra financial costs and with a reduction in the metabolic cost (assessed using glucose absorption).
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Low-GDP fluid (Gambrosol trio) attenuates decline of residual renal function in PD patients: a prospective randomized study.
Haag-Weber, M, Krämer, R, Haake, R, Islam, MS, Prischl, F, Haug, U, Nabut, JL, Deppisch, R, ,
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2010;(7):2288-96
Abstract
BACKGROUND Residual renal function (RRF) impacts outcome of peritoneal dialysis (PD) patients. Some PD fluids contain glucose degradation products (GDPs) which have been shown to affect cell systems and tissues. They may also act as precursors of advanced glycosylation endproducts (AGEs) both locally and systemically, potentially inflicting damage to the kidney as the major organ for AGE elimination. We conducted a clinical study in PD patients to see if the content of GDP in the PD fluid has any influence on the decline of the residual renal function. METHODS In a multicentre approach, 80 patients (GFF > or = 3 mL/min/1.732 or creatinine clearance > or =3 mL/min/1.73 m(2)) were randomized to treatment with a PD fluid containing low levels of GDP or standard PD fluid for 18 months. RRF was assessed every 4-6 weeks. Fluid balance, mesothelial cell mass marker CA125, peritoneal membrane characteristics, C-reactive protein (CRP), total protein, albumin, electrolytes and phosphate were measured repeatedly. RESULTS Data from 69 patients revealed a significant difference in monthly RRF change: -1.5% (95% CI = -3.07% to +0.03%) with low GDP (43 patients) vs -4.3% (95% CI = -6.8% to -2.06%) with standard fluids (26 patients) (P = 0.0437), independent of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker medication. Twenty-four-hour urine volume declined more slowly with low-GDP fluid compared to standard fluids (12 vs 38 mL/month, P = 0.0241), and monthly change of phosphate level was smaller (+0.013 vs +0.061 mg/dL, P = 0.0381). CONCLUSIONS Our prospective study demonstrates for the first time a significant benefit concerning preservation of RRF and urine volume of using a PD fluid with low GDP levels. These findings suggest that GDPs might affect patient outcome related to RRF.
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Increased efficiency of hemodialysis with citrate dialysate: a prospective controlled study.
Kossmann, RJ, Gonzales, A, Callan, R, Ahmad, S
Clinical journal of the American Society of Nephrology : CJASN. 2009;(9):1459-64
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Abstract
BACKGROUND AND OBJECTIVES A bicarbonate dialysate acidified with citrate (CD) has been reported to have local anticoagulant effect. This study examines the effect of CD on dialysis efficiency, measured as eKt/Vurea, and predialysis concentrations of BUN, creatinine, phosphate, and beta-2 microglobulin in chronic dialysis units. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS Three outpatient chronic hemodialysis units with 142 patients were switched to CD for 6 mo. Using each patient's prior 6 mo on regular bicarbonate dialysate acidified by acetate (AD) as control, eKt/Vurea was compared with that of CD. Follow-up data for 7 mo after the study were collected from about one-half of the participants remaining on CD and the others returned to AD. RESULTS eKt/Vurea, increased (P < 0.0001) from pre-CD value of 1.51 +/- 0.01 to 1.57 +/- 0.01 with CD. During CD use beta-2 microglobulin levels declined (P = 0.0001) from 28.1 +/- 10.0 to 25.9 +/- 10.0. Similarly, the concentrations of BUN, creatinine, and phosphate also decreased on CD (P < 0.008). In the poststudy period, eKt/Vurea for the patients staying on CD remained unchanged at 1.60 +/- 0.17 versus 1.59 +/- 0.18 (P = NS), whereas in those returning to AD the eKt/Vurea decreased from 1.55 +/- 0.20 to 1.52 +/- 0.17 (P < 0.0001). CONCLUSIONS Data suggest that CD use is associated with increased solute removal.