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Hypersensitivity reactions to bicarbonate dialysate containing acetate: a case report with literature review.
Nishiuchi, Y, Shima, H, Fukata, Y, Tao, T, Okamoto, T, Takamatsu, N, Okada, K, Minakuchi, J
CEN case reports. 2020;(3):243-246
Abstract
Although hemodialysis-hypersensitivity reactions have various causes, only a few cases of hypersensitivity to acetate dialysate accompanied by fever have been reported. We present the case of a 69-year-old hemodialysis patient who was admitted due to fever after dialysis. He had undergone online hemodiafiltration using acetate-free citrate-containing dialysate. After admission, we switched to acetate-containing bicarbonate dialysate. He was diagnosed with pneumonia and treated with ceftriaxone. However, fever that occurred post dialysis persisted, displaying a gradual elevation in CRP level and eosinophils (up to 9.7 mg/dL and 3774 cells/μL, respectively). After a series of negative workups for infection and dialysis membrane allergy, we suspected that acetate-containing bicarbonate dialysate to be the cause of the allergic reaction and switched to acetate-free bicarbonate dialysate. Consequently, eosinophil count decreased and the fever abated. The drug-induced lymphocyte stimulation test finding (for acetate dialysate) was positive, and he was diagnosed with acetate dialysate-induced hypersensitivity reactions. The condition was not detected earlier due to the complications associated with pneumonia.
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Dialysate Calcium Levels: Do They Matter?
van der Sande, FM, Ter Meulen, KJA, Kotanko, P, Kooman, JP
Blood purification. 2019;(1-3):230-235
Abstract
BACKGROUND Calcium (Ca) is an essential element that plays a critical role in many biological processes. In dialysis patients, the regulation of Ca balance is highly complex, given the absence of kidney function, endocrine disturbances and the use of drugs such as phosphate binders, vitamin D analogues, and calcimimetics. Also, the use of different dialysate Ca (DCa) baths has profound effect on Ca balance, which depends both on the difference between the Ca concentration in the bath and the serum of the patients, as on the ultrafiltration volume. SUMMARY The choice of DCa may have important short- and long-term consequences. While lower DCa (especially < 2.5 mEq/L) concentrations have been associated with an increased risk of sudden cardiac death in observational studies, DCa in the higher ranges (3.0 mEq/L and above) may contribute to vascular pathology. Intra-dialytic hemodynamics may also be affected by the choice of DCa. In general, lower DCa concentrations are associated with an increase, and higher DCa concentrations with a decrease in parathyroid hormone (PTH) levels. Preliminary data has suggested that a DCa of 2.75 mEq/L may help in obtaining a net zero intradialytic Ca balance in individual patients, but clinical experience is still limited. Key Message: The optimal Ca balance depends on multiple parameters including blood Ca levels, PTH and the use of phosphate binders and vitamin D analogues, as well as on the risk of hemodynamic stability and cardiac arrhythmias. Therefore, DCa prescription should be individualised. A DCa of 2.75 mEq/L may be useful adjunct for dialysis providers.
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Feeding during dialysis-risks and uncertainties.
Agarwal, R, Georgianos, P
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2018;(6):917-922
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Abstract
Allowing dialysis patients to eat during the treatment is controversial. It is, therefore, no surprise that practices and policies with respect to intradialytic food consumption vary considerably from unit to unit and from country to country. Those who defend the position of feeding during dialysis reason that intradialytic meals offer a supervised and effective therapy for protein-energy wasting. Those who take the opposite view argue that intradialytic food intake should be avoided for the following three reasons. First, interventional studies show that eating during dialysis causes a clinically significant reduction in systemic blood pressure during the postprandial period and elevates the risk of symptomatic intradialytic hypotension; the latter is associated with increased mortality risk. Second, clinical studies have shown that eating during dialysis interferes with the adequacy of the delivered dialysis, whereas eating 2-3 h before the dialysis session has no impact on the efficiency of the subsequent dialysis treatment. And third, randomized studies show that eating during dialysis focus on the positive outcomes but do not adequately balance this potential benefit against the risk of intradialytic hemodynamic instability and poor quality of delivered dialysis. Even after half a century of providing long-term dialysis, definitive randomized trials that balance risks and benefits of eating during dialysis are missing. These knowledge gaps require randomized trials. Since there is a real possibility of harm with eating during dialysis, we caution that instead of encouraging the widespread use of intradialytic meals, practices and policies should focus on adequate nutrient intake during the interdialytic interval.
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Vitamin and trace element deficiencies in the pediatric dialysis patient.
Harshman, LA, Lee-Son, K, Jetton, JG
Pediatric nephrology (Berlin, Germany). 2018;(7):1133-1143
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Abstract
Pediatric dialysis patients are at risk of nutritional illness secondary to deficiencies in water-soluble vitamins and trace elements. Unlike 25-OH vitamin D, most other vitamins and trace elements are not routinely monitored in the blood and, consequently, the detection of any deficiency may not occur until significant complications develop. Causes of vitamin and trace element deficiency in patients on maintenance dialysis patient are multifactorial, ranging from diminished nutritional intake to altered metabolism as well as dialysate-driven losses of water-soluble vitamins and select trace elements. In this review we summarize the nutritional sources of key water-soluble vitamins and trace elements with a focus on the biological roles and clinical manifestations of their respective deficiency to augment awareness of potential nutritional illness in pediatric patients receiving maintenance dialysis. The limited pediatric data on the topic of clearance of water-soluble vitamins and trace elements by individual dialysis modality are reviewed, including a brief discussion on clearance of water-soluble vitamins and trace elements with continuous renal replacement therapy.
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Prevention of hypophosphatemia during continuous renal replacement therapy-An overlooked problem.
Heung, M, Mueller, BA
Seminars in dialysis. 2018;(3):213-218
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Abstract
Hypophosphatemia is a common and potentially serious complication occurring during continuous renal replacement therapy (CRRT). Phosphate supplementation is required in the vast majority of patients undergoing CRRT, particularly beyond the first 48 hours. Supplementation can be provided either as a standalone oral or parenteral treatment or as an additive to CRRT solutions. Each approach has advantages and disadvantages, and clinicians must weigh the individual factors most relevant in their practice setting. Currently there are no consensus protocols for phosphate replacement in CRRT, and many centers replete phosphate in response to hypophosphatemia as opposed to pre-emptively. Repletion protocols have also been challenged in recent years by shortages in injectable phosphate solutions. More recently a commercially available phosphate-containing CRRT solution was approved in the United States, but there has been limited clinical experience with this product. In this review, we present recommendations for phosphate repletion in CRRT to prevent hypophosphatemia, and describe our experience using phosphate-containing CRRT solutions.
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Optimal dialysate sodium-what is the evidence?
Mc Causland, FR, Waikar, SS
Seminars in dialysis. 2014;(2):128-34
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Abstract
Oligo-anuric patients with end-stage kidney disease are dependent on hemodialysis to achieve and maintain the desired goal of euvolemia. The dialysis prescription, in addition to sodium and fluid restriction, is therefore a critically important factor in the care of hemodialysis patients. Various dialysate sodium concentrations have been favored throughout the history of dialysis, but the "optimal" concentration remains unclear. In this manuscript, we examine the historical context of changes to the dialysate sodium prescription, review the evidence of its associated effects, discuss 'individualization' of dialysate sodium, and highlight the need for definitive trials that are powered for important clinical outcomes.
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Practical considerations when prescribing icodextrin: a narrative review.
Silver, SA, Harel, Z, Perl, J
American journal of nephrology. 2014;(6):515-27
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Abstract
BACKGROUND Icodextrin is a peritoneal dialysis solution that is commonly used to increase ultrafiltration during the long dwell. The other major clinical benefit of icodextrin is that it is glucose-sparing, which may help preserve peritoneal membrane function. Since it has a different chemical composition than dextrose, and with its increasing use, there are several clinical considerations healthcare providers must familiarize themselves with prior to prescribing icodextrin. SUMMARY Failure to recognize these special properties of icodextrin can lead to adverse events reaching patients. This narrative review explores the hemodynamic, metabolic, and idiopathic effects of icodextrin to facilitate the safe use of icodextrin in peritoneal dialysis. KEY MESSAGES Hemodynamic effects include hypotension from enhanced ultrafiltration contributing to loss of residual kidney function. Metabolic effects include the chemical structure of icodextrin interfering with biochemical assays, resulting in misleading glucose readings on non-specific glucometers. Idiopathic adverse effects include a diffuse rash and sterile peritonitis. It is also important to remember that not all antibiotic combinations have undergone stability testing in icodextrin. This narrative review will help healthcare providers to confidently prescribe icodextrin to maximize its benefit in peritoneal dialysis patients.
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The KDIGO guideline for dialysate calcium will result in an increased incidence of calcium accumulation in hemodialysis patients.
Gotch, FA, Kotanko, P, Thijssen, S, Levin, NW
Kidney international. 2010;(4):343-50
Abstract
The recently published KDIGO (Kidney Disease: Improvement of Global Outcomes) guideline (GL) for dialysate calcium suggests a narrow range of dialysate inlet calcium concentrations (C(di)Ca(++)) of 2.50-3.00 mEq/l. The work group's primary arguments supporting the GL were (1) there is a negligible flux of body Ca(++) during dialysis and (2) C(di)Ca(++) of 2.50 mEq/l will generally result in neutral Ca(++) mass balance (Ca(MB)). We believe we have shown that both of these arguments are incorrect. Kinetic modeling and analysis of dialyzer Ca(++) transport during dialysis (J(d)Ca(++)) demonstrates that more than 500 mg of Ca can be transferred during a single dialysis and that on average 76% of this Ca flux is from the miscible calcium pool rather than plasma pool. Kinetic modeling of intestinal calcium absorption (Ca(Abs)) shows a strong dependence of Ca(Abs) on the dose of vitamin D analogs and weaker dependence on the level of Ca intake (Ca(INT)). We used the Ca(Abs) model to calculate Ca(Abs) as a function of total Ca(INT) and prescribed doses of vitamin D analogs in 320 hemodialysis patients. We then calculated total dialyzer calcium removal (TJ(d)Ca(++)) and the C(di)Ca(++) that would be required to achieve TJ(d)Ca(++)=Ca(Abs), that is, Ca(MB)=0 over the whole dialysis cycle (that is, covering both the intra- and the inter-dialytic period). The results indicate that 70% of patients on Ca-based binders and 20-50% of patients on non-Ca-based binders would require C(di)Ca(++) <2.50 mEq/l to prevent long-term Ca accumulation.
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New insight of amino acid-based dialysis solutions.
Park, MS, Choi, SR, Song, YS, Yoon, SY, Lee, SY, Han, DS
Kidney international. Supplement. 2006;(103):S110-4
Abstract
Malnutrition is a major complication of peritoneal dialysis (PD) and is associated with increased morbidity and mortality. Daily losses of proteins and amino acids (AAs) into dialysate contribute to this problem. Previous metabolic balance study demonstrated that treatment with 1.1% AA-based dialysis solution is safe and may improve protein malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients ingesting low protein intake. Other prospective studies also showed that AA solution can provide nutritional benefit for malnourished PD patients resulting in a significant improvement in some biochemical and/or anthropometric nutritional parameters. However, there are other studies showing no particular improvement in nutritional parameters after long-term use of AA solution. This may be related to the differences in the study design, sample size, methods used to assess nutritional status, and other factors such as dietary intake and comorbidities of study subjects. Published data will be reviewed to further emphasize the nutritional benefit of long-term use of AA solution in malnourished PD patients along with a brief discussion on the various reasons that may partly explain the different study results. We will also present the results of a longitudinal observational study evaluating changes in nutritional parameters following use of one exchange of 1.1% AA solution in malnourished Korean PD patients. A significant improvement of somatic protein status such as lean body mass (LBM) and hand grip strength was observed. No significant change in serum albumin level was noted. Patients with a positive estimated coefficient for LBM in the fitted regression model to the repeated observations over 1 year were classified as responders and patients with neutral or negative coefficient were considered as non-responders. Thirty-one out of 43 malnourished patients (72%) showed nutritional benefit based on the change of LBM. Hand grip strength and back lift strength were significantly higher in responders at baseline. Other baseline parameters did not differ between the two groups.
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Do dialysate conductivity measurements provide conductivity clearance or ionic dialysance?
Petitclerc, T
Kidney international. 2006;(10):1682-6
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Abstract
Dialysate conductivity measurements allow on-line estimation of urea clearance during hemodialysis session. Conductivity measurements provide a value of 'conductivity clearance' for some authors, but a value of 'ionic dialysance' for others. This paper aims at explaining which term should be the more appropriate. Clearance is a parameter defined for measuring the power of a mechanism, which aims at 'clearing' a solution by depurating some solutes. In hemodialysis, clearance measures the efficacy of patient's depuration. In contrast, dialysance measures the capability of transferring solutes between blood and dialysate. The conventional definition of dialysance, requiring the absence of convective transfer, should be generalized to the case of the usual presence of ultrafiltration during the hemodialysis session. For a solute (as urea) absent from the dialysate delivered to the dialyzer inlet, the clearance is equal to its dialysance. In order to avoid a dramatic fall in ionic concentrations during hemodialysis treatment, the clearance of ions is reduced by adding these ions in the dialysate and becomes lower than their dialysance. Conductivity measurements provide a value of electrolytes dialysance. Thus the term of 'ionic dialysance' is more appropriate than the term of 'conductivity clearance'. Nevertheless ionic dialysance represents a good estimation of urea clearance.