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Total serum and intraerythrocyte magnesium concentrations in hemodialysis patients using different dialysate solutions.
Kusic, J, Markovic, R, Andjelkovic Apostolovic, M, Dragovic, G
Magnesium research. 2020;(2):28-36
Abstract
Beside routinely used 0.5 mmol/L dialysate-magnesium, higher dialysate-magnesium (1.0 mmol/L) was recently introduced. The aim of this study was to evaluate the impact of different dialysate-magnesium on serum and intraerythrocyte levels of magnesium (Mg) before and after dialysis. The study included 43 patients receiving chronic hemodialysis, divided into two groups based on dialysate-magnesium (0.5 or 1.0 mmol/L) used prior to study initiation and during 12 months of follow-up. Blood samples were taken at the mid-week dialysis; total serum Mg was measured colorimetrically and intraerythrocyte Mg by atomic absorption spectrophotometry. Hypermagnesiemia-associated complications were observed for 12 months. Total serum Mg was 1.14 ± 0.19 mmol/L before and 0.95 ± 0.16 mmol/L after dialysis in patients using lower dialysate-Mg (p < 0.001), whereas it was 1.47 ± 0.25 mmol/L before and 1.49 ± 0.18 mmol/L after dialysis in patients using higher dialysate-Mg (p = 0.926). Intraerythrocyte Mg was 1.98 ± 0.34 mmol/L before and 1.97 ± 0.28 mmol/L after dialysis in the lower dialysate-Mg group (p = 0.939), while it was 2.09 ± 0.37 mmol/L before and 2.19 ± 0.48 mmol/L after dialysis in the higher dialysate group (p = 0.067). After 12 months total serum Mg decreased in both the groups, remaining lower in 0.5 mmol/L dialysate-Mg group. No hypermagnesiemia-related symptoms occur during 12 months of follow-up in both the groups. In patients using lower dialysate-Mg total serum Mg remains within the reference range and shows postdialytic decline, while in higher dialysate-Mg group it exceeded reference range before and after dialysis without significant intradialytic change. The intraerythrocyte values remain within reference range with both dialysates used. No clinical signs and symptoms of hypermagnesiemia occur during longer administration of higher dialysate-magnesium despite high total serum Mg level.
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Flexitrate regional citrate anticoagulation in continuous venovenous hemodiafiltration: a retrospective analysis.
Lenga, I, Hopman, WM, O'Connell, AJ, Hume, F, Wei, CCY
BMC nephrology. 2019;(1):452
Abstract
BACKGROUND Flexitrate, an innovative regional citrate anticoagulation (RCA) protocol, was compared to traditional RCA (tRCA) and Heparin anticoagulation protocols in intensive care patients treated with continuous renal replacement therapy (CRRT). METHODS A single-center, retrospective, cohort study, was done in a 26-bed intensive care unit in a large community hospital. Eighty dialysis sessions (Flexitrate = 2852 h, tRCA = 3580 h and Heparin = 2026 h), performed in 53 patients, were evaluated for filter life, RCA control, and metabolic control. RESULTS In the Flexitrate cohort, 3.8% of filters clotted, compared to 16.9% with tRCA and 28.3% with Heparin (p < 0.001 for Flexitrate compared to either tRCA or Heparin). Filter survival was significantly improved with Flexitrate compared to tRCA (HR 0.24, p = 0.018) or Heparin (HR 0.14, p = 0.004). Anticoagulation control was superior with Flexitrate with Patient Ionized Calcium out of target a median of 16% of the time, compared to 27% for tRCA (p < 0.001). Filter Ionized Calcium was out of target a median of 6.8% of the time, compared to 23% for tRCA (p = 0.03). Flexitrate produced significantly less alkalosis, hypernatremia, and hypocalcemia than tRCA, and overall metabolic control was comparable to Heparin anticoagulation. The only adverse metabolic outcome with Flexitrate was increased hypomagnesemia. CONCLUSIONS The Flexitrate protocol extended filter life, delivered more consistent anticoagulation, and provided superior metabolic control compared to a tRCA protocol. Filter life was superior to Heparin anticoagulation, with similar metabolic control. A randomized control trial comparing these protocols is recommended.
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Differences between Measured Total Nitrogen Losses in Spent Peritoneal Dialysate Effluent and Estimated Nitrogen Losses.
Vongsanim, S, Salame, C, Eaton, S, Grimble, G, Davenport, A
Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2019;(3):243-247
Abstract
OBJECTIVE Patients treated by peritoneal dialysis (PD) are at increased risk of muscle wasting, and clinical guidelines recommend assessing dietary intake, by calculating protein equivalent of nitrogen appearance (PNA) to assure protein sufficiency. The PNA equations were developed many years ago, and we wished to re-evaluate them by comparing estimated and measured peritoneal nitrogen losses. DESIGN AND METHODS This is a cross-sectional observational cohort study. The study setting was an outpatient PD center of a university hospital and the study subjects included 67 patients undergoing PD, in which 61.2% were males, and the median age was 67.3 (53.2-79.4) years. The nitrogen content of 24-hour spent peritoneal dialysate by automated chemiluminescence analyzer was measured and compared with estimates of nitrogen losses based on dialysate urea loss using the Bergstrom, Randerson, and Blumenkrantz equations. RESULTS Measured total dialysate nitrogen was more than urea nitrogen equivalent, 5.79 ± 4.07 versus 2.66 ± 1.67 g/day (P < .001). Each equation has an inflation factor to compensate for nonurea protein losses; however, measured nitrogen loss was 27.7 (15.5-59.6) g/day versus Bergstrom, 16.5 (9.8-27.1); Randerson, 16.4 (9.8-27.3); and Blumenkrantz, 12.9 (7.9-25.4) g/day, P < .001. The BlandAltman analysis demonstrated systematic bias with increasing underestimation by these equations with increasing measured nitrogen losses (r = 0.74, P < .001). CONCLUSION Our findings demonstrate that at higher protein losses, the currently used predictive equations underestimate the amount lost. It is important to attempt to compensate the iatrogenic protein loss by recommending the appropriate intake of dietary protein to patients, in an attempt to minimize muscle wasting. This discrepancy may have arisen because of the characteristics of newer PD prescriptions and change in patient demographics. We propose a new equation PNA g/day = 0.31 × (urea loss mmol) + 7.17, which will require prospective validation in additional studies.
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Longer-Period Effects of Bicarbonate/Lactate-Buffered Neutral Peritoneal Dialysis Fluid in Patients Undergoing Peritoneal Dialysis.
Hoshino, T, Kaneko, S, Minato, S, Yanai, K, Mutsuyoshi, Y, Ishii, H, Kitano, T, Shindo, M, Miyazawa, H, Aomatsu, A, et al
Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy. 2018;(6):641-648
Abstract
High concentrations of lactate are considered to contribute to impairment of the peritoneal membrane. We investigated the longer-period effects of bicarbonate/lactate-buffered neutral peritoneal dialysis fluid (PDF) in patients undergoing PD for about 2 years. Patients undergoing PD were changed from a lactate-buffered neutral PDF to a bicarbonate/lactate-buffered neutral PDF. We then investigated the patients' clinical outcomes and peritoneal membrane functions as well as the surrogate markers in the drained dialysate. Fourteen patients undergoing PD were enrolled. Peritonitis was observed in one patient. No other adverse events were observed. Peritoneal function did not change as the ultrafiltration volume decreased. Fibrin degradation products and vascular endothelial growth factor in the drained dialysate decreased while the interleukin level increased. These results suggest that bicarbonate/lactate-buffered neutral PDF may have beneficial effects in terms of peritoneal preservation and can be safely used in patients undergoing PD.
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Serum-to-dialysate potassium gradient and its association with short-term outcomes in hemodialysis patients.
Brunelli, SM, Spiegel, DM, Du Mond, C, Oestreicher, N, Winkelmayer, WC, Kovesdy, CP
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2018;(7):1207-1214
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Abstract
BACKGROUND A high serum-to-dialysate potassium (K+) gradient at the start of dialysis leads to rapid lowering of serum K+ and may confer a greater risk of adverse events. Here, we examined the near-term association of K+ gradient with clinical outcomes. METHODS This retrospective (2010-11) event-based study considered 830 741 patient-intervals, each defined by a pre-dialysis measurement of serum K+ made among adult Medicare Parts A and B enrollees who received in-center hemodialysis on a Monday/Wednesday/Friday schedule at a large US dialysis organization. K+ gradient was considered based on the difference in K+ concentration (serum-dialysate) on the date of measurement; analyses accounted for multiple observations per patient. Outcomes considered were: all-cause and cardiovascular hospital admissions, emergency department (ED) visits and deaths. RESULTS Higher K+ gradient was associated with younger age, greater fistula use, lower comorbidity scores and better nutritional indices. Adjusting for patient differences, there was a dose-response relationship between higher K+ gradient and greater risks of all-cause hospitalization and ED visit. A similar trend was seen for cardiovascular hospitalization but did not achieve statistical significance. No associations were observed with mortality, potentially due to a low number of events. CONCLUSIONS Higher K+ gradient is independently associated with greater risk of all-cause hospitalizations and ED visits. Further research is needed to determine whether interventions that reduce the K+ gradient ameliorate this risk.
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Initiation of peritoneal dialysis in the first weeks after catheter insertion: A comparison of a neutral-pH, low-GDP PD fluid and a conventional PD fluid
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Farhat, K, van Ittersum, FJ, Ter Wee, PM, Paauw, NJ, Beelen, RHJ, Douma, CE
Clinical nephrology. 2018;(2):75-82
Abstract
BACKGROUND Chronic exposure to peritoneal dialysis (PD) fluid is associated with development of functional and structural alterations of the peritoneal membrane. The exact time point at which these changes actually occur is not known. Whether changes to the peritoneum occur immediately after installation of PD fluids and whether there is a difference between neutral-pH, low glucose degradation product (low-GDP) PD fluids and conventional PD fluids is not known either. MATERIALS AND METHODS We performed an observational study. Markers related to inflammation, fibrosis, mesothelial activation, and cytokines/growth factors were measured in effluents immediately after PD-catheter insertion and during the first days and weeks of PD treatment in patients using either dianeal® or physioneal®. RESULTS Peritoneal response was observed instantly upon insertion of the PD catheter and instillation of PD fluids and persisted during daily PD therapy. Particularly during the first contacts of the peritoneum with PD fluids, high levels of cytokines and biomarkers were observed. In general, CA125 is slightly higher with dianeal. There is no difference between the fluids in hyaluronic acid (HA), IL-6, IL-8, MCP-1, VEGF, and TGFβ-1 levels. CONCLUSION Implantation of the Tenckhoff catheter and installation of PD fluids induce inflammation, which in the first days resembles an acute inflammatory response. More continuous infusion of PD fluids further enhances peritoneal inflammation. The use of the bicarbonate/lactate-buffered, neutral-pH, low-GDP PD fluid physioneal exerts lower CA125 levels, lower D/P4 creatinine, but similar inflammatory response compared to conventional dianeal PD fluids in this early stage of PD therapy.
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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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The Effects of High Level Magnesium Dialysis/Substitution Fluid on Magnesium Homeostasis under Regional Citrate Anticoagulation in Critically Ill.
Zakharchenko, M, Los, F, Brodska, H, Balik, M
PloS one. 2016;(7):e0158179
Abstract
BACKGROUND The requirements for magnesium (Mg) supplementation increase under regional citrate anticoagulation (RCA) because citrate acts by chelation of bivalent cations within the blood circuit. The level of magnesium in commercially available fluids for continuous renal replacement therapy (CRRT) may not be sufficient to prevent hypomagnesemia. METHODS Patients (n = 45) on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min) with RCA modality (4% trisodium citrate) using calcium free fluid with 0.75 mmol/l of Mg with additional magnesium substitution were observed after switch to the calcium-free fluid with magnesium concentration of 1.50 mmol/l (n = 42) and no extra magnesium replenishment. All patients had renal indications for CRRT, were treated with the same devices, filters and the same postfilter ionized calcium endpoint (<0.4 mmol/l) of prefilter citrate dosage. Under the high level Mg fluid the Qb, dosages of citrate and CRRT were consequently escalated in 9h steps to test various settings. RESULTS Median balance of Mg was -0.91 (-1.18 to -0.53) mmol/h with Mg 0.75 mmol/l and 0.2 (0.06-0.35) mmol/h when fluid with Mg 1.50 mmol/l was used. It was close to zero (0.02 (-0.12-0.18) mmol/h) with higher blood flow and dosage of citrate, increased again to 0.15 (-0.11-0.25) mmol/h with 3,000 ml/h of high magnesium containing fluid (p<0.001). The arterial levels of Mg were mildly increased after the change for high level magnesium containing fluid (p<0.01). CONCLUSIONS Compared to ordinary dialysis fluid the mildly hypermagnesemic fluid provided even balances and adequate levels within ordinary configurations of CRRT with RCA and without a need for extra magnesium replenishment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01361581.
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Impact of Dialysate Calcium Concentration on Clinical Outcomes in Incident Hemodialysis Patients.
Kim, HW, Kim, SH, Kim, YO, Jin, DC, Song, HC, Choi, EJ, Kim, YL, Kim, YS, Kang, SW, Kim, NH, et al
Medicine. 2015;(40):e1694
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Abstract
The association between dialysate calcium (DCa) concentration and mortality in hemodialysis (HD) patients is controversial. In this study, we evaluated the impact of DCa concentration on mortality in incident HD patient. Incident HD patients were selected from the Clinical Research Center registry-a prospective cohort study on dialysis patients in Korea. Patients were categorized into 3 groups according to the prescribed DCa concentration at the time of enrollment. High DCa was defined as a concentration of 3.5 mEq/L, mid-DCa as 3.0 mEq/L, and low DCa as 2.5 to 2.6 mEq/L. The primary outcome was all-cause mortality and secondary outcomes were cardiovascular or infection-related hospitalization. A total of 1182 patients with incident HD were included. The number of patients in each group was 182 (15.4%) in high DCa group, 701 (59.3%) in the mid-DCa group, and 299 (25.3%) in the low DCa group. The median follow-up period was 16 months. The high DCa group had a significantly higher risk of all-cause mortality compared with the mid-DCa group (hazard ratio [HR] 2.23, 95% confidence interval [CI] 1.28-3.90, P = 0.005) and the low DCa group (HR 3.67, 95% CI 1.78-7.55, P < 0.001) after adjustment for clinical variables. The high DCa group was associated with higher risk of cardiovascular and infection-related hospitalization compared with the low DCa group (HR 3.25, 95% CI 1.53-6.89, P = 0.002; and HR 2.77, 95% CI 1.29-5.94, P = .009, respectively). Of these 1182 patients, 163 patients from each group were matched by propensity scores. In the propensity score matched analysis, the high DCa group had a significantly higher risk of all-cause mortality compared with the mid-DCa group (HR 2.52, 95% CI 1.04-6.07, P = 0.04) and the low DCa group (HR 4.25, 95% CI 1.64-11.03, P = 0.003) after adjustment for clinical variables. Our data showed that HD using a high DCa was a significant risk factor for all-cause mortality and cardiovascular or infection-related hospitalization in incident HD patients.