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Seminars in Dialysis Sep 2022On-line hemodiafiltration (ol-HDF) was developed in the 1980s in response to the unmet medical needs observed with conventional low- and high-flux hemodialysis. Firstly,...
On-line hemodiafiltration (ol-HDF) was developed in the 1980s in response to the unmet medical needs observed with conventional low- and high-flux hemodialysis. Firstly, the limited overall efficacy of conventional HD treatment programs as compared to native kidney function has been consistently documented over the broad MW spectrum of uremic toxins as well as fluid volume and hemodynamic control. Secondly, the unphysiological profile of intermittent treatment leading to repetitive dialysis-induced hemodynamic stress is now a well-recognized component of cardiovascular disease and end organ damage. Thirdly, the bioincompatibility of patient-dialysis system leading to dialysis-induced biological reactions also identified as contributing to dialytic morbidity and mortality. To overcome these limitations and pitfalls, alternative convective-based therapies (hemofiltration and hemodiafiltration), using higher hemoincompatible membranes and ultrapure dialysis fluid, were proposed as a solution to enhance and enlarge MW spectrum of uremic compounds cleared and to reduce dialysis-patient biological interactions. In this context, online HDF appeared soon as the best viable and efficient renal replacement modality to cover these needs. Clinical development and implementation of ol-HDF showed also that dialytic convective dose matters with a threshold point (23 L/1.73 m in postdilution mode) to observe clinical benefits and outcomes improvements.
Topics: Dialysis Solutions; Hemodiafiltration; Hemofiltration; Humans; Kidney Failure, Chronic; Renal Dialysis
PubMed: 35304772
DOI: 10.1111/sdi.13069 -
International Urology and Nephrology Apr 2020Thirst has been defined as "the sensation that leads animal's and human's actions toward the goal of finding and drinking water" or as "any drive that can motivate water... (Review)
Review
Thirst has been defined as "the sensation that leads animal's and human's actions toward the goal of finding and drinking water" or as "any drive that can motivate water intake, regardless of cause". Thirst, together with xerostomia, is the main cause of poor adherence to fluid restriction and of excessive intake of fluids in patients on chronic hemodialysis, and consequently of high interdialytic weight gain. Interdialytic weight gain (IDWG) should be lower than 4.0-4.5% of dry weight. Unfortunately, many patients have an IDWG greater than this value and some have IDWG of 10-20%. High IDWG is associated with a higher risk of all-cause and cardiovascular death and increased morbidity, such as ventricular hypertrophy and major adverse cardiac and cerebrovascular events. In addition, high IDWG leads to supplementary weekly dialysis sessions with consequent deterioration of quality of life and increased costs. Thus, the knowledge of thirst in patients on chronic hemodialysis is essential to prompt its adequate management to limit IDWG in the routine clinical practice. The present review aims to describe the physiology of thirst in patients on chronic hemodialysis, as well as the prevalence, its measures, the associated variables, the consequences, and the strategies for its reduction.
Topics: Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Dialysis Solutions; Diet, Sodium-Restricted; Heart Failure; Humans; Osmolar Concentration; Renal Dialysis; Sodium Chloride, Dietary; Thirst; Weight Gain; Xerostomia
PubMed: 32100204
DOI: 10.1007/s11255-020-02401-5 -
Pediatric Nephrology (Berlin, Germany) Dec 2023The risk of cardiovascular disease remains exceedingly high in pediatric patients with chronic kidney disease stage 5 on dialysis (CKD 5D). Sodium (Na) overload is a... (Review)
Review
The risk of cardiovascular disease remains exceedingly high in pediatric patients with chronic kidney disease stage 5 on dialysis (CKD 5D). Sodium (Na) overload is a major cardiovascular risk factor in this population, both through volume-dependent and volume-independent toxicity. Given that compliance with a Na-restricted diet is generally limited and urinary Na excretion impaired in CKD 5D, dialytic Na removal is critical to reduce Na overload. On the other hand, an excessive or too fast intradialytic Na removal may lead to volume depletion, hypotension, and organ hypoperfusion. This review presents current knowledge on intradialytic Na handling and possible strategies to optimize dialytic Na removal in pediatric patients on hemodialysis (HD) and peritoneal dialysis (PD). There is increasing evidence supporting the prescription of lower dialysate Na in salt-overloaded children on HD, while improved Na removal may be achieved in children on PD with an individual adaptation of dwell time and volume and with icodextrin use during the long dwell.
Topics: Humans; Child; Renal Dialysis; Sodium; Peritoneal Dialysis; Dialysis Solutions; Kidney Failure, Chronic
PubMed: 37148342
DOI: 10.1007/s00467-023-05999-7 -
Kidney360 Apr 2021Metabolic acidosis is a common threat for patients on hemodialysis, managed by alkaline dialysate. The main base is bicarbonate, to which small amounts of acetic,...
BACKGROUND
Metabolic acidosis is a common threat for patients on hemodialysis, managed by alkaline dialysate. The main base is bicarbonate, to which small amounts of acetic, citric, or hydrochloric acid are added. The first two are metabolized to bicarbonate, mostly by the liver. Citric acid-containing dialysate might improve dialysis efficiency, anticoagulation, calcification propensity score, and intradialytic hemodynamic stability. However, a recent report from the French dialysis registry suggested this dialysate increases mortality risk. This prompted us to assess whether citric acid-containing bicarbonate-based dialysate was associated with mortality in the international Dialysis Outcomes and Practice Patterns Study (DOPPS).
METHODS
Detailed patient-based information on dialysate composition was collected in DOPPS phases 5 and 6 (2012-2017). Cox regression was used to model the association between baseline bicarbonate dialysate containing citric acid versus not containing citric acid and mortality among DOPPS countries and phases where citric acid-containing dialysate was used.
RESULTS
Citric acid-containing dialysate was most commonly used in Japan, Italy, and Belgium (25%, 25%, 21% and of patients who were DOPPS phase 6, respectively) and used in <10% of patients in other countries. Among 11,306 patients in DOPPS country and phases with at least 15 patients using citric acid-containing dialysate, patient demographics, comorbidities, and laboratories were similar among patients using (14%) versus not using (86%) citric acid-containing dialysate. After accounting for case mix, we did not observe a directional association between citric acid-containing dialysate use (any versus none) and mortality (HR, 1.14; 95% CI, 0.97 to 1.34), nor did we find evidence of a dose-dependent relationship when parameterizing the citric acid concentration in the dialysate as 1, 2, and 3+ mEq/L.
CONCLUSIONS
The use of citric acid-containing dialysate was not associated with greater risk of all-cause mortality in patients on hemodialysis participating in DOPPS. Clinical indications for the use of citric acid-containing dialysate deserve further investigation.
Topics: Bicarbonates; Citric Acid; Dialysis Solutions; Humans; Renal Dialysis; Survival Rate
PubMed: 35373053
DOI: 10.34067/KID.0006182020 -
Seminars in Dialysis Sep 2019During the last two decades, oxidative stress (OS) has emerged as a novel risk factor for a variety of adverse events, including atherosclerosis and mortality in chronic... (Review)
Review
During the last two decades, oxidative stress (OS) has emerged as a novel risk factor for a variety of adverse events, including atherosclerosis and mortality in chronic kidney disease (CKD) patients. Increased OS occurs even in early stages of the disease, progresses with deterioration of renal function and is further aggravated by hemodialysis (HD), due to the bioincompatibility of the method. Compared to HD, peritoneal dialysis (PD) is a more biocompatible dialysis modality, characterized by a significantly reduced, but still high, OS status. The culprit for OS in PD is mainly the composition of PD solutions (low pH, lactate buffer, increased osmolarity and high glucose concentration). After heat sterilization of PD solutions, formation of glucose degradation products (GDPs) and advanced glycation end-products (AGEs) trigger inflammation and enhance OS. Chronic exposure of the peritoneum to this toxic, hyperglycemic environment leads to OS-derived morphologic damage of peritoneal cells, loss of ultrafiltration capacity and decreased technique survival. Moreover, OS is linked with peritonitis, loss of residual renal function, inflammation, atherosclerosis, cardiovascular (CV) disease, and increased mortality. To ameliorate OS status in PD, a multitargeted approach is necessary that includes use of neutral pH, low GDP, low lactate and iso-ismolar PD solutions, strict glycemic control, optimal volume management and, probably supplementation with antioxidants, N-acetylcysteine being the most promising among them.
Topics: Dialysis Solutions; Humans; Oxidative Stress; Peritoneal Dialysis; Renal Insufficiency, Chronic
PubMed: 31044475
DOI: 10.1111/sdi.12818 -
Blood Purification 2023Dialysis therapy is the predominant choice for renal failure in Japan, and almost 30% of the patients with renal failure have been treated for 10 years or more. Dialysis... (Review)
Review
Dialysis therapy is the predominant choice for renal failure in Japan, and almost 30% of the patients with renal failure have been treated for 10 years or more. Dialysis became the standard procedure to treat renal failure nationwide in the 1980s. However, at that time, managing the increased number of patients on maintenance hemodialysis as well as operating and maintaining the newly developed advanced medical technologies at extensive numbers of clinical sites proved problematic. To help address this, the clinical engineer system was established in 1987 and certain aspects of the clinical engineers' role remain unique to Japan today. For the last 30 years, clinical engineers have worked as frontline medical personnel not only operating dialysis-related devices but also placing their hands directly on patients when providing care, routinely performing puncture, and administering drugs through the blood circuit under physicians' instructions. As part of their work, they crucially maintain the use of central dialysis fluid delivery systems (CDDSs) - also unique to Japan - which prepare and deliver a large quantity of dialysis fluid through a central circuit to individual dialysis consoles. CDDSs are widely used because they effectively alleviated the early confusion at clinical sites caused by the rapidly increasing hemodialysis population and the serious shortage in medical personnel. Moreover, clinical engineers alone have the technical ability to provide safe dialysis fluids adjusted to strict standards at clinical sites. In this review article, we focus on the crucial roles that clinical engineers have in maintaining the safety of dialysis-related medical devices and the preparation and delivery of dialysis fluid at many dialysis facilities across the country.
Topics: Humans; Renal Dialysis; Hemodialysis Solutions; Japan; Dialysis Solutions; Renal Insufficiency; Safety Management
PubMed: 33684920
DOI: 10.1159/000512349 -
Therapeutic Apheresis and Dialysis :... Dec 2023Hemodialysis is considered a treatment of choice for patients with renal failure worldwide, allowing the replacement of some kidney functions by diffusion and... (Review)
Review
Hemodialysis is considered a treatment of choice for patients with renal failure worldwide, allowing the replacement of some kidney functions by diffusion and ultrafiltration processes. Over 4 million people require some form of renal replacement therapy, with hemodialysis being the most common. During the procedure, contaminants in the water and the resulting dialysate may pass into the patient's blood and lead to toxicity. Thus, the quality of the associated dialysis solutions is a critical issue. Accordingly, the discussion of the importance of a dialysis water delivery system controlled by current standards and recommendations, with efficient monitoring methods, disinfection systems, and chemical and microbiological analysis, is crucial for improving the health outcomes of these patients. The importance of treatment, monitoring, and regulation is emphasized by presenting several case studies concerning the contamination of hemodialysis water and the adverse effects on the respective patients.
Topics: Humans; Water Quality; Renal Dialysis; Dialysis Solutions; Ultrafiltration; Continuous Renal Replacement Therapy; Hemodialysis Solutions
PubMed: 37381091
DOI: 10.1111/1744-9987.14032 -
Seminars in Dialysis Nov 2022Clinical application of continuous flow peritoneal dialysis (CFPD) has been explored since the 1960s, but despite anticipated clinical benefits, CFPD has failed to gain... (Review)
Review
Clinical application of continuous flow peritoneal dialysis (CFPD) has been explored since the 1960s, but despite anticipated clinical benefits, CFPD has failed to gain a foothold in clinical practice, among others due to the typical use of two catheters (or a dual-lumen catheter) and large dialysate volumes required per treatment. Novel systems applying CFPD via the existing single-lumen catheter using rapid dialysate cycling may solve one of these hurdles. Novel on-demand peritoneal dialysate generation systems and sorbent-based peritoneal dialysate regeneration systems may considerably reduce the storage space for peritoneal dialysate and/or the required dialysate volume. This review provides an overview of current evidence on CFPD in vivo. The available (pre)clinical evidence on CFPD is limited to case reports/series with inherently nonuniform study procedures, or studies with a small sample size, short follow-up, and no hard endpoints. Small solute clearance appears to be higher in CFPD compared to conventional PD, in particular at dialysate flows ≥100 mL/min using two single-lumen catheters or a double-lumen catheter. Results of CFPD using rapid cycling via a single-lumen catheter are too preliminary to draw any conclusions. Continuous addition of glucose to dialysate with CFPD appears to be effective in reducing the maximum intraperitoneal glucose concentration while increasing ultrafiltration efficiency (mL/g absorbed glucose). Patient tolerance may be an issue since abdominal discomfort and sterile peritonitis were reported with continuous circulation of the peritoneal dialysate. Thus, well-designed clinical trials of longer duration and larger sample size, in particular applying CFPD via the existing catheter, are urgently required.
Topics: Humans; Renal Dialysis; Peritoneal Dialysis; Dialysis Solutions; Peritoneum; Glucose
PubMed: 35650168
DOI: 10.1111/sdi.13097 -
Nephrology, Dialysis, Transplantation :... Nov 2022In patients admitted to the Intensive Care Unit (ICU), Kidney Replacement Therapy (KRT) is an important risk factor for hypophosphataemia. However, studies addressing...
BACKGROUND
In patients admitted to the Intensive Care Unit (ICU), Kidney Replacement Therapy (KRT) is an important risk factor for hypophosphataemia. However, studies addressing the development of hypophosphatemia during prolonged intermittent KRT modalities are lacking. Thus, we evaluated the incidence of hypophosphatemia during Sustained Low-Efficiency Dialysis (SLED) in ICU patients; we also examined the determinants of post-SLED serum phosphate level (s-P) and the relation between s-P and phosphate supplementation and ICU mortality.
METHODS
We conducted a retrospective analysis on a cohort of critically ill patients with severe renal failure and KRT need, who underwent at least three consecutive SLED sessions at 24-72 h time intervals with daily monitoring of s-P concentration. SLED with Regional Citrate Anticoagulation (RCA) was performed with either conventional dialysis machines or continuous-KRT monitors and standard dialysis solutions. When deemed necessary by the attending physician, intravenous phosphate supplementation was provided by sodium glycerophosphate pentahydrate. We used mixed-effect models to examine the determinants of s-P and Cox proportional hazards regression models with time-varying covariates to examine the adjusted relation between s-P, intravenous phosphate supplementation and ICU mortality.
RESULTS
We included 65 patients [mean age 68 years (SD 10.0); mean Acute Physiology and Chronic Health Evaluation II score 25 (range 9-40)] who underwent 195 SLED sessions. The mean s-P before the start of the first SLED session (baseline s-P) was 5.6 ± 2.1 mg/dL (range 1.5-12.3). Serum phosphate levels at the end of each SLED decreased with increasing age, SLED duration and number of SLED sessions (P < .05 for all). The frequency of hypophosphatemia increased after the first through the third SLED session (P = .012). Intravenous phosphate supplementation was scheduled after 12/45 (26.7%) SLED sessions complicated by hypophosphataemia. The overall ICU mortality was 23.1% (15/65). In Cox regression models, after adjusting for potential confounders and for current s-P, intravenous phosphate supplementation was associated with a decrease in ICU mortality [adjusted hazard ratio: 0.24 (95% confidence interval: 0.06 to 0.89; P = 0.033)].
CONCLUSIONS
Hypophosphatemia is a frequent complication in critically ill patients undergoing SLED with standard dialysis solutions, that worsens with increasing SLED treatment intensity. In patients undergoing daily SLED, phosphate supplementation is strongly associated with reduced ICU mortality.
Topics: Humans; Aged; Critical Illness; Hybrid Renal Replacement Therapy; Dialysis Solutions; Retrospective Studies; Acute Kidney Injury; Renal Dialysis; Hypophosphatemia; Phosphates
PubMed: 35481705
DOI: 10.1093/ndt/gfac159 -
Journal of Mathematical Biology Jun 2023Chronic kidney diseases imply an ongoing need to remove toxins, with hemodialysis as the preferred treatment modality. We derive analytical expressions for phosphate...
Chronic kidney diseases imply an ongoing need to remove toxins, with hemodialysis as the preferred treatment modality. We derive analytical expressions for phosphate clearance during dialysis, the single pass (SP) model corresponding to a standard clinical hemodialysis and the multi pass (MP) model, where dialysate is recycled and therefore makes a smaller clinical setting possible such as a transportable dialysis suitcase. For both cases we show that the convective contribution to the dialysate is negligible for the phosphate kinetics and derive simpler expressions. The SP and MP models are calibrated to clinical data of ten patients showing consistency between the models and provide estimates of the kinetic parameters. Immediately after dialysis a rebound effect is observed. We derive a simple formula describing this effect which is valid both posterior to SP or MP dialysis. The analytical formulas provide explanations to observations of previous clinical studies.
Topics: Humans; Phosphates; Kinetics; Renal Dialysis; Dialysis Solutions; Kidney Failure, Chronic
PubMed: 37332042
DOI: 10.1007/s00285-023-01942-4