Trial design of the MOTheR HDx study: a multicenter, open-label, prospective, randomized study to explore the morbidity and mortality in patients dialyzed with the Theranova HDx in comparison with online hemodiafiltration.

Background: Dialysis patients have been maintaining a high rate of cardiovascular morbidity and mortality. For this reason, it is to introduce necessary new technical advances in clinical practice. There is a relation between toxins retention and inflammation, mortality and morbidity. Medium cut-off (MCO) membranes are a new generation of membranes that allow the removal of a greater number of medium-sized molecules compared with high-flux hemodialysis (HF-HD), but retaining albumin. MCO membranes have an increased permeability and the presence of internal filtration. Because of these special properties, MCO generated a new concept of therapy called expanded HD (HDx). Until now, online hemodiafiltration (OL-HDF) has demonstrated its superiority, in terms of survival, compared with HF-HD. However, the comparison between OL-HDF and HDx remains an unsolved question. Methods: The MOTheR HDx study trial (NCT03714386) is an open-label, multicenter, prospective, 1:1 randomized, parallel-group trial designed to evaluate the efficacy and safety of HDx compared with OL-HDF in patients treated for dialysis in Spain for up to 36 months. The main endpoint is to determinate whether HDx is non inferior to OL-HDF at reducing the combined outcome of all-cause death and stroke (ischemic or hemorrhagic), acute coronary syndrome (angina and myocardial infarction), peripheral arterial disease (amputation or revascularization) and ischemic colitis (mesenteric thrombosis). Results: The trial has already started.

Advantages of the use of citrate over acetate as a stabilizer in hemodialysis fluid: A randomized ABC-treat study.

Hemodialysis (HD) with bicarbonate dialysis fluid (DF) requires the presence of an acid to prevent the precipitation of calcium and magnesium carbonate. The most used acid is acetic acid, with it several complications have been described. In a previous work we described the acute changes during an HD session with a DF with citrate instead of acetate. Now we report the results in the medium term, 16 weeks. It is a prospective, multicenter, crossover and randomized study, where 56 HD patients with bicarbonate three times a week were dialysed for 16 weeks with 3 mmol/L acetate and 16 weeks with 1 mmol/L citrate. Patients older than 18 years with a previous stay on HD of more than 3 months and with a normal functioning arteriovenous fistula were included. Epidemiological data, dialysis, bioimpedance, biochemistry before and after HD, as well as hypotensive episodes, were collected monthly. After 16 weeks of citrate treatment, preHD ionic calcium and magnesium were significantly lower and PTH higher than in the acetate period. No differences were observed in the effectiveness of dialysis. Hypotensive episodes were significantly more frequent with acetate than with citrate: 311 (14.1%) vs 238 (10.8%) sessions. The lean mass index increased by 0.96 ±â€¯2.33 kg/m2 when patients switched from LD with acetate to citrate. HD with citrate modifies several parameters of bone mineral metabolism, not only acutely as previously described, but also in the long term. The substitution of acetate for citrate improves hemodynamic stability, producing less hypotension and can improve nutritional status.

Factors associated with falls in hemodialysis patients: a case-control study.

OBJECTIVE: to identify possible associations between a higher probability of falls among hemodialysis patients and laboratory values, comorbidities, pharmacological treatment, hemodynamic changes, dialysis results and stabilometric alterations. METHOD: this was a retrospective case-control study with hemodialysis patients. Patients in a hemodialysis unit who had suffered one or more falls were included in the case group. Patients from the same unit who had not suffered falls were the controls. Data were gathered from the patients' clinical history and also from the results of a balance test conducted six months before the study. RESULTS: thirty-one patients were included (10 cases and 21 controls). Intradialytic body weight change was significantly greater among cases (p <0.05). Patients in the case group also presented greater lateral instability after dialysis (p <0.05). Other factors such as high blood pressure, antihypertensives, beta-blockers, and lower heart rates were also associated with falls. CONCLUSION: a greater intradialytic weight change was associated with an increase in risk of falls. Nursing staff can control these factors to prevent the incidence of falls in dialysis patients.

Advantages of the use of citrate over acetate as a stabilizer in hemodialysis fluid: A randomized ABC-treat study. / Ventajas del uso de citrato respecto al acetato como estabilizante en el líquido de hemodiálisis: estudio aleatorizado ABC-treat.

Hemodialysis (HD) with bicarbonate dialysis fluid (DF) requires the presence of an acid to prevent the precipitation of calcium and magnesium carbonate. The most used acid is acetic acid, with it several complications have been described. In a previous work, we described the acute changes during an HD session with a DF with citrate instead of acetate. Now, we report the results in the medium term, 16 weeks. It is a prospective, multicenter, crossover and randomized study, where 56 HD patients with bicarbonate three times a week were dialysed for 16 weeks with 3mmol/L acetate and 16 weeks with 1mmol/L citrate. Patients older than 18 years with a previous stay on HD of more than 3 months and with a normal functioning arteriovenous fistula were included. Epidemiological data, dialysis, bioimpedance, biochemistry before and after HD, as well as hypotensive episodes, were collected monthly. After 16 weeks of citrate treatment, pre-HD ionic calcium and magnesium were significantly lower and paratiroid hormone (PTH) higher than in the acetate period. No differences were observed in the effectiveness of dialysis. Hypotensive episodes were significantly more frequent with acetate than with citrate: 311 (14.1%) vs 238 (10.8%) sessions. The lean mass index increased by 0.96±2.33kg/m2 when patients switched from DF with acetate to citrate. HD with citrate modifies several parameters of bone mineral metabolism, not only acutely as previously described, but also in the long-term. The substitution of acetate for citrate improves hemodynamic stability, producing less hypotension and can improve nutritional status.

Factors associated with falls in hemodialysis patients: a case-control study / Factores asociados a caídas en pacientes hemodializados: un estudio de caso-control / Fatores associados às quedas em pacientes de hemodiálise: um estudo caso-controle

Objective: to identify possible associations between a higher probability of falls among hemodialysis patients and laboratory values, comorbidities, pharmacological treatment, hemodynamic changes, dialysis results and stabilometric alterations. Method: this was a retrospective case-control study with hemodialysis patients. Patients in a hemodialysis unit who had suffered one or more falls were included in the case group. Patients from the same unit who had not suffered falls were the controls. Data were gathered from the patients' clinical history and also from the results of a balance test conducted six months before the study. Results: thirty-one patients were included (10 cases and 21 controls). Intradialytic body weight change was significantly greater among cases (p <0.05). Patients in the case group also presented greater lateral instability after dialysis (p <0.05). Other factors such as high blood pressure, antihypertensives, beta-blockers, and lower heart rates were also associated with falls. Conclusion: a greater intradialytic weight change was associated with an increase in risk of falls. Nursing staff can control these factors to prevent the incidence of falls in dialysis patients.

Objetivo: identificar la posible asociación entre los valores analíticos, comorbilidades, tratamiento farmacológico, cambios hemodinámicos, resultado de la diálisis y alteraciones estabilométricas con una mayor probabilidad de caídas en pacientes en hemodiálisis. Método: estudio retrospectivo de casos y controles en pacientes en hemodiálisis. Se consideraron como casos pacientes de una unidad de hemodiálisis que habían sufrido una o varias caídas. Los controles fueron pacientes de la misma unidad que no sufrieron caídas. Se obtuvieron los datos de la historia clínica de los pacientes y, también, se valoró una prueba de equilibrio realizada 6 meses antes a dichos pacientes. Resultados: se incluyeron 31 pacientes (10 casos y 21 controles). El cambio de peso durante la diálisis fue significativamente mayor en el grupo de personas que sufrieron una caída (p <0,05). Los pacientes que sufrieron una caída presentaron mayor inestabilidad lateral después de la diálisis (p <0.05). Otros factores como la hipertensión arterial, los antihipertensivos, los betabloqueantes y las frecuencias cardiacas más bajas también se relacionaron con las caídas. Conclusión: un mayor cambio de peso intradiálisis se relaciona con mayor riesgo de caídas. El control de estos factores por parte del personal de enfermería podría prevenir la incidencia de caídas en pacientes dializados.

Objetivo: identificar a possível associação entre valores laboratoriais, comorbidades, tratamento farmacológico, alterações hemodinâmicas, resultado da diálise e alterações estabilométricas com uma maior probabilidade de quedas em pacientes de hemodiálise. Método: estudo caso-controle retrospectivo em pacientes de hemodiálise. Foram analisados os casos de pacientes de uma unidade de hemodiálise que sofreram uma ou mais quedas. Os controles foram pacientes da mesma unidade que não sofreram quedas. Os dados foram obtidos a partir do histórico clínico dos pacientes e, também, de um teste de equilíbrio realizado seis meses antes nesses pacientes. Resultados: 31 pacientes foram avaliados (10 casos e 21 controles). A alteração de peso durante a diálise foi significativamente maior no grupo de pessoas que sofreu uma queda (p <0,05). Pacientes que sofreram queda apresentaram maior instabilidade lateral após a diálise (p <0,05). Outros fatores, como hipertensão, anti-hipertensivos, betabloqueadores e frequência cardíaca mais baixa, também foram associados às quedas. Conclusão: uma maior alteração do peso intradialítico está relacionada a um maior risco de quedas. O controle desses fatores pela equipe de enfermagem poderia prevenir a incidência de quedas em pacientes em diálise.

Haemodialysis patients have worse postural balance with an associated risk of falls. / Los pacientes en hemodiálisis presentan peor equilibrio postural, que se relaciona con el riesgo de caídas.

INTRODUCTION: Postural balance is the result of a complex interaction of sensory input which keeps us upright. Haemodialysis patients have alterations which can lead to postural instability and a risk of falls. Our objective was to analyse postural stability and its relationship with the risk of falls in haemodialysis patients using a force platform. MATERIAL AND METHODS: This was a prospective cross-sectional study. Postural balance was recorded using a force platform in prevalent haemodialysis patients. We collected epidemiological, dialysis, analytical and treatment data. The incidence of falls was recorded over the 6 months following the tests. The postural stability analysis was performed with a portable strain gauge platform (AMTI AccuGait®) and a specific software unit for stabilometry (Balance Trainer® program). We measured 31 balance parameters; the balance variables used were: Area95; AreaEffect; VyMax; Xrange and Yrange. The stabilometry studies were performed in 3 situations: with eyes open; with eyes closed; and with the patient performing a simultaneous task. We performed one study at the start of the dialysis session, and a second study at the end. Stabilometry was measured in a control group under similar conditions. RESULTS: We studied 32 patients with a mean age of 68 years old; of this group, 20 subjects were male and 12 were female. Their mean weight was 74kg, with a mean BMI of 27.6kg/m2. In the controls, there were no significant differences in the stabilometry between the 3 situations studied. Both pre- and post-haemodialysis, patients with closed eyes showed greater imbalance, and there were significant differences with the other situations and controls. We found a significant increase in instability after the haemodialysis session, and greater instability in the 13 patients with diabetes (P<.05). The 4 patients with hyponatraemia (Na<136mmol/l) had worse balance in the simultaneous task situation (P=.038). Various drugs, such as insulin (P=.022), antiplatelet agents (P=.036) and beta-blockers (P=.029), were associated with imbalance. The 10 patients who suffered falls had greater imbalance, Yrange, Xrange, Area95 and AreaEffect, both pre- and post-haemodialysis (P<.05) than those without falls. CONCLUSIONS: Haemodialysis patients have alterations which can lead to postural instability and a risk of falls. Prevention programmes which include specific exercises to improve balance could be beneficial in reducing the risk of falls in this population.

Hypomagnesaemia in haemodialysis is associated with increased mortality risk: its relationship with dialysis fluid. / La hipomagnesemia en hemodiálisis se asocia a mayor riesgo de mortalidad: su relación con el líquido de diálisis.

Hypomagnesaemia in haemodialysis (HD) is associated with increased mortality risk: its relationship with dialysis fluid (DF). INTRODUCTION: Low concentrations of magnesium (Mg) in blood have been linked to the development of diabetes, hypertension, arrhythmias, vascular calcifications and an increased risk of death in the general population and in haemodialysis patients. The composition of the dialysis fluid in terms of its magnesium concentration is one of the main determinants of magnesium in haemodialysis patients. OBJECTIVE: To study magnesium concentrations in haemodialysis patients, their predictive mortality rate and what factors are associated with hypomagnesaemia and mortality in haemodialysis. METHODS: Retrospective study of a cohort of prevalent haemodialysis patients followed up for two years. Serum magnesium was measured every six months. The analysis used the initial and average magnesium values for each patient, comparing patients with magnesium below the mean (2.1mg/dl) with those with magnesium above the mean. During the follow-up, three types of dialysis fluid were used: type 1, magnesium 0.5 mmol/l; type 3, magnesium 0.37 mmol/l (both with acetate); and type 2, magnesium 0.5 mmol/l with citrate. RESULTS: We included 137 haemodialysis patients in the study, of which 72 were male and 65 were female, with a mean age of 67 (15) [26-95] years old. Of this group, 57 patients were diabetic, 70 were on online haemodiafiltration (OL-HDF) and 67 were on high-flow haemodialysis (HF-HD). The mean magnesium of the 93 patients with dialysis fluid type 1 was 2.18 (0.37) mg/dl. In the 27 patients with dialysis fluid type 3 it was 2.02 (0.42) mg/dl. And in the 17 with dialysis fluid type 2 it was 1.84 (0.24) mg/dl (p=.01). There was a pronounced direct relationship between Mg and P and albumin. After a mean follow-up of 16.6 (8.9) [3-24] months, 77 remained active, 24 had died and 36 had been transplanted or transferred. Patients with magnesium above than 2.1mg/dl had a longer survival (p=.008). The survival of patients with the three types of dialysis fluid did not differ significantly (Log-Rank, p=.424). Corrected for blood magnesium, patients with dialysis fluid with citrate have better survival (p=.009). The COX regression analysis shows how age, serum albumin, magnesium, dialysis technique and type of dialysis fluid have an independent predictive mortality rate. CONCLUSIONS: Low serum magnesium levels have a greater association with an increased risk of mortality compared to high levels. The type of dialysis fluid affects the magnesium concentration and the risk of death.

Statins and antiplatelet agents are associated with changes in the circulatory markers of endothelial dysfunction in chronic kidney disease. / El uso de estatinas y antiagregantes se asocia con cambios en los marcadores de disfunción endotelial en la enfermedad renal crónica.

BACKGROUNDS AND PURPOSES: Patients with chronic kidney disease (CKD) have higher risk of developing cardiovascular disease. In CKD patients the mechanisms involved in, endothelial damage and the role of different drugs used on these patients are not completely understood. The aim of this work is to analyze the effect of statins and platelet antiaggregant (PA) on endothelial microvesicles (EMVs) and other markers of endothelial dysfunction. EXPERIMENTAL APPROACH: Cross-sectional study of 41 patients with CKD 3b-4 and 8 healthy volunteers. Circulating levels of EMVs, vascular endothelial growth factor (VEGF), and advance oxidized protein products (AOPPS) were quantified and the correlation with different comorbidity variables and therapeutic strategies were evaluated. RESULTS: EMVs are increased in CKD patients as compared with controls (171.1 vs. 68.3/µl, P<.001). It was observed a negative correlation between age and EMVs. Statins and PA were associated with a reduction in EMVs and VEGF levels, independently of the serum total cholesterol levels (TC). The levels of AOPPS and VEGF were not different in CKD vs. controls. CONCLUSION: CKD is associated with a change in EMVs, VEGF and AOPP levels. The treatment with statins and PA normalizes these values to almost the observed in controls and this effect is independently of the prevailing TC level. These findings explain the existence of the pleiotropic effects of statins and PA which deserve further studies.

Prospective randomised multicentre study to demonstrate the benefits of haemodialysis without acetate (with citrate): ABC-treat Study. Acute effect of citrate. / Estudio prospectivo aleatorizado multicéntrico para demostrar los beneficios de la hemodiálisis sin acetato (con citrato): Estudio ABC-treat. Efecto agudo del citrato.

INTRODUCTION: Dialysis fluid (DF), an essential element in hemodialysis (HD), is manufactured in situ by mixing three components: treated water, bicarbonate concentrate and acid concentrate. To avoid the precipitation of calcium and magnesium carbonate that is produced in DF by the addition of bicarbonate, it is necessary to add an acid. There are 2 acid concentrates that contain acetate (ADF) or citrate (CDF) as a stabilizer. OBJECTIVE: To compare the acute effect of HD with CDF vs. ADF on the metabolism of calcium, phosphorus and magnesium, acid base balance, coagulation, inflammation and hemodynamic stability. METHODS: Prospective, multicenter, randomized and crossed study, of 32 weeks duration, in patients in three-week HD, AK-200-Ultra-S or Artis monitor, 16 weeks with ADF SoftPac®, prepared with 3mmol/L of acetate, and 16 weeks with CDF SelectBag Citrate®, with 1mmol/L of citrate. Patients older than 18 years were included in HD for a minimum of 3 months by arteriovenous fistula. Epidemiological, dialysis, pre and postdialysis biochemistry, episodes of arterial hypotension, and coagulation scores were collected monthly during the 8 months of the study. Pre and post-dialysis analysis were extracted: venous blood gas, calcium (Ca), ionic calcium (Cai), phosphorus (P), magnesium (Mg) and parathyroid hormone (PTH) among others. ClinicalTrials.gov NCT03319680. RESULTS: We included 56 patients, 47 (84%) men and 9 (16%) women, mean age: 65.3 (16.4) years, technique HD/HDF: 20 (35.7%)/36 (64.3%). We found differences (p<0.05) when using the DF with citrate (C) versus acetate (A) in the postdialysis values of bicarbonate [C: 26.9 (1.9) vs. A: 28.5 (3) mmol/L], Cai [C: 1.1 (0.05) vs. A: 1.2 (0.08) mmol/L], Mg [C: 1.8 (0.1) vs A: 1, 9 (0.2) mg/dL] and PTH [C: 255 (172) vs. 148 (149) pg/mL]. We did not find any differences in any of the parameters measured before dialysis. Of the 4,416 sessions performed, 2,208 in each group, 311 sessions (14.1%) with ADF and 238 (10.8%) with CDF (p<0.01), were complicated by arterial hypotension. The decrease in maximum blood volume measured by Hemoscan® biosensor was also lower [-3.4 (7.7) vs -5.1 (8.2)] although without statistical significance. CONCLUSION: Dialysis with citrate acutely produces less postdialysis alkalemia and significantly modifies Ca, Mg and PTH. CDF has a positive impact on hemodynamic tolerance.

Unlike Kt, high Kt/V is associated with greater mortality: The importance of low V. / El Kt/V alto, a diferencia del Kt, se asocia a mayor mortalidad: importancia de la V baja.

INTRODUCTION: Kt/V has been used as a synonym for haemodialysis dose. Patient survival improved with a Kt/V>1; this target was subsequently increased to 1.2 and 1.3. The HEMO study revealed no significant relationship between Kt/V and mortality. The relationship between Kt/V and mortality often shows a J-shaped curve. Is V the confounding factor in this relationship? The objective of this study is to determine the relationship between mortality and Kt/V, Kt and body water content (V) and lean mass (bioimpedance). METHODS: We studied a cohort of 127 prevalent haemodialysis patients, who we followed-up for an average of 36 months. Kt was determined by ionic dialysance, and V and nutrition parameters by bioimpedance. Kt/V, Kt corrected for body surface area (Kt/BSA) and target Kt/BSA were calculated. The mean data from 18,998 sessions were used as haemodialysis parameters, with a mean of 155 sessions per patient. RESULTS: Mean age was 70.4±15.3 years and 61% were male; 76 were dialysed via an arteriovenous fistula and 65 were on online haemodiafiltration. Weight was 70.6 (16.8)kg; BSA 1.8 (0.25) m2; total body water (V) 32.2 (7.41) l and lean mass index (LMI) 11.1 (2.7)kg/m2. Mean Kt/V was 1.84 (0.44); Kt 56.1 (7)l and Kt/BSA 52.8 (10.4)l. The mean target Kt/BSA was 49.7 (4.5)l. Mean Kt/BSA-target Kt/BSA +6.4 (7.0)l. Patients with a higher Kt/V had worse survival rates than others; with Kt this is not the case. Higher Kt/V values are due to a lower V, with poorer nutrition parameters. LMI and serum albumin were the parameters that best independently predicted the risk of death and are lower in patients with a higher Kt/V and lower V. CONCLUSION: Kt/V is not useful for determining dialysis doses in patients with low or reduced body water. Kt or the Kt/BSA are proposed as an alternative.

Asymmetric cellulose triacetate is a safe and effective alternative for online haemodiafiltration. / El triacetato de celulosa asimétrico es una alternativa segura y eficaz para la hemodiafiltración en línea.

BACKGROUND: In post-dilution haemodiafiltration only synthetic membranes have been used to date. Asymmetric cellulose triacetate (ATA™) is now available, whose characteristics are suitable for this technique. OBJECTIVES: To describe the in vivo performance and behaviour of this membrane, to identify its depurative effectiveness, use in clinical practice and its biocompatibility, both acute and after one month of treatment. METHODS: Observational prospective study of 23 patients who were dialysed for 4 weeks using an ATA™ membrane and who maintained their prior regimen. RESULTS: A total of 287 sessions were performed and 264 complete sessions were collected. With an effective time of 243.7 (17.6) min and a mean blood flow of 371.7 (23) ml/min, an average Kt of 56.3 (5.3) l was observed, as well as a convection volume of 27.1 (4.2) l, a filtration fraction of 29.9 (3.7) %, a urea reduction ratio (RR) of 81 (5.2) %, a creatinine RR of 74.7 (4.6) %, a ß2-microglobulin RR of 76.5 (4.8) % and a retinol binding protein RR of 18.6 (7.6) %. There were no technical problems or alarms. Changing the heparin dosage was not necessary. No increases in C3a or C5a concentrations or leukopenia were observed in the first 30min of the session. Neither the monocyte subpopulations nor IL-ß1 or IL-6 were significantly altered after one month of treatment. CONCLUSIONS: The new ATA™ membrane achieves adequate Kt and convection volume, without technical problems and with good biocompatibility and inflammatory profiles. It is therefore a valid option for post-dilution haemodiafiltration, particularly in patients allergic to synthetic membranes.

Increased mortality in haemodialysis patients administered high doses of erythropoiesis-stimulating agents: a propensity score-matched analysis.

Background: Erythropoiesis-stimulating agents (ESAs) are widely used to treat anaemia in patients with chronic kidney disease. The issue of ESA safety has been raised in multiple studies, with correlates derived for elevated cancer incidence and mortality. Whether these associations are related to ESA dose or the typology of the patient remains obscure. Methods: A multicentre, observational retrospective propensity score-matched study was designed to analyse the effects of weekly ESA dose in 1679 incident haemodialysis (HD) patients. ESA administration was according to standard medical practice. Patients were grouped as quintiles, according to ESA dose, in order to compare mortality and hospitalization data. Using propensity score matching (PSM), we defined two groups of 324 patients receiving weekly threshold ESA doses of either > or ≤8000 IU. Results: Kaplan-Meier survival curves indicated significant increases in the risk of mortality in patients administered with high doses of ESAs (>8127.4 IU/week). Multivariate Cox models identified a high ESA dose as an independent predictor for all-cause and cardiovascular (CV) mortality. Moreover, logistic regression models identified high ESA doses as an independent predictor for all-cause, CV and infectious hospitalization. PSM analyses confirmed that weekly ESA doses of >8000 IU constitute an independent predictor of all-cause mortality and hospitalization, even though the adjusted cohort displayed the same demographic features, inflammatory profile, clinical HD parameters and haemoglobin levels. Conclusions: Our data suggest that ESA doses of >8000 IU/week are associated with an increased risk of all-cause mortality and hospitalization in HD patients.

Relationships between iron dose, hospitalizations and mortality in incident haemodialysis patients: a propensity-score matched approach.

Background: Intravenous iron management is common in the haemodialysis population. However, the safest dosing strategy remains uncertain, in terms of the risk of hospitalization and mortality. We aimed to determine the effects of cumulative monthly iron doses on mortality and hospitalization. Methods: This multicentre observational retrospective propensity-matched score study included 1679 incident haemodialysis patients. We measured baseline demographic variables, haemodialysis clinical parameters and laboratory analytical values. We compared outcomes among quartiles of cumulative iron dose (mg/kg/month). We implemented propensity-score matching (PSM) to reduce confounding due to indication. In the PSM cohort (330 patients), we compared outcomes between groups that received cumulative iron doses above and below 5.66 mg/kg/month. Results: Kaplan-Meier analyses showed that the high iron dose group had significantly worse survival than the low iron dose group. A univariate analysis indicated that the monthly iron dose could significantly predict mortality. However, a multivariate regression did not confirm that finding. The multivariate regression analysis revealed that iron doses >5.58 mg/kg/month were not associated with elevated mortality risk, but they were associated with elevated risks of all-cause and cardiovascular-related hospitalizations. These results were ratified in the PSM population. Conclusions: Intravenous iron administration is advisable for maintaining haemoglobin levels in patients that receive haemodialysis. Our data suggested that large monthly iron doses, adjusted for body weight, were associated with more hospitalizations, but not with mortality or infection-related hospitalizations.

Citrate dialysate does not induce oxidative stress or inflammation in vitro as compared to acetate dialysate. / El líquido de diálisis con citrato no induce in vitro estrés oxidativo ni inflamación en comparación con el acetato.

Increased acetataemia during haemodialysis sessions has been associated with a number of abnormalities, including increased oxidative stress, pro-inflammatory cytokines and nitric oxide synthesis. However, citric acid may play an alternative role to acetate as a dialysate stabiliser given that the effect of citrate on complement and leukocyte activation is different to that of acetate. The purpose of this study was to compare the inflammatory effect in immunocompetent blood cells of acetate dialysate and citrate dialysate. MATERIAL AND METHODS: The effect of acetate and/or citrate was investigated in the whole blood of uraemic patients and in healthy in vitro samples. Four types of dialysate were tested: dialysate 1, acetate-free with 1mmol/L of citrate; dialysate 2, with 0.8mmol/L of citrate and 0.3mmol/L of acetate; dialysate 3, citrate-free with 3mmol/L of acetate; and dialysate 4, citrate-free with 4mmol/L of acetate. The cell types used were: human monocyte culture (THP-1); and peripheral blood mononuclear cells (PBMCs) from healthy subjects and uraemic patients on haemodialysis. ICAM-1 was determined and levels of reactive oxygen species and total microvesicles were quantified. RESULTS: Unlike the citrate dialysates, the dialysates with acetate (dialysate 3 and dialysate 4) induced increased ICAM-1 expression density in THP-1 cells; an increase in ICAM-1 expression was observed in the immunocompetent cells of healthy subjects with acetate dialysate (dialysate 3 and dialysate 4) but not with citrate dialysate (dialysate 1 and dialysate 2). No significant ICAM-1 differences were found between the different dialysates in the cells of haemodialysed patients. Reactive oxygen species expression and the number of microvesicles increased significantly with acetate dialysate but not with citrate dialysate in the cells of both healthy subjects and haemodialysed patients. CONCLUSIONS: At the concentrations in which it is generally used in clinical practice, acetate-based dialysate increases oxidative stress and the total number of microvesicles and may induce other pro-inflammatory stimuli typical of uraemic patients on haemodialysis. Citrate dialysates do not induce this activation, which could make them a suitable alternative in clinical practice.

Residual Renal Function in Hemodialysis and Inflammation.

Residual renal function (RRF) has an important effect on uremic toxin clearance, on volume control, on quality of life, and on mortality. In patients with chronic kidney disease (CKD), microinflammation with an increased percentage of CD14+ /CD16++ inflammatory monocytes has been reported, even with no clinical evidence of inflammation. No correlation has been established between these and RRF in hemodialysis (HD) patients. Our objective was to assess the relationship between RRF and the inflammatory parameters in HD patients. Cross-sectional observational study was carried out on 69 adult patients on chronic HD for at least 6 months, from which demographic, analytic and HD-technique data were collected and the following were measured: (i) RRF with average urea and creatinine clearance ((CCr + CU)/2) in 24-h urine (if >1 mL/min and diuresis >100 mL/day, RRF was considered); (ii) Inflammation through biochemical parameters (C-reactive protein, ß2 microglobulin, albumin) and monocyte subpopulations in peripheral blood. The average age was 70.9 [40-88] years old; 38 (55.1%) were male; and 25 (36.2%) were diabetic. 43.5% (30/69) presented RRF, with an average of ((CCr + CU)/2): 1.8 (2.6) mL/min and diuresis: 454.5 (569) mL /24 h. Patients with RRF presented lower concentrations of C-reactive protein (6.2 vs 21.4 mg/L) (P = 0.038) and a lower percentage of non-classical CD14+ /CD16++ monocytes (14.6 vs. 28.3%, P = 0.02). In our study, patients with RRF present lower concentrations of inflammatory parameters, which is another reason why its preservation is an essential objective in HD.

Hemodiafiltration Reduces All-Cause and Cardiovascular Mortality in Incident Hemodialysis Patients: A Propensity-Matched Cohort Study.

BACKGROUND: The majority of studies suggesting that online hemodiafiltration reduces the risk of mortality compared to hemodialysis (HD) have been performed in dialysis-prevalent populations. In this report, we conducted an epidemiologic study of mortality in incident dialysis patients, comparing post-dilution online hemodiafiltration and high-flux HD, with propensity score matching (PSM) used to correct indication bias. METHODS: Our study cohort comprised 3,075 incident dialysis patients treated in 64 Spanish Fresenius Medical Care clinics between January 2009 and December 2012. The primary outcome of this study was to investigate the impact of the type of renal replacement on all-cause mortality. An analysis of cardiovascular mortality was defined as the secondary outcome. To achieve these objectives, patients were followed until December 2016. Patients were categorized as high-flux HD patients if they underwent this treatment exclusively. If >90% of their treatment was with online hemodiafiltration, then the patient was grouped to that modality. RESULTS: After PSM, a total of 1,012 patients were matched. Compared with patients on high-flux HD, those on online hemodiafiltration received a median replacement volume of 23.45 (interquartile range 21.27-25.51) L/session and manifested 24 and 33% reductions in all-cause and cardiovascular mortality (all-cause mortality hazards ratio [HR] 0.76, 95% CI 0.62-0.94 [p = 0.01]; and cardiovascular mortality HR 0.67, 95% CI 0.50-0.90 [p = 0.008]). CONCLUSIONS: This study shows that post-dilution online hemodiafiltration reduces all-cause and cardiovascular mortality compared to high-flux HD in an incident HD population.