Treatment of preeclampsia at extremely preterm gestation with therapeutic plasma exchange.

AIMS: Different forms of apheresis have been proposed as potential therapeutic approaches to remove soluble Fms-like tyrosine kinase-1 (sFlt-1) and allow safe pregnancy prolongation in cases of extremely preterm preeclampsia. This is a follow-up study presenting our experiences with therapeutic plasma exchange (TPE) in 5 women with preeclampsia at < 28 weeks of gestational age. MATERIALS AND METHODS: All women received standard treatment for preeclampsia and 2 - 3 TPE treatments per week. Blood samples for sFlt-1 and placental growth factor (PlGF) measurements were collected before and after each TPE. RESULTS: Seventeen TPE procedures were performed, 2 - 5 per patient. TPE significantly reduced sFlt-1 (by 35 ± 6%), sFlt-1/PlGF ratio (by 24 ± 13%), and to a lesser degree also PlGF (by 12 ± 16%), with a rebound observed on day 1 post procedure. TPE procedures were well tolerated by pregnant women and fetuses. Stabilization of sFlt-1 allowed pregnancy prolongation for a median of 8 (range 2 - 14) days from first TPE and for a median of 10 (range 4 - 17) days from hospital admission. There were no signs of increased risks of adverse neonatal outcome associated with TPE. One neonate died due to extreme prematurity 3 days after delivery, 2 had bronchopulmonary dysplasia, and 1 had retinopathy of prematurity. CONCLUSION: This study provides new evidence of effective reduction in sFlt-1 and sFlt-1/PlGF ratio with TPE treatment, which seems to allow a clinically meaningful prolongation of pregnancy. Controlled studies are necessary to convincingly show the potential benefit of apheresis treatment in preeclampsia at extremely preterm gestation.

A national cohort study on hemodialysis arteriovenous fistulas after kidney transplantation - long-term patency, use and complications.

OBJECTIVE: To describe the long-term hemodialysis arteriovenous fistula (AVF) patency, incidence of AVF use, incidence and nature of AVF complications and surgery in patients after kidney transplantation. PATIENTS AND METHODS: We retrospectively analysed the AVF outcome and complications in all adult kidney allograft recipients transplanted between January 1st, 2000 and December 31, 2015 with a functional AVF at the time of transplantation. Follow-up was until December 31, 2019. RESULTS: We included 626 patients. Median AVF follow-up was 4.9 years. One month after kidney transplantation estimated AVF patency rate was 90%, at 1 year it was 82%, at 3 years it was 70% and at 5 years it was 61%; median estimated AVF patency was 7.9 years. The main cause of AVF failure was spontaneous thrombosis occurring in 76% of AVF failure cases, whereas 24% of AVFs were ligated or extirpated. In a Cox multivariate model female sex and grafts were independently associated with more frequent AVF thrombosis. AVF was used in about one third of our patients. AVF-related complications occurred in 29% of patients and included: growing aneurysms, complicated thrombosis, high-flow AVF, signs of distal hypoperfusion, venous hypertension, trauma of the AVF arm, or pain in the AVF/arm. CONCLUSIONS: AVFs remain functional after kidney transplantation in the majority of patients and are often re-used after graft failure. AVF-related complications are common and require proper care.

Therapeutic plasma exchange and dextran-sulfate plasma adsorption as extracorporeal treatments of extremely preterm preeclampsia with fetal growth restriction.

AIM: To evaluate effectiveness and safety of therapeutic plasma exchange (TPE) and dextran-sulfate plasma adsorption (DSA) for extracorporeal removal of soluble Fms-like tyrosine kinase-1 (sFlt-1) as part of expectant management of preeclampsia at extremely preterm gestational age. METHODS: Retrospective case series of six patients with preeclampsia at <28 weeks of gestation, treated with DSA or TPE. Laboratory results, clinical characteristics and neonatal outcomes were collected from charts and National Perinatal Information System. RESULTS: Fetal growth restriction (FGR) was diagnosed in all cases. Pregnancy was prolonged for a median of 14 (range 5-74) days from admission and 10 (3-73) days from first apheresis. A mixed effects model showed a decrease in sFlt-1 and sFlt-1/PlGF ratio during DSA/TPE (significant effect of time [before/after]), which was comparable between DSA and TPE (no effect of procedure type). Median absolute reduction in sFlt-1 was 42% (inter-quartile range [IQR] 13%-57%) during DSA and 34% (16%-40%) during TPE; for sFlt-1/PlGF ratio it was 29% (22%-36%) and 38% (29%-42%), respectively. All procedures were well tolerated by fetuses. Anaphylactoid reaction, often with angioedema, occurred in 4/6 patients undergoing DSA and was attributed to bradykinin activation. One patient developed wound hematoma after cesarean section, possibly attributed to depletion coagulopathy. CONCLUSIONS: As potential novel treatment of early preeclampsia, a non-selective and widely available TPE was comparable to DSA regarding sFlt-1 reduction but was associated with fewer side-effects. Both seem to allow maternal stabilization and pregnancy prolongation even when early preeclampsia is complicated by FGR.

Regional citrate anticoagulation for continuous renal replacement therapy in newborns and infants: Focus on citrate accumulation.

Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur. There are only a few studies reporting the detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in the 2011-2016 period were included in this retrospective observational study. Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding the circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5), and metabolic complications. We included 10 children with mean age of 2.6 ± 3.8 months and BW of 4.6 ± 2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46 ± 9 mL/min (12 ± 5 mL/min/kg BW), citrate dose 2.8 ± 0.6 mmol/L of blood resulting in estimated citrate load to the patient of 1.7 ± 0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39 ± 29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cutoff value (sensitivity 71% and specificity 72%). CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping the blood flow below 9 mL/min/kg BW.

Anticoagulation assessment methods in plasma exchange with regional citrate anticoagulation: evaluation of post-filter and filtered plasma ionized calcium.

AIM: To assess the possibility of using filtered plasma instead of postfilter ionized calcium (iCa) for the assessment of anticoagulation in plasma exchange (PE) with citrate anticoagulation. METHODS: 140 PE treatments were performed using either 4% or 15% citrate at a comparable dose. Paired samples of postfilter blood and filtered plasma were taken for iCa measurements with a point-of-care analyzer. Anticoagulation was also assessed with a bedside clotting time and visual assessment of the circuit after procedures. RESULTS: In 490 paired samples, mean postfilter iCa was 0.39 ± 0.14 mmol/L, and filtered plasma iCa was 0.33 ± 0.11 mmol/L. Mean bedside clotting time was 18 ± 7 minutes. Neither the postfilter (r = 0.03, p = 0.73) nor the filtered plasma iCa (r = 0.09, p = 0.25) correlated significantly with bedside clotting time. Bland-Altman analysis showed a modest agreement between filtered plasma and postfilter iCa values (mean difference -0.07 mmol/L, upper and lower 95% limits of agreement 0.10 and -0.23 mmol/L). Median visual assessment score was excellent at all three checkpoints. CONCLUSIONS: A modest agreement between filtered plasma and postfilter iCa values could be acceptable if only a confirmation of anticoagulant effect is required. Measuring filtered plasma instead of postfilter iCa would reduce blood loss with sampling, which could be important in some settings.
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Acute kidney injury in critically-ill adult patients with seasonal influenza infection.

BACKGROUND: Acute kidney injury (AKI) occurs in 22.4 - 100% of critically-ill hospitalized patients with influenza infection. In up to 2/3, it is severe enough to necessitate renal replacement therapy. We aimed to document the incidence of AKI among patients with influenza-related critical illness and its relation to clinical outcomes. METHODS: We conducted a retrospective observational study of all adult patients with acute respiratory illness and laboratory-confirmed influenza infection admitted to non-surgical intensive care units at the University Medical Centre Ljubljana between January 1, 2016, and March 31, 2016. RESULT: Our sample consisted of 28 adult patients with mean age in years of 57.5 ± 20.2. Incidence of AKI was 71.4%. Mortality was 28.6% (35% in patients with AKI and 41.6% in patients who required renal replacement therapy). CONCLUSIONS: Influenza-related critical illness is rare but can cause AKI in a large proportion of affected patients. In this setting, requirement for renal replacement therapy could be associated with increased mortality risk.
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Treatment of antibody-mediated rejection of kidney grafts with bortezomib and/or rituximab compared to standard regimen: experience of Slovene National Center.

BACKGROUND: The aim of our study was to determine outcomes of standard treatment of antibody-mediated rejection (ABMR) of kidney grafts as compared to the addition of bortezomib or rituximab. METHODS: The cohort of this retrospective study included patients treated for ABMR of kidney grafts at our national center in the period of 2005 - 2017, divided into two groups: standard (ST) group treated standardly with plasmapheresis or immunoadsorption, intravenous immunoglobulins, and corticosteroids, and BR group treated with the addition of bortezomib and/or rituximab. Patient and graft survival at 2 years was analyzed by Kaplan-Meier method, and predictors of graft survival were analyzed by Cox regression. RESULTS: There were 78 patients with ABMR (48 in the ST group, 30 in the BR group), 41 (53%) were men, mean age 49.5 ± 13.8 years. In ST and BR, respectively, mean serum creatinine was 267 ± 164 and 208 ± 112 µmol/L (p = 0.088), donor-specific antibodies (DSA) were positive in 75% and 97% (p = 0.022), and ABMR was acute in 50% and 33% (p = 0.149). Patient survival at 2 years was 89% in the ST and 100% in the BR group (p = 0.125). Cumulative proportion of kidney graft survival at 1 and 2 years was 67% and 53% in the ST group and 73% and 48% in the BR group, respectively, (p = 0.641). Chronic ABMR (HR 5.22, p = 0.004) was significant, while dialysis dependency at biopsy (HR 3.28, p = 0.072), serum creatinine at kidney biopsy (HR 1.003, p = 0.082), and presence of DQ-DSA (HR 3.37, p = 0.062) were borderline significant predictors of worse graft outcome. Infections were relatively common in both groups, with a trend towards more rehospitalizations due to infections in the first 6 months after treatment in the BR group (p = 0.066). In 5 patients (17%), treatment with bortezomib was discontinued prematurely due to cytopenia. CONCLUSIONS: Bortezomib or rituximab, added to standard treatment, did not significantly improve kidney graft survival and was also not associated with significant side effects, except cytopenia in some cases. Treatment of acute ABMR resulted in better graft survival than chronic ABMR.
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Treatment Efficacy and Safety During Plasma Exchange With Citrate Anticoagulation: A Randomized Study of 4 Versus 15% Citrate.

In plasma exchange (PE), contrary to dialysis, there is no ultrafiltration, and the volume of anticoagulant contributes to volume overload of the patient and might also reduce PE efficiency through dilution. To reduce the volume of citrate, we compared 4 and 15% citrate anticoagulation protocols in PE in a randomized study, aiming to evaluate PE efficacy, anticoagulation efficiency, and overall safety. In addition to standard biochemical analyses during PE treatments, the elimination rate (ER) of immunoglobulins was calculated to evaluate PE efficacy. Anticoagulation was evaluated by postfilter ionized calcium, visual evaluation of the extracorporeal system, and change in the sieving coefficient (SC) during PE. Accumulation of citrate was determined by calculating the total-to-ionized calcium ratio and measuring the citrate concentration after PE. One hundred forty procedures (70 in each group) were performed in 37 patients. The mean citrate infusion rate was 197 ± 10 mL/h in the 4% and 59 ± 5.5 mL/h in the 15% groups, respectively; the total volume of infused citrate was 502 ± 77 mL versus 164 ± 52 mL (P < 0.001). ER for immunoglobulin G (0.57 ± 0.06 vs. 0.55 ± 0.1, P = 0.18), M, and A were comparable. Ionized calcium was stable during the procedures, and there were no significant side effects. Although postfilter ionized calcium was on the upper limit of the target range (0.41 ± 0.16 vs. 0.37 ± 0.14 mmol/L, P = 0.38), the visual assessment score was excellent, and even a rise in SC was observed during the procedures in both groups. The total-to-ionized calcium ratio was increased in 20 versus 22% of procedures, and citrate concentrations after PE were also similar (1306 ± 441 vs. 1263 ± 405 µmol/L). To conclude, we were unable to show superior PE efficacy in the 15% citrate group, but we significantly reduced the infused volume, which is important in patients with fluid overload. Both citrate protocols were found to provide excellent anticoagulation without significant metabolic disturbances or other side effects, confirming the safety of 15% citrate as anticoagulant during PE.

Very old patients on hemodialysis: how they start and can we predict survival?

BACKGROUND: We describe circumstances of dialysis initiation, dialysis prescription and factors affecting survival in elderly patients. METHODS: We included all incident patients ≥ 80 years old from a National Registry for which clinical and laboratory data at dialysis initiation could retrospectively be obtained. RESULTS: Of 170 patients included, 24% had diabetes, 30% ischemic heart disease, 13% peripheral arterial disease, 15% active malignancy and 60% prior nephrology care. Mean creatinine was 672 ± 225 µmol/l, eGFR 7.3 ± 3.7 ml/min/1.73 m2, 81% started dialysis in hospital and 78% with a catheter. 32% had < 2 sessions/week and 29% had single-needle dialysis. One-year survival was 74% (median 26 months). In multivariate analysis only age (HR 1.10) and prior nephrology care (HR 0.48) were significant predictors of survival. CONCLUSIONS: The majority of elderly patients started dialysis with a catheter and in hospital setting. We estimate observed survival as good. Only age and prior nephrology care were independent predictors of survival.

Intermittent high-volume predilution on-line haemofiltration versus standard intermittent haemodialysis in critically ill patients with acute kidney injury: a prospective randomized study.

BACKGROUND: The optimal modality of dialysis treatment in critically ill patients with acute kidney injury (AKI) remains unclear. Intermittent high-volume predilution on-line haemofiltration (HF) is not a well-established dialysis modality. The purpose of the study was to compare clinical outcomes between HF and standard intermittent haemodialysis (HD) in this specific population. METHODS: In this prospective, randomized, controlled single-centre clinical study, we compared mortality and recovery of kidney function between HF and HD in critically ill adult patients with AKI. The primary study outcome was 60-day all-cause mortality. Secondary study outcomes included 30-day and in-hospital all-cause mortality along with recovery of kidney function. Time to kidney function recovery and the number of required dialysis procedures were analyzed in the subgroup of patients with in-hospital recovery of kidney function. RESULTS: Baseline characteristics of the 273 patients in the two study groups were similar. All-cause mortality by Day 60 was 65.0% in the HF group and 65.5% in the HD group (hazard ratio, 0.98; 95% confidence interval, 0.71-1.33; P = 0.87). There were also no significant differences between the two groups in 30-day and in-hospital all-cause mortality or recovery of kidney function. Time to kidney function recovery and the number of required dialysis procedures were similar between the HF and the HD subgroup of patients with in-hospital recovery of kidney function. CONCLUSIONS: Dialysis treatment with intermittent high-volume predilution on-line HF in critically ill patients with AKI did not decrease mortality, improve recovery of kidney function or reduce the need for dialysis support compared to standard intermittent HD.

Clinical and dialysis-related characteristics of extremely long-term hemodialysis survivors: Three case reports.

More than 40-year hemodialysis survivors are living evidence of the achievements of hemodialysis therapy. We present the case reports of three patients treated by chronic hemodialysis for 47 (Patient 1), 43 (Patient 2), and 42 years (Patient 3) from a single center. These patients possess characteristics that were already shown to be associated with improved long-term survival: initiation of hemodialysis at a young age, absence of diabetes, and a relatively low and stable body weight with good nutritional status. Although all of them underwent complications of long-term hemodialysis treatment, they lived (Patient 3), or are still living (Patients 1 and 2), an independent and full life. Their hemodialysis prescriptions included long sessions with a moderate blood flow rate, state-of-the-art hemodialysis technology, vascular access surgeries and care provided by nephrologists, good overall management of chronic kidney disease, and preventive measures and/or immediate action in case of cardiovascular disease.

Standard citrate versus sequential citrate/anticoagulant-free anticoagulation during hemodialysis: a randomized trial.

In a randomized study, sequential anticoagulation for hemodialysis (citrate for the first 3.5 h, switching to 30-min anticoagulation-free hemodialysis) was compared to standard citrate anticoagulation. Fifty-two hemodialysis procedures were randomized either to sequential (n = 27) or standard citrate group (n = 25). The antithrombotic effect in the circuit was visually assessed after hemodialysis using a score from 1 (total clotting) to 5 (no clotting). The antithrombotic score for sequential versus standard group was as follows: dialyzer, 4.0 +/- 1.1 versus 4.8 +/- 0.4 (P < 0.01); arterial bubble trap, 4.0 +/- 1.2 versus 4.7 +/- 0.6 (P = 0.013); venous bubble trap, 4.0 +/- 1.3 versus 4.8 +/- 0.6 (P < 0.01). Serum citrate levels during sequential versus standard citrate anticoagulation (micromol/L) were as follows: at the beginning, 143 +/- 65 versus 148 +/- 77 (not significant [NS]); after 2 h, 317 +/- 157 versus 354 +/- 111 (NS); at the end, 125 +/- 81 versus 405 +/- 133 (P < 0.01). Sequential anticoagulation reduces the final serum citrate concentration to predialysis level. It can be a good anticoagulation strategy for patients in whom the reduction of citrate load is desired.

Regional citrate anticoagulation for single-needle hemodialysis: a prospective clinical study.

AIM: Regional citrate anticoagulation protocol for single-needle hemodialysis was tested prospectively for safety and efficacy. METHODS: 15 chronic dialysis patients at risk of bleeding were included. 4% trisodium citrate (200 ml/h), calcium-free dialysate and 1 mol/l calcium chloride (7 ml/h) were used. After dialysis the antithrombotic effect in the circuit was assessed visually (grade 5, no clotting, to 1, total occlusion) and serum citrate was measured. RESULTS: Of 32 dialyses performed, 94% were uneventful and in 2 cases (6%) there was severe (ionized calcium < or = 0.8 mmol/l) but asymptomatic hypocalcemia. Mean anticoagulation score after dialysis was 4.8 +/- 0.7 for the arterial bubble trap, 4.6 +/- 0.8 for the dialyzer and 4.8 +/- 0.7 for the venous bubble trap. Serum citrate after dialysis was 158 +/- 60 micromol/l. CONCLUSION: Regional citrate anticoagulation in single-needle dialysis is safe and efficient.

Does Guidewire Exchange Influence Infection Rate Related to Catheters Used for Vascular Access in Children on Chronic Hemodialysis?

A central venous catheter (CVC) can either be inserted "de novo" or placed by guidewire exchange (GWE). From September 1998 to September 2015, 32 children (19 boys, 13 girls) were hemodialyzed in our unit by using a CVC. The mean age at CVC insertion was 12.6 ± 0.5 years. A total of 121 uncuffed catheters were placed, either "de novo" or by GWE in 64 (52.9%) and 57 (47.1%) cases, respectively. The most frequent cause for line revision was catheter dysfunction in 40/121 (33.1%) patients. The overall incidence of bacteremia was 1.5/1000 catheter-days. The incidence in newly inserted and GWE catheters was 1.4 and 1.7/1000 catheter-days, respectively. The difference did not reach statistical significance (P = 0.939). The infection rate correlated with patient age, and was higher in younger children (P = 0.006). GWE is an effective option of line revision, and did not influence the infection rate in our study.

Calcium Mass Balance during Citrate Hemodialysis: A Randomized Controlled Trial Comparing Normal and Low Ionized Calcium Target Ranges.

BACKGROUND: Regional citrate anticoagulation (RCA) during hemodialysis interferes with calcium homeostasis. Optimal ionized calcium (iCa) target range during RCA and consequent calcium balance are unknown. METHODS: In a randomized controlled trial (ACTRN12613001029785) 30 chronic hemodialysis patients were assigned to normal (1.1-1.2 mmol/) or low (0.95-1.05 mmol/l) iCa target range during a single hemodialysis with RCA. The primary outcome was calcium mass balance during the procedure, using a partial spent dialysate collection method; magnesium mass balance was also measured. Intact parathormone (iPTH), total calcium (tCa) and magnesium were measured before and after procedures. RESULTS: Mean iCa during procedures was significantly different in the two groups (1.12±0.06 in normal and 1.06±0.07 mmol/l in low iCa group, p <0.001), resulting in different tCa (2.18±0.22 vs. 1.95±0.17, p = 0.003) after the procedure. Mean delivered calcium during the procedure was 58.3±4.8 mmol in the normal and 51.5±8.2 mmol in the low iCa group (p = 0.010), which resulted in a significantly higher mean positive calcium mass balance of 14.6±8.3 mmol (584±333 mg) per procedure in normal as compared to 7.2±8.5 mmol (290±341 mg) in low iCa group (p = 0.024). Linear mixed effects model showed a significant interaction effect of time and iCa target range group on iPTH, i.e. a significant increase in iPTH in the low as compared to normal iCa target group (p = 0.008). Magnesium mass balance was mildly negative and comparable in both groups. CONCLUSIONS: Low iCa target range resulted in a significantly less positive calcium mass balance, but in a significant increase in iPTH. To achieve a more neutral calcium balance, we recommend allowing a mild hypocalcemia during hemodialysis with RCA, especially when it is used for prolonged periods.

D-dimer levels in maintenance hemodialysis patients: High prevalence of positive values also in the group without predisposing diseases.

We aimed to estimate the prevalence of elevated D-dimer levels in all chronic hemodialysis patients and those without additional disease, and to identify factors associated with increased D-dimer. In 167 chronic hemodialysis patients from our center, D-dimer was measured before dialysis. The effects of age, C-reactive protein (CRP), recent acute illness, vascular access, anticoagulation type, dialysis vintage, and chronic diseases, considered to predispose for increased D-dimer levels, were analyzed. The median D-dimer in the whole group was 966 (inter-quartile range [IQR] 524-1947) µg/L and was positive (>500 µg/L) in 75% of cases. D-dimer was positive in 91% of patients with acute illness, 76% of those with predisposing chronic diseases, but was still positive in 52% of patients without additional disease (i.e., acute illness or predisposing chronic diseases) - median D-dimer was 538.5 (IQR 359-966) µg/L. D-dimer was correlated to patients' age, but not dialysis vintage. In univariate analysis, the D-dimer levels were significantly higher in patients with atrial fibrillation, ischemic heart disease, recent acute illness, increased CRP, dialyzed over a catheter, and on citrate anticoagulation. Multivariate logistic regression showed that only age >65 years (odds ratio [OR] 2.93), catheter (OR 4.86), and positive CRP (OR 4.07) were independently associated with positive D-dimer at 500 µg/L cut-off, while the significance of age disappeared at 2000 µg/L cut-off. To conclude, the high prevalence of positive D-dimer values even in hemodialysis patients without additional disease limits the use of D-dimer for exclusion of thromboembolic diseases in hemodialysis patients.

Citrate Anticoagulation in Tandem Membrane Plasma-Exchange or Immunoadsorption and Hemodialysis in Patients With Immunological Diseases and Dialysis-Dependence.

In 1996 we performed tandem membrane plasma exchange-hemodialysis in a 3-year-old girl and tandem immunoadsorption-hemodialysis with citrate as the only anticoagulant in a patient with Goodpasture's syndrome. In the present study, we evaluated the feasibility, efficacy and safety of 24 tandem plasma exchange/immunoadsorption hemodialysis procedures in four different circuit setups with citrate as the only anticoagulant. In two setups, the tandem procedures were connected in series (plasma exchange hemodialysis and immunoadsorption hemodialysis), while in the other two setups they were in parallel (plasma exchange hemodialysis with independent blood circuits and plasma exchange hemodialysis with independent arterial blood lines, but with a common return line). All tandem procedures were feasible, efficient and safe. No serious side-effects were recorded. The most elegant setup was the procedure with independent, parallel blood circuits. However, serial tandem procedures provided for the elimination of citrate and normalization of electrolytes before blood was returned to the patient.

Phosphate Removal During Long Nocturnal Hemodialysis/Hemodiafiltration: A Study With Total Dialysate Collection.

The aim of our prospective study was to quantify phosphate removal during long nocturnal high-flux hemodialysis or hemodiafiltration (HD) with total dialysate collection. Eight patients (two women) were studied for the first-in-the-week HD session that lasted 7-8 h. Total dialysate was collected. Serum and collected dialysate phosphate concentrations were measured every hour. Phosphate removal as assessed from the serum concentration was most important during the first 2 h of HD, and then a plateau was reached. The highest average phosphate concentration in the total dialysate was in the 1(st) hour, thereafter the concentration decreased but remained stable. The average total removed mass of phosphate quantified from hourly collected dialysate was 5195.7 ± 1898 mg. Phosphate had been removed in a consistent manner during the whole duration of nocturnal HD as assessed through dialysate (despite stable serum phosphate concentration). This could indicate phosphate transfer from intracellular space. The total removed phosphate quantified from the total dialysate collection was higher than previously reported and exceeded the normal phosphate food intake.

Temporary Catheters as a Permanent Vascular Access in Very Elderly Hemodialysis Patients: Frequency of Complications and Interventions.

The choice of vascular access in very elderly hemodialysis patients can be complex. Data on the frequency of interventions and complications when temporary catheters are used for long periods in this population are lacking. All incident patients ≥80 years old, dialyzed over non-tunneled catheters, were included and the frequency of interventions (re-insertions and wire-exchanges) and complications (catheter-related blood stream infections) were recorded. In 31 patients aged 84 ± 4 years, dialyzed for 1.4 ± 1.1 years, 87 interventions were needed (2.02/patient-year). The median time to first intervention was 5.5 months and the 1-year intervention-free rate was 32%. There were three catheter-related blood stream infections (0.2/1000 access-days), comparing favorably to tunneled catheters. To conclude, temporary catheters are associated with a low rate of complications and an acceptable rate of interventions. Therefore, they could be the optimal vascular access in very elderly patients when the placement of an arterio-venous fistula is not feasible.