Could incremental haemodialysis be a new standard of care? A suggestion from a long-term observational study.

Introduction: The term incremental haemodialysis (HD) means that both dialysis dose and frequency can be low at dialysis inception but should be progressively increased, to compensate for any subsequent reduction in residual kidney function. Policy of the Matera Dialysis Center is to attempt an incremental start of HD without a strict low-protein diet in all patients choosing HD and with urine output (UO) >500 ml/day. The present study aimed at analyzing the results of this policy over the last 20 years. Subjects and methods: The dataset of all patients starting HD between January 1st, 2000 and December 31st, 2019 was retrieved from the local electronic database. Exclusion criteria were: urine output <500 ml/day or follow-up <3 months after the start of the dialysis treatment. Results: A total of 266 patients were retrieved; 64 of them were excluded from the study. The remaining 202 patients were enrolled into the study and subdivided into 3 groups (G1, G2 and G3) according to the frequency of treatment at the start of dialysis: 117 patients (57.9%) started with once-a-week (1HD/wk) (G1); 46 (22.8%) with twice-a-week (2HD/wk) (G2); 39 (19.3%) with thrice-a-week (3HD/wk) dialysis regimen (G3). Patients of G1 remained on 1HD/wk for 11.9 ±14.8 months and then transferred to 2HD/wk for further 13.0 ±20.3 months. Patients of G2 remained on 2HD/wk for 16.7 ±23.2 months. Altogether, 25943 sessions were administered during the less frequent treatment periods instead of 47988, that would have been delivered if the patients had been on 3HD/wk, thus saving 22045 sessions (45.9%). Gross mortality of the entire group was 12.6%, comparable to the mean mortality of the Italian dialysis population (16.2%). Survival at 1 and 5 years was not significantly different among the 3 groups: 94% and 61% (G1); 83% and 39% (G2); 84% and 46% (G3). Conclusions: Our long-term observational study suggests that incremental HD is a valuable option for incident patients. For most of them (80.7%) it is viable for about 1-2 years, with obvious socio-economic benefits and survival rates comparable to that of the Italian dialysis population. However, randomized controlled trials are lacking and therefore urgently needed. If they will confirm observational data, incremental HD will be a new standard of care.

The lacking equation that estimates the protein catabolic rate in patients on once-weekly haemodialysis.

BACKGROUND: The normalized protein catabolic rate (PCRn) is one of the key indices derived from the urea kinetic model (UKM) in haemodialysis (HD) patients. Ideally, it should be assessed using the double pool UKM (KDOQI clinical practice guidelines, AIKD, 2015), as the web-based software Solute-Solver (SS) does (Daugirdas et al., AJKD, 2009). Simple formulae exist to compute PCRn for patients on thrice- or twice-weekly HD schedule, but not for patients on once-weekly HD schedule (1HD/wk). Aim of the present technical note was to introduce the lacking equation that estimates PCRn in the 1HD/wk regimen. METHODS: Data of a single HD session associated to monthly UKM studies were retrieved from the electronic database of our dialysis unit for 80 historical patients on 1HD/wk regimen. The UKM parameters, as calculated with SS, were used in a subgroup of 40 randomly selected patients (group 1) to build-up a multiple regression model of PCRn. The latter was used to predict PCRn (PCRnPred) values in the cohort of the remaining 40 patients (group 2). The Bland-Altman plot was used to analyse the agreement between PCRnPred and the paired "observed" (PCRnObs) values, as measured with SS. RESULTS: The following equation was established by means of the multiple regression analysis: PCRn = - 0.46 + 0.01 × C0 + 0.09 × eKt/V + 3.94 × Kru/V, where C0 is pre-dialysis blood urea nitrogen concentration, eKt/V is the equilibrated Kt/V, Kru is the residual renal urea clearance and V is the post-dialysis urea distribution volume. The PCRnPred values were 0.99 ± 0.24 g/kg/day; the PCRnObs values were 0.96 ± 0.23 g/kg/day (mean difference 0.03 ± 0.05 g/kg/day). Their difference at the Bland-Altman analysis ranged from - 0.08 to + 0.13 g/kg/day. Finally, a nomogram was drawn: it can be used to estimate not only PCRn from Kru/V and C0, but also C0 as a function of Kru/V and PCRn. CONCLUSIONS: The equation here introduced allows a simple and accurate estimate of PCRn in patients on once-weekly HD regimen. The availability of the nomogram relating C0 to PCRn and Kru/V could be a further step to make safer and safer the once-weekly HD regimen. The following equation was established by means of the multiple regression analysis [Formula: see text] where PCRn is the normalized protein catabolic rate (PCRn), C0 is pre-dialysis blood urea nitrogen concentration (BUN), eKt/V is the equilibrated Kt/V, Kru is the residual renal urea clearance and V is the post-dialysis urea distribution volume. A nomogram relating pre-dialysis BUN to PCRn and Kru/V could be drawn: it can be used to estimate not only PCRn from Kru/V and pre-dialysis BUN, but also pre-dialysis BUN as a function of Kru/V and PCRn.

The Effects of Vaccinium myrtillus Extract on Hamster Pial Microcirculation during Hypoperfusion-Reperfusion Injury.

INTRODUCTION: The present study was aimed to assess the in vivo hamster pial microvessel alterations due to 30 min transient bilateral common carotid artery occlusion (BCCAO) and reperfusion (60 min); moreover, the neuroprotective effects of Vaccinium myrtillus extract, containing 34.7% of anthocyanins, were investigated. MATERIALS AND METHODS: Two groups of male hamsters were used: the first fed with control diet and the other with Vaccinium myrtillus supplemented diet. Hamster pial microcirculation was visualized by fluorescence microscopy through an open cranial window. Pial arterioles were classified according to Strahler's method. RESULTS: In age-matched control diet-fed hamsters, BCCAO caused a decrease in diameter of all arterioles. At the end of reperfusion, the reduction of diameter in order 3 arterioles was by 8.4 ± 3.1%, 10.8 ± 2.3% and 12.1 ± 1.1% of baseline in the 2, 4 and 6 month control diet-fed hamsters, respectively. Microvascular permeability and leukocyte adhesion were markedly enhanced, while perfused capillary length (PCL) decreased. The response to acetylcholine and papaverine topical application was impaired; 2'-7'-dichlorofluoresceine-diacetate assay demonstrated a significant ROS production. At the end of BCCAO, in age-matched Vaccinium myrtillussupplemented diet-fed hamsters, the arteriolar diameter did not significantly change compared to baseline. After 60 min reperfusion, order 3 arterioles dilated by 9.3 ± 2.4%, 10.6 ± 3.1% and 11.8 ± 2.7% of baseline in the 2, 4 and 6 month Vaccinium myrtillus supplemented diet-fed hamsters, respectively. Microvascular leakage and leukocyte adhesion were significantly reduced in all groups according to the time-dependent treatment, when compared with the age-matched control diet-fed hamsters. Similarly, the reduction in PCL was progressively prevented. Finally, the response to acetylcholine and papaverine topical application was preserved and there was no significant increase in ROS production in all groups. CONCLUSIONS: In conclusion, Vaccinium myrtillusextract protected pial microcirculation during hypoperfusion-reperfusion, preventing vasoconstriction, microvascular permeability, leukocyte adhesion, reduction in PCL and preserving the endothelium function.