Effects of Kt/Vurea on outcomes according to age in patients on maintenance hemodialysis.

Background: The guidelines recommended target and minimum single-pool Kt/Vurea are 1.4 and 1.2, respectively, in hemodialysis patients. However, the optimal hemodialysis dose remains controversial. We investigated the effects of Kt/Vurea on patient outcomes according to age, with a focus on older patients. Methods: This study used the hemodialysis quality assessment program and claims datasets. Patients were divided into four subgroups according to age (<65, 65-74, 75-84, and ≥85 years). Each group was divided into three subgroups according to Kt/Vurea : reference (ref) (1.2 ≤ Kt/Vurea ≤ 1.4), low (< 1.2), and high (> 1.4). Results: The low, ref, and high Kt/Vurea groups included 1668, 8156, and 16 546 (< 65 years); 474, 3058, and 7646 (65-74 years); 225, 1362, and 4194 (75-84 years); and 14, 126, and 455 (≥85 years) patients, respectively. The low Kt/Vurea group had higher mortality rates than the ref Kt/Vurea group irrespective of age [adjusted hazard ratio (aHR), 95% confidence interval (CI): 1.23, 1.11-1.36; 1.14, 1.00-1.30; 1.28, 1.09-1.52; and 2.10, 1.16-3.98, in patients aged <65, 65-74, 75-84, and ≥85 years, respectively]. The high Kt/Vurea group had lower mortality rates than the ref Kt/Vurea group in patients aged <65 and 65-74 years (aHR, 95% Cl: 0.87, 0.82-0.92 and 0.93, 0.87-0.99 in patients aged <65 and 65-74 years, respectively). Conclusions: These results support the current recommendations of a minimum Kt/Vurea of 1.2 even in patients age ≥85 years. In young patients, Kt/Vurea above the recommended threshold can be beneficial for survival.

Dialysis Adequacy: A Cross-Sectional Study to Assess the Reliability of the Online Clearance Monitor to Measure Dialysis Dose.

Background Frequent assessment of the dialysis dose delivered to hemodialysis patients might help improve morbidity and mortality. Daugirdas' second-generation formula is the recommended method for calculating dialysis doses. However, urea reduction ratios (URRs) and online clearance monitors (OCMs) are frequently used to assess dialysis adequacy due to their more straightforward concept and ease of use. This study was conducted to determine the most reliable method for measuring dialysis adequacy by comparing the correlation of urea reduction ratio and online clearance monitor measurements with the dialysis dose measured using the recommended Daugirdas' second-generation formula. Methods This study was an observational, cross-sectional, single-center study. The dialysis dose was measured as a urea reduction ratio and by an online clearance monitor simultaneously for 50 patients. It was compared to the dialysis dose measurements obtained using Daugirdas' second-generation formula. Results There was a statistically significant strong positive correlation (r = 0.929; p ≤ 0.001) of the urea reduction ratio and a poor concordance (ρC = 0.401; p ≤ 0.001) of online clearance monitor measurements with the dialysis dose measured using Daugirdas' second generation formula. Conclusion Our findings illustrate that the urea reduction ratio may be a more straightforward and reliable means for assessing the adequacy of intermittent hemodialysis with minimal errors in patients compared to online clearance monitors. Online clearance monitors offer easy estimation and practicality with minimal effort but are prone to multiple errors and may not be accurate in some settings.

Relationship between number of daily exchanges at CAPD start with clinical outcomes.

BACKGROUND: Peritoneal dialysis (PD) continues to be demanding for patients affected by kidney failure. In kidney failure patients with residual kidney function, the employment of incremental PD, a less onerous dialytic prescription, could translate into a decrease burden on both health systems and patients. METHODS: Between 1st January 2009 and 31st December 2021, 182 patients who started continuous ambulatory peritoneal dialysis (CAPD) at our institution were included in the study. The CAPD population was divided into three groups according to the initial number of daily CAPD exchanges prescribed: one or two (50 patients, CAPD-1/2 group), three (97 patients, CAPD-3 group) and four (35 patients, CAPD-4 group), respectively. RESULTS: Multivariate analysis showed a difference in term of peritonitis free survival in CAPD-1/2 in comparison to CAPD-3 (hazard ratio (HR): 2.20, p = 0.014) and CAPD-4 (HR: 2.98, p < 0.01). A tendency towards a lower hospitalisation rate (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.11 and 0.13, respectively) and decreased mortality (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.13 and 0.22, respectively) in patients who started PD with less than three daily exchanges was detected. No discrepancy of the difference of the mean values between baseline and 24 months residual kidney function was observed among the three groups (p = 0.33). CONCLUSIONS: One- or two-exchange CAPD start was associated with a lower risk of peritonitis in comparison to three- or four-exchange start. Furthermore, an initial PD prescription with less than three exchanges may be associated with an advantage in term of hospitalisation rate and patient survival.

Comparative Clinical Performances of Tunneled Central Venous Catheters versus Arterio-Venous Accesses in Patients Receiving High-Volume Hemodiafiltration: The Case for High-Flow DualCath, a Tunneled Two-Single-Lumen Silicone Catheter.

Tunneled central venous catheters (CVC) are mainly considered as a rescue vascular access option in dialysis but are still used on approximately one quarter of prevalent patients worldwide even though they are associated with poor performances and higher risks. STUDY DESIGN: in this retrospective single-center study, we aimed to report on the clinical performances achieved with high-flow tunneled CVCs (DualCath or DCath) and compared them with arteriovenous accesses (AVAs, e.g., AV fistula, AV graft, and Thomas Shunt) in a hospital-based dialysis unit. METHODS: Sixty-eight stage 5 chronic kidney disease dialysis-dependent patients (CKD5D) receiving high volume hemodiafiltration were followed-up with for 30 months. The study consisted of two phases: baseline cross-sectional and longitudinal follow-ups of key performance indicators. Clinical performances consisting of effective blood flow and blood volume, recirculation, urea and ionic Kt/V, total Kt, ultrafiltration volume, and percent reduction in ß2-M were measured monthly as part of quality control in our unit. RESULTS: At baseline, the effective blood flow using a DCath was close to 400 mL/min, similar to an AVA. Recirculation with a DCath (7%, 6-13%) was higher than with an AVA. The diffusive dialysis dose delivered with a DCath (spKt and eKt/V) and convective dialysis dose achieved with a DCath were slightly lower than those achieved with AVAs, but they were still much higher than is recommended by guidelines. The percent reduction in ß2-M achieved with a DCath was also 4 to 10% lower than that achieved with an AVA. On longitudinal follow-up, the main clinical performance indicators of DCaths (total Kt and total ultrafiltration volume, L/session) were maintained as very stable over time and close to those achieved with AVAs. CONCLUSIONS: As shown in this study, high-flow DualCath tunneled two-single-lumen silicone catheters may be used to deliver high volume hemodiafiltration in a reliable and consistent manner without compromising clinical performance. These results relied on the specific design of the two silicone cannulas and the strict adherence to best catheter practices.

Peritoneal dialysis: An effective therapeutic modality in acute kidney injury.

Background: Peritoneal dialysis (PD) as a modality of renal replacement therapy (RRT) in acute kidney injury (AKI), continues to be underused. We present our experience with PD in patients with AKI. Method: The data of patients with AKI requiring RRT were retrospectively analyzed. The primary end point was the adequacy of dialysis, and the secondary end point included hemodynamic stability and procedure-related complications. Result: A total of 32 patients with AKI requiring RRT were included in the study. The mean age and the blood pressure at the time of hospitalization were 65.3 ± 6.73 years and 73.7 ± 8.4 mm Hg, respectively. All the patients required vasopressor support; 26 (81%) patients required ventilator support. RRT was initiated at a mean serum creatinine of 6.24 ± 1.17 mg/dL. Rigid stylet catheter was used in 9 (28.2%) and Tenckhoff catheter in 23 (71.8%) patients. The average daily ultrafiltration and weekly Kt/V achieved were 1701 ± 327 mL and 2.19, respectively; these were significantly higher in survivors. After the initiation of PD, hemodynamic instability was observed in 10 (31.2%) patients. The major therapy-related complication noted was PD peritonitis. Conclusions: In a resource-poor environment, PD is an effective modality of RRT for AKI.

A New Cycler for Automated Peritoneal Dialysis to Provide Efficient Dialysis and Improved Sleep Quality.

INTRODUCTION: Automated peritoneal dialysis (APD) employs cyclers to control inflow and outflow of the dialysis fluid to the patient's abdomen. To allow more patients to use this modality, cyclers should support the achievement of an adequate dialysis dose and be easy to use, cost-effective, and silent. The new SILENCIA cycler (Fresenius Medical Care, Bad Homburg, Germany), designed to improve these characteristics in comparison to its predecessor device, was evaluated in this respect in a prospective study. METHODS: This cross-over study comprised two 2-week study periods, separated by a 3-week training phase. First, patients underwent APD with their current cycler (PD-NIGHT [Fresenius Medical Care, Bad Homburg, Germany] or HomeChoice Pro [Baxter, Deerfield, IL, USA] as control), followed by training on the SILENCIA cycler. Then, patients were switched to the SILENCIA cycler. During each treatment period, we collected data on total Kt/Vurea, ultrafiltration (UF) volume, patient-reported outcomes (sleep quality, among others), and device handling. RESULTS: Sixteen patients were enrolled; 2 patients terminated the study prematurely before study intervention, 1 patient due to a protocol violation. In 13 patients, total Kt/Vurea and UF could be evaluated. Neither Kt/Vurea nor UF differed significantly between control and SILENCIA cyclers. Out of 10 patients answering the questionnaire on sleep quality after the 2-week phase with the SILENCIA cycler, sleep quality improved in 5 patients; in the other patients, sleep quality was rated unchanged compared to the previously used cycler. The average reported sleep time was 5.9 ± 1.8 h with the PD-NIGHT, 7.2 ± 2.1 h with HomeChoice Pro, and 8.0 ± 1.6 h with the SILENCIA cycler. All patients were much or very much satisfied with the new cycler. CONCLUSION: The SILENCIA cycler delivers adequate urea clearance and UF. Importantly, sleep quality improved, possibly related to less caution messages and alarms.

Vascular Access in Hemodialysis: Peculiarities in a Low-Income Setting, Pattern, Prevalence and Relationship with Intradialysis Events and Dialysis Dose.

OBJECTIVES: Dialysis vascular access has remained a major determinant of intra and inter-dialytic events and the dialysis dose, and this impacts the quality of life, morbidity and mortality of dialysis patients. Assessing the different access types would help minimize peri-dialytic events and improve outcome. METHODS: This was a retrospective, age and sex-matched, comparative study that assessed dialysis sessions with tunneled dialysis catheters (TDCs) with arteriovenous fistula (AVF). RESULTS: Two hundred and four participants with 1062 sessions were involved. The male participants had 66.7% of all sessions, 60.6% of sessions with TDCs and 87.3% of sessions with AVF, P=0.001. The elderly constituted 23.5% of all participants but 37.7% of sessions with AVF, P=0.04. The percentage of the health-insured was more in sessions with AVF compared to the study population, P<0.001. Diabetics were more likely to use the TDCs, P=0.06. Participants using AVF were more likely to receive full dialysis and erythropoietin treatment, P<0.001. Intradialytic hypotension and dialysis termination were commoner with AVF than TDCs, P=0.03 and P=0.04 respectively. The dialysis dose was higher with AVF than TDCs, P=0.02. Predictors of AVF as dialysis access were male gender, advancing age, health insurance and full treatment compliance. CONCLUSION: There is predominance of venous catheters in our dialysis population. The AVF gave better BP control, fluid and solute clearance, and dialysis dose, and was commoner with males, the health insured and older participants. Intradialytic hypotension was commoner with AVF as IDHT was commoner with TDCs.

OBJECTIFS: L'accès vasculaire à la dialyse reste un déterminant majeur des événements intra et inter-dialytiques et de la dose de dialyse, ce qui a un impact sur la qualité de vie, la morbidité et lamortalité des dialysés. L'évaluation des différents types d'accès permettrait de minimiser les événements péridialytiques et d'améliorer les résultats. MÉTHODES: Il s'agit d'une étude comparative rétrospective, appariée selon l'âge et le sexe, qui a évalué les séances de dialyse avec des cathéters de dialyse tunnellisés (CDT) et des fistules artérioveineuses (FAV). RÉSULTATS: Deux cent quatre participants ont participé à 1 062 séances. Les hommes représentaient 66,7 % de toutes les séances, 60,6 % des séances avec CDT et 87,3 % des séances avec FAV, P=0,001. Les personnes âgées représentaient 23,5 % de l'ensemble des participants, mais 37,7 % des séances avec FVA, P=0,04. Le pourcentage d'assurés sociaux était plus élevé dans les sessions avec AVF que dans la population étudiée, P<0.001. Les diabétiques étaient plus susceptibles d'utiliser les CDT, P=0,06. Les participants utilisant la FVA étaient plus susceptibles de recevoir une dialyse complète et un traitement à l'érythropoïétine, P<0,001. L'hypotension intradialytique et l'arrêt de la dialyse étaient plus fréquents avec l'AVF qu'avec les CDT, P=0,03 et P=0,04. La dose de dialyse était plus élevée en cas de FVA qu'en cas de CDT, P=0,02. Les facteurs prédictifs de l'utilisation de la FVA comme accès à la dialyse étaient le sexe masculin, l'âge avancé, l'assurance maladie et l'observance totale du traitement. CONCLUSION: Il y a une prédominance des cathéters veineux dans notre population de dialysés. Le FVA permet un meilleur contrôle de la PA, de la clairance des fluides et des solutés et de la dose de dialyse, et il est plus fréquent chez les hommes, les assurés sociaux et les participants plus âgés. L'hypotension intradialytique était plus fréquente avec le FVA que l'IDHT était plus fréquente avec les CDT. Mots-clés: Cathéters veineux centraux, fistule artério-veineuse, veine jugulaire interne tunnellisée.

Incremental peritoneal dialysis allows to reduce the time spent for dialysis, glucose exposure, economic cost, plastic waste and water consumption.

BACKGROUND: Incremental peritoneal dialysis (incPD) as the initial PD strategy represents a convenient and resource-sparing approach, but its impact on patient, healthcare and environment has not been thoroughly evaluated. METHODS: This study includes 147 patients who started incPD at our institution between 1st January, 2009 and 31st December, 2021. Adequacy measures, peritoneal permeability parameters, peritonitis episodes, hospitalizations and increase in CAPD dose prescriptions were recorded. The savings related to cost, patient glucose exposure, time needed to perform dialysis, plastic waste, and water usage were compared to full-dose PD treatment. RESULTS: During the study follow-up 11.9% of the patients transitioned from incremental to full dose PD. Patient cumulative probability of remaining on PD at 12, 24, 36, 48 and 60 months was 87.6, 65.4, 46.1, 30.1 and 17.5%, respectively. The median transition time from 1 to 2 exchanges, from 2 to 3 and 3 to 4 exchanges were 5, 9 and 11.8 months, respectively. Compared to full dose PD, 1, 2, and 3 exchanges per day led to reduction in glucose exposure of 20.4, 14.8 or 8.3 kg/patient-year, free lifetime gain of 18.1, 13.1 or 7.4 day/patient-year, a decrease in cost of 8700, 6300 or 3540 €/patient-year, a reduction in plastic waste of 139.2, 100.8 or 56.6 kg/patient-year, and a decline in water use of 25,056, 18,144 or 10,196 L/patient-year. CONCLUSIONS: In comparison with full-dose PD, incPD allows to reduce the time spent for managing dialysis, glucose exposure, economic cost, plastic waste, and water consumption.

Inflammation and hemodialysis adequacy: are C-reactive protein levels influenced by the dose of dialysis?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the "dialysis dose" (Kt / V) using ionic dialysance. METHODS: Multicenter cross-sectional study. 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into two groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (p = 0.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log INL (p < 0.001) and inversely proportional with serum albumin values (p = 0.014), Kt/V (p = 0.037) and serum iron (p < 0.001). CONCLUSION: The poorer adequacy in terms of dialysis doses, lower Kt / V values, may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Comparison of measured vs kinetic-model predicted phosphate removal during hemodialysis and hemodiafiltration.

BACKGROUND: To what extent hemodiafiltration (HDF) improves management of hyperphosphatemia over hemodialysis (HD) is a subject of ongoing investigation. METHODS: We modified a previously described phosphate kinetic model to include incorporation of EUDIAL recommended equations for hemodiafiltration (HDF) clearance. We used the model to predict the recovery of phosphate from spent dialysate/hemofiltrate and compared this with averaged data from five published studies. Mean study average predialysis serum phosphate was 1.81 ± 0.20 mmol/L. Session length was close to 240 min per treatment. All HDF was done postdilution, at an average rate of 65 ± 24 mL/min. RESULTS: Measured mean phosphate removal was 1039 ± 136 mg (33.5 ± 4.41 mmol, slightly lower than the model-predicted mean value of 1092 ± 127 mg (35.3 ± 4.09 mmol). The measured ratio of phosphate removal with HDF compared with HD averaged 1.15 ± 0.22, ranging from 1.01 to 1.44. Using mean study input parameters for patient size and treatment characteristics, the predicted ratio of phosphate removal with HDF compared with HD averaged 1.095 ± 0.029, ranging from 1.05 to 1.13. CONCLUSIONS: Addition of EUDIAL-recommended convective clearance equations to a phosphate kinetic model predicts a 10% or greater benefit in terms of phosphate removal for HDF compared with HD at typical dialysis and hemodiafiltration treatment settings. These predictions are similar to the HDF advantage reported in the literature in studies where phosphate removal has been measured in spent dialysate.

Pregnancy in a woman undergoing peritoneal dialysis: Management and dialysis options.

Pregnancy in patients with end-stage renal disease on maintenance dialysis is uncommon, with annual incidences reported at 0.3 - 2.7%. Peritoneal dialysis usage in pregnancy has been less reported than hemodialysis, although outcomes are similar. Nowadays, there are insufficient data to establish a generalizable dialysis strategy in pregnant women with end-stage renal disease. As such, decisions should be individualized, depending on clinical factors, residual renal function, and, whenever possible, choice of the patient. We report the case of a 22-year-old patient receiving peritoneal dialysis who delivered a full-term, normal weight, healthy baby with increased dialysis dose achieved by supplementary hemodialysis during pregnancy, thus enabling peritoneal dialysis to be continued until the third trimester and minimizing hemodialysis requirements.

Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida? / Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose?

Introducción : La inflamación crónica y la subyacente comorbilidad cardiovascular aún son problemas vigentes en los pacientes en hemodiálisis crónica. Existen pocos estudios que comparen la «dosis de diálisis» (Kt/V) con el grado de inflamación del paciente. Nuestro objetivo principal fue determinar si existe una relación entre los niveles séricos de proteína C reactiva (PCR) y el Kt/V utilizando la dialisancia iónica.Métodos : Estudio transversal multicéntrico. Se incluyeron 536 pacientes prevalentes en hemodiálisis crónica. Se recogieron los niveles de PCR, el índice neutrófilo-linfocito y el índice plaqueta-linfocito. Se obtuvo el Kt por dialisancia iónica y el volumen de distribución de la urea mediante la fórmula de Watson. Se dividió la muestra en 2 grupos tomando como punto de corte la mediana de PCR y se comparó la adecuación de diálisis en cada uno. Finalmente, se realizó un modelo de regresión logística para determinar las variables de mayor influencia.Resultados : La mediana de PCR fue 4,10mg/L (q25-q75: 1,67-10). El Kt/V medio fue de 1,48±0,308. El Kt/V fue menor en los pacientes incluidos en el grupo de inflamación alta (p=0,01). En la regresión logística multivariante, los niveles «altos» de PCR tuvieron una correlación directa con el Log índice neutrófilo-linfocito (p<0,001) e inversamente proporcional con los valores de albúmina sérica (p=0,014), Kt/V (p=0,037) y hierro sérico (p<0,001).Conclusión : La peor adecuación en términos de dosis de diálisis (valores de Kt/V más bajos) puede contribuir a un mayor grado de inflamación en los pacientes en hemodiálisis crónica. (AU)

Introduction : Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the “dialysis dose” (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance.Methods : Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence.Results : Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the “high” levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001).Conclusion : The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients. (AU)

Incremental peritoneal dialysis in incident end-stage kidney disease patients.

BACKGROUND: This retrospective cohort study investigated the characteristics and outcomes of the end-stage kidney disease (ESKD) patients treated with incremental peritoneal dialysis (PD) at a large academic centre. METHODS: ESKD patients initiating PD with a dialysate volume ≤6 L/day were analysed. RESULTS: One hundred and seventy-five patients were included and were followed up for 352.6 patient-years. The baseline residual kidney function (RKF) was 8.3 ± 3.4 mL/min/1.73 m2. The unadjusted 1- to 5-year patient survival rate was 89.6%, 80.4%, 65.4%, 62.7% and 48.8%, respectively, and the corresponding time on PD therapy rate was 95.1%, 89.1%, 89.1%, 82.4% and 77.6%. Greater initial PD dose (hazard ratio = 1.608, 95% confidence interval 1.089-2.375) was associated with death after adjusting for age, Charlson comorbidity index (CCI), haemodialysis prior to PD, assisted PD and baseline RKF, likely as a result of residual confounding. There was no association with PD discontinuation. The average peritonitis rate and hospitalisation rate were 0.122 and 0.645 episodes per patient-year, respectively. The dialysate volume increased from 4.5 (4.3-5.7) L/day to 8.0 (6.0-9.8) L/day at 5 years. Fifty-seven (32.6%) patients graduated to full-dose PD at a median time of 10.3 (6.2, 15.7) months. Male sex, greater body mass index and lower baseline serum albumin were risk factors for increasing PD dose to over 6 L/day within 1 year. CONCLUSIONS: Incremental PD is a safe approach to initiate dialysis, and it offers satisfactory outcomes. Close monitoring, comprehensive evaluation of clinical responses and prompt adjustment of the prescription as needed play a crucial role in this patient-centred treatment.

Dialyzer Performance During Hemodialysis Without Systemic Anticoagulation Using a Heparin-Grafted Dialyzer Combined With a Citrate-Enriched Dialysate: Results of the Randomized Crossover Noninferiority EvoCit Study.

RATIONALE & OBJECTIVE: The EvoCit study was designed to evaluate performance of a heparin-grafted dialyzer during hemodialysis with and without systemic anticoagulation. STUDY DESIGN: Randomized, crossover, noninferiority trial. Noninferiority was defined as a difference of≤10% for the primary outcome. SETTING & PARTICIPANTS: Single hemodialysis center; 26 prevalent patients treated with 617 hemodialysis sessions. INTERVENTIONS: Hemodialysis using a heparin-grafted dialyzer combined with a 1.0mmol/L citrate-enriched dialysate ("EvoCit") without systemic anticoagulation compared with hemodialysis performed with a heparin-grafted dialyzer with systemic heparin ("EvoHep"). Patients were randomly allocated to a first period of 4 weeks and crossed over to the alternative strategy for a second period of 4 weeks. OUTCOMES: The primary end point was the difference in Kt/Vurea between EvoCit and EvoHep. Secondary end points were urea reduction ratio, middle molecule removal, treatment time, thrombin generation, and reduction in dialyzer blood compartment volume. RESULTS: The estimated difference in Kt/Vurea between EvoCit and EvoHep was-0.03 (95% CI, -0.06 to-0.007), establishing noninferiority with mean Kt/Vurea of 1.47±0.05 (SE) for EvoCit and 1.50±0.05 for EvoHep. Noninferiority was also established for reduction ratios of urea and ß2-microglobulin. Premature discontinuation of dialysis was required for 4.2% of sessions among 6 patients during EvoCit and no sessions during EvoHep. Effective treatment time was 236±5 minutes for EvoCit and 238±1 minutes for EvoHep. Thrombin generation was increased and there was greater reduction in dialyzer blood compartment volume after treatments with EvoCit compared with EvoHep. LIMITATIONS: The effects of avoiding systemic anticoagulation on clinical outcomes were not evaluated. CONCLUSIONS: EvoCit is noninferior to EvoHep with respect to solute clearance but results in a greater number of shortened treatments, more membrane clotting, and greater thrombin generation TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT03887468.

Early Detection of Arteriovenous Fistula Stenosis in Hemodialysis Patients through Routine Measurements of Dialysis Dose (Kt/V).

BACKGROUND: Monitoring of arteriovenous (AV) fistula to detect hemodynamically important stenosis is crucial for the prevention of AV fistula thrombosis. The aim of our study was to analyze the importance of dialysis dose (Kt/V) during online postdilution hemodiafiltration (HDF) for early detection of AV fistula stenosis. METHODS: Hemodialysis patients with AV fistula were included in this study. We compared a group of 44 patients who have undergone fistulography and subsequently percutaneous transluminal angioplasty (PTA) of significant AV fistula stenosis (active group) with a group of 44 age- and sex-matched patients without PTA (control group). Observational time in both groups was the same. RESULTS: All patients had postdilution online HDF using a F5008 dialysis machine, which can measure online single-pool Kt/V. All data were analyzed during the performance of 2056 HDF procedures. In the active group, we found statistically significantly lower values of Kt/V, all 8 weeks before PTA. In the active group, there was a significant improvement in Kt/V in the first (p < 0.001) and second week (p = 0.049) after PTA. Three and 8 weeks after PTA, we did not find any statistically significant difference in Kt/V between both groups (p = 0.114; p = 0.058). Patients in the active group had statistically significantly lower substitution volumes and blood pump flow rates during HDF over the whole observation period before and after PTA. In contrast, there were no differences in venous pressure in the dialysis circuit between both groups throughout the observation period. CONCLUSION: In hemodialysis patients with AV fistula, treated with online HDF, routine measurements of Kt/V during each HDF are a beneficial, quick, and straightforward method for early detection of hemodynamically significant AV fistula stenosis.

Integrating Monitoring of Volume Status and Blood Volume-Controlled Ultrafiltration into Extracorporeal Kidney Replacement Therapy.

PURPOSE: Volume management in hemodialysis (HD) requires the ability to assess volume status objectively and determine treatment strategies that achieve euvolemia without compromising hemodynamic stability. The aim of this study was to compare dialysis with and without blood volume-controlled ultrafiltration (UF) in combination with body composition monitoring, and to evaluate indicators for adequate dialysis (Kt/V), ultrafiltration volume, fluid status, and the occurrence of intradialytic morbid events (IME). PATIENTS AND METHODS: Patients undergoing hemodialysis or on-line hemodiafiltration with support of a blood volume monitor (BVM) - a feedback control device integrated into the 5008 and 6008 HD systems - were enrolled. Patients received treatment for four weeks using the 6008 CAREsystem and the BVM (6008+). Data on dialysis dose (Kt/V), UF volume and predialysis fluid status were documented. This data was also documented retrospectively for four weeks with (5008+) and without (5008-) the use of the BVM with the 5008 system. Comparisons were analyzed using linear mixed models. RESULTS: Twenty-four patients were enrolled. Kt/V was unaffected by blood volume-controlled UF (5008- vs 5008+: p=0.230) and was equally achieved with both HD systems (5008+ vs 6008+: p=0.922). The UF volume and fluid status achieved were comparable, independent of the use of UF control with BVM (5008- vs 5008+; UF volume: p=0.166; fluid overload: p=0.390) or the HD system (5008+ vs 6008+: UF volume: p=0.003; fluid overload: p=0.838), except for UF volume being higher in the 6008+ phase. IMEs occurred in less than 3% of treatments, with no difference between study phases. CONCLUSION: This study demonstrates that a clinical approach to kidney replacement therapy that tracks volume status and manages intradialytic fluid removal by blood volume-controlled UF delivers adequate dialysis without compromising fluid removal. It maintains volume status and ensures low incidence of IMEs.

Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose? / Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance. METHODS: Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001). CONCLUSION: The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Dialysis dose and mortality in haemodialysis: is higher better?

BACKGROUND: The effect of dialysis dose on mortality remains unsettled. Current guidelines recommend targeting a single-pool Kt/V (spKt/V) at 1.20-1.40 per thrice-weekly dialysis session. However, the optimal dialysis dose remains mostly disputed. METHODS: In a nationwide registry of all incident patients receiving thrice-weekly haemodialysis, 32 283 patients had available data on dialysis dose, estimated by Kt/V and its variants epuration volume per session (Kt) and Kt indexed to body surface area (Kt/A). Survival was analysed with a multivariate Cox model and a concurrent risk model accounting for renal transplantation. A predictive model of Kt in the upper quartile was developed. RESULTS: Regardless of the indicator, a higher dose of dialysis was consistently associated with better survival. The survival differential of Kt was the most discriminating, but marginally, compared with the survival differential according to Kt/V and Kt/A. Patient survival was higher in the upper quartile of Kt (>69 L/session) then deteriorated as the Kt decreased, with a difference in survival between the upper and lower quartile of 23.6% at 5 years. Survival differences across Kt distribution were similar after accounting for kidney transplantation as a competing risk. Predictive factors for Kt in the upper quartile were arteriovenous fistula versus catheters and graft, haemodiafiltration versus haemodialysis, scheduled dialysis start versus emergency start, long weekly dialysis duration and spKt/V measurement versus double-pool equilibrated Kt/V. CONCLUSIONS: Our data confirm the existence of a relationship between dialysis dose and survival that persisted despite correcting for known confounders. A model for predicting a high dose of dialysis is proposed with practical relevance.

Routine online assessment of dialysis dose: Ionic dialysance or UV-absorbance monitoring?

For three-weekly hemodialysis, a single-pool Kt/V target of at least 1.4 together with a minimal dialysis dose Kt at 45 L for men and 40 L for women per each session is currently recommended. Fully automatic online calculation of Kt and Kt/V from conductivity or UV-absorbance measurements in the dialysate is standardly implemented on some hemodialysis monitors and makes it possible to estimate the dialysis dose without the need for blood or dialysate samples. Monitoring the UV-absorbance of the spent dialysate is the most direct method for estimating Kt/V as it does not require an estimate of V. Calculation of ionic dialysance from conductivity measurements is the most direct method for estimating Kt and BSA-scaled dialysis dose. Both ionic dialysance monitoring and UV-absorbance monitoring may help detect a change in urea clearance occurring during the session, but this change must be interpreted differently depending on the monitoring being considered. An abrupt decrease in urea clearance results in a decrease in ionic dialysance but, paradoxically, a sudden increase in estimated urea clearance provided by dialysate UV-absorbance monitoring. Healthcare teams who monitor both ionic dialysance and UV-absorbance in their hemodialysis units must be clearly informed of this difficulty.

Optimizing dialysis dose in the context of frailty: an exploratory study.

INTRODUCTION: Frailty is a multicausal syndrome characterized by a decrease in strength, resistance and physiological function, which makes the individual vulnerable and dependent, and increases his/her mortality. This syndrome is more prevalent among older individuals, and chronic kidney disease patients, particularly those on dialysis. Dialysis dose is currently standardized for hemodialysis (HD) patients regardless of their age and functional status. However, it has been postulated that the dialysis dose required in older patients, especially frail ones, should be lower, since it could increase their degree of frailty. Then, the purpose of this study was to evaluate if there would be a correlation between the dose of Kt/V and the degree of frailty in a population of adult patients on HD. MATERIALS AND METHODS: A cross-sectional study with 82 patients on HD in Barranquilla (Colombia) and Lobos (Argentina) was conducted. Socio-demographic and laboratory data, as well as dialysis doses (Kt/V) were recorded and scales of fragility, physical activity, gait and grip strength were applied. Then these data were correlated by a Spearman's correlation and a logistic regression. RESULTS: CFS, social isolation, physical activity, gait speed, and prehensile strength tests were outside the reference ranges in the studied group. No significant correlation was found between dialysis dose and all the above mentioned functional tests. However, a significant and inverse correlation between physical activity and CFS was documented (score - 1.41 (CI - 2.1 to - 0.7). CONCLUSION: No significant correlation was documented between Kt/V value and different parameters of the frailty status, but this status correlated significantly and inversely with physical activity in this group. Frailty status in hemodialysis patients was significantly higher in older individuals, although young individuals were not exempt from it.