Expanded hemodialysis: Is anticoagulation of the dialysis circuit different from online hemodiafiltration and high-flux hemodialysis?

Expanded hemodialysis (HDx) has a high capacity for removing medium and medium-large molecules; however, there are no specific recommendations during HDx for anticoagulation of the dialysis circuit. We aimed to evaluate the differences in the efficacy of anticoagulation procedures using the venous port and 40 mg enoxaparin in HDx compared to high-flux hemodialysis (HF-HD) and postdilution online hemodiafiltration (HDF). We compared anticoagulant activity in 11 patients in HDx, HF-HD, and HDF under similar dialysis conditions. In the 33 dialysis sessions, 40 mg enoxaparin was administered through the venous port, and pre- and postdialysis antifactor Xa activity (aXa) and activated partial thromboplastin time (APTT), postdialysis clotting time of the vascular access, visual clotting score of the dialyzer, and any complications with the extracorporeal circuit or bleeding were registered. APTT postdialysis in HDx was not significantly different from that in HF-HD and HDF. Postdialysis aXa in HDx was not significantly different from that in HF-HD and HDF. We found no significant differences in visual clotting score of the dialyzer. Enoxaparin administered through the venous port was sufficient for anticoagulation within the extracorporeal circuit in HDx, HF-HD, and HDF. There were no differences in postdialysis aXa or APTT, most likely because when low molecular-weight heparin is applied through venous port, lesser enoxaparin concentration reaches the dialyzer. Thus, we conclude that the dose of enoxaparin administered through the venous port should not be adjusted according to dialysis technique.

[Monoclonal gammopathy of undetermined significance and evolution to myeloma: Experience in 153 patients]. / Gammapatía monoclonal de significado incierto y evolución a mieloma múltiple: Experiencia en 153 pacientes.

INTRODUCTION: Based on risk factors, the Mayo Clinic Multiple Myeloma Group (MCMMG) established a model of progression from monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM) at 20 years. It is also described that MGUS with a progressive increase of monoclonal protein (M-protein) and/or immunoparesis (IMP) may be more predisposed to progress to myeloma. Our objective was to make a review of MGUS, to see how those who presented IMP and/or progression of their M-protein, contrasting them with MGUS that presented intermediate/high and high risk according to MCMMG. METHODOLOGY AND MATERIALS: A review of the MGUS objectified during the realization of a serum proteinogram (SPEP) was carried out during 2010-2014, in our area. Serum immunoglobulins, serum immunofixation (IFs), and serum free light chain ratio (FLCr) were determined for all MGUS. RESULTS: Of the 153 MGUS that are followed up for 4 years, 6 progress to MM. Of these 6 MM, 5 progress from MGUS with intermediate/high risk taking into account the MCMMG. Of these 5, 3 have IMP or progression of their M-protein. 2 present IMP plus progression of their M-protein. The sixth MM evolves from a MGUS without any risk factor, but with progression of its M-protein plus IMP. CONCLUSIONS: IMP and/or M-protein progression are important risk factors to be taken into account in the MGUS, in the first years after diagnosis, due to their possible evolution to MM.

Efficacy of enoxaparin in preventing coagulation during high-flux haemodialysis, expanded haemodialysis and haemodiafiltration.

BACKGROUND: Low-molecular-weight heparins (LMWHs) are easily dialysable with high-flow membranes; however, it is not clear whether the LMWH dose should be adjusted according to the membrane type and dialysis technique. This study aimed to evaluate the influence of the dialyser on anticoagulation of the extracorporeal dialysis circuit. METHODS: Thirteen patients received the same dose of LMWH through the arterial port via three dialysis techniques: high-flux haemodialysis (HF-HD), online haemodiafiltration (HDF) and expanded haemodialysis (HDx). All dialysis was performed under similar conditions: duration, 4 h; blood flow, 400 mL/min; and dialysate flow, 500 mL/min. Antifactor Xa (aXa) activity and activated partial thromboplastin time (APTT) were measured before and after the dialysis. Clotting time of the vascular access site after haemodialysis, visual clotting score of the dialyser and any complications with the extracorporeal circuit or bleeding were registered. RESULTS: Post-dialysis aXa activity in HF-HD (0.26 ± 0.02 U/mL) was significantly different from that in HDF (0.21 ± 0.02 U/mL, P = 0.024), and there was a trend in HDx (0.22 ± 0.01 U/mL, P = 0.05). APTT post-dialysis in HF-HD (30.5 ± 0.7 s) was significantly different from that in HDx (28.2 ± 0.64 s, P = 0.009) and HDF (28.8 ± 0.73 s, P = 0.009). CONCLUSIONS: AXa activity in HDF was significantly lower than that in HF-HD, possibly because of more losses of LMWH through the dialyser. Given the higher anticoagulant loss in HDF and probably in HDx than in HF-HD, the enoxaparin dose administered may be adjusted according to the dialysis technique.

Intradialytic hypotension and relationship with cognitive function and brain morphometry.

BACKGROUND: The haemodynamic stress brought about by dialysis could justify the loss of structural and functional integrity of the central nervous system (CNS). The main objective of this study was to analyse the relationship between intradialytic hypotension (IDH) and cognitive function and brain morphometry. METHODS: The cross-sectional KIDBRAIN study (Cohort Study of Morphological Changes of the Brain by MRI in Chronic Kidney Disease Patients) included 68 prevalent patients with no history of neurological disorders (cerebrovascular disease and cognitive impairment) undergoing haemodialysis (HD). We analysed 18 non-consecutive dialysis sessions (first three of each month over a 6-month period) and various definitions of IDH were recorded. Global cognitive function (GCF) was assessed using the Mini-Mental State Examination (MMSE) and parameters of structural integrity of the CNS were obtained using volume morphometry magnetic resonance imaging analysis [grey matter (GM), white matter (WM) and hippocampus). RESULTS: A greater number of sessions with IDH were associated with less volume of WM (r = -0.359,P = 0.003) and hippocampus (r = -0.395, P = 0.001) independent of cardiovascular risk factors according to multivariable linear regression models (ß = -0.198, P = 0.046 for WM; ß = -0.253, P = 0.017 for hippocampus). The GCF by the MMSE was 27.3 ± 7.3.1 and was associated with WM volume (ß = 0.403, P = 0.001) independent of GM and hippocampus volume. Symptomatic IDH was associated with GCF (r = -0.420, P < 0.001) in adjusted analysis (ß = -0.339, P = 0.008). CONCLUSIONS: Even when asymptomatic, IDH is associated with a lower WM and hippocampus volume and reduced GCF in patients undergoing HD, thus suggesting greater vulnerability of the brain to the haemodynamic stress that may be generated by a dialysis session.

Impact of Serum Magnesium Levels on Kidney and Cardiovascular Prognosis and Mortality in CKD Patients.

INTRODUCTION: In the general population, hypomagnesemia has been associated with cardiovascular events and hypermagnesemia with overall mortality. In chronic kidney disease (CKD) the evidence is not so strong. The objective of our study was to investigate the relationship between serum magnesium (SMg) concentration and cardiovascular morbidity and mortality, all-cause mortality, and the progression to kidney failure in a population with CKD. METHODS: Observational study of a cohort of 746 patients with CKD. Baseline characteristics and analytical profile were collected at the first visit, and patients were followed for a mean of 42.6 months. RESULTS: A cohort of 746 patients were analyzed, age 70 ± 13 years, 62.9% were male, 45.2% had CKD grade 3, and 35.9% grade 4. The mean SMg concentration was 2.09 ± 0.33 mg/dL, with a close correlation between SMg concentration and serum creatinine, phosphorus, and intact parathyroid hormone (iPTH) values. Use of calcitriol was associated with higher SMg (SMgH) concentration, while calcium supplements and proton pump inhibitors (PPIs) were associated with lower SMg concentration. For risk of cardiovascular events, patients with hypermagnesemia had an overall higher risk on a crude analysis (Log Rank 4.83, P = .28) and adjusted analysis (HR = 1.34, CI 1.02-1.77, P = .037). For risk of all-cause mortality, patients with hypermagnesemia had an overall higher risk on crude analysis (Log Rank 13.11, P > .001) and adjusted analysis (HR = 1.5424, IC = 1.002-2.319, P = .049). After performing a propensity score matching for SMg concentration, we achieved two comparable groups of 287 patients, finding again higher all-cause mortality in the hypermagnesemia group (LogRank 15.147, P < .001), that persisted in the Cox model adjusted for calcium, phosphorus, and iPTH. No association was found between SMg concentration and initiation of kidney replacement therapy (KRT). CONCLUSIONS: Magnesium concentration increases with decreasing kidney function. Hypermagnesemia predicts cardiovascular events and all-cause mortality in this same population. Thus, magnesium supplementation should be used with caution in these patients.

Definiciones de hipotensión intradiálisis con poder predictivo de mortalidad en una cohorte de hemodiálisis / Intradialytic hypotension definitions with mortality prediction capacity in a cohort of haemodialysis patients

INTRODUCCIÓN: La hipotensión arterial intradiálisis (HAID) es una complicación frecuente que se asocia a una mayor morbimortalidad en hemodiálisis, aunque es una tarea pendiente la uniformidad de criterios respecto a su definición. El objetivo del estudio es analizar las características de distintas definiciones de hipotensión y su relación con la morbimortalidad en una cohorte de pacientes en hemodiálisis. METODOLOGÍA: Estudio observacional, con un seguimiento de 30 meses, que incluye 68 pacientes prevalentes en hemodiálisis con al menos 6 meses de tratamiento. Se recogieron parámetros de diálisis, y distintas definiciones de hipotensión, de 18 sesiones no consecutivas (las primeras 3 sesiones de cada mes de un período de 6 meses). Se definió como evento positivo de HAID si ocurría cualquier definición en más del 25% de las sesiones estudiadas. Se analizó el poder predictivo para cada definición de hipotensión (Nadir90, Nadir100, Fall20, Fall30, Fall20Nadir90, Fall30Nadir90, KDOQI, HEMO) mediante un análisis de supervivencia. Se estimó la relación con los eventos cardiovasculares no fatales y la mortalidad global mediante distintos modelos proporcionales de Cox. RESULTADOS: Encontramos definiciones de HAID que ocurrieron con una significativa mayor frecuencia (Nadir100: 339,8/1.000 sesiones; Nadir90: 172,3/1.000 sesiones) en comparación con otras (KDOQI: 98/1.000 sesiones; HEMO 129,9/1.000 sesiones). Con una media de seguimiento de 27,12 ± 6,84 meses se registraron 13 eventos mortales. Un mayor número de sesiones con HAID conforme a la definición Nadir90 fue un factor predictor de mortalidad (Log rank 5,02, p = 0,025), independiente según los modelos ajustados (HR: 3,23 [IC95%: 1,08-9,6], p = 0,035). Las definiciones Nadir100 (HR: 4,54 [IC95%: 1,25-16,4], p = 0,02) y Fall30Nadir90 (HR: 3,08 [IC95%: 1,07-8,8], p = 0,03) fueron predictores independientes de eventos cardiovasculares no fatales en los modelos ajustados. CONCLUSIONES: La hipotensión intradiálisis, incluso asintomática, tiene poder predictivo de mortalidad y eventos cardiovasculares no fatales en pacientes prevalentes en hemodiálisis

INTRODUCTION: Intradialytic hypotension (IDH) is a common complication and is associated with higher morbidity and mortality in patients on haemodialysis. However, there is a lack of uniformity in definitions of IDH. The main objective of this study is to analyse clinical and dialysis related factors with several IDH definitions, and its relationship with morbidity and mortality in a cohort of haemodialysis patients. METHODOLOGY: Observational study with a 30-month follow-up period that includes 68 prevalent patients on haemodialysis with at least six months of treatment. We analysed 18 non-consecutive dialysis sessions (first three of each month of a six-month period), and different definitions of IDH were recorded. A positive event of IDH was defined if any definition occurred in more than 25% of the sessions studied. Using survival analysis, we analysed the prediction capacity of each IDH definition (Nadir90, Nadir100, Fall20, Fall30, Fall20Nadir90, Fall30Nadir90, KDOQI, HEMO). The relationship with non-fatal cardiovascular disease and global mortality was estimated using different Cox proportional models. RESULTS: We found IDH definitions that occurred significantly more frequently (Nadir100: 339.8/1,000 sessions, Nadir90: 172.3/1,000 sessions) than others (KDOQI: 98/1,000 sessions, HEMO 129.9/1,000 sessions). We registered 13 fatal events with a mean follow-up of 27.12 ± 6.84 months. A greater number of sessions with IDH according to the Nadir90 definition was a predictive factor of mortality (Log rank 5.02, p = 0.025), independent according to adjusted models (HR: 3.23 [95% CI: 1.08-9.6], p = 0.035). The definitions Nadir100 (HR: 4.54 [95% CI: 1.25-16.4], p = 0.02) and Fall30Nadir90 (HR: 3.08 [95% CI: 1.07-8.8], p = 0.03) were independent predictors of non-fatal cardiovascular disease in adjusted models. CONCLUSIONS: Intradialytic hypotension, even asymptomatic, is a predictor of mortality and non-fatal cardiovascular disease in prevalent patients on haemodialysis

Intradialytic hypotension definitions with mortality prediction capacity in a cohort of haemodialysis patients. / Definiciones de hipotensión intradiálisis con poder predictivo de mortalidad en una cohorte de hemodiálisis.

INTRODUCTION: Intradialytic hypotension (IDH) is a common complication and is associated with higher morbidity and mortality in patients on haemodialysis. However, there is a lack of uniformity in definitions of IDH. The main objective of this study is to analyse clinical and dialysis related factors with several IDH definitions, and its relationship with morbidity and mortality in a cohort of haemodialysis patients. METHODOLOGY: Observational study with a 30-month follow-up period that includes 68 prevalent patients on haemodialysis with at least six months of treatment. We analysed 18 non-consecutive dialysis sessions (first three of each month of a six-month period), and different definitions of IDH were recorded. A positive event of IDH was defined if any definition occurred in more than 25% of the sessions studied. Using survival analysis, we analysed the prediction capacity of each IDH definition (Nadir90, Nadir100, Fall20, Fall30, Fall20Nadir90, Fall30Nadir90, KDOQI, HEMO). The relationship with non-fatal cardiovascular disease and global mortality was estimated using different Cox proportional models. RESULTS: We found IDH definitions that occurred significantly more frequently (Nadir100: 339.8/1,000 sessions, Nadir90: 172.3/1,000 sessions) than others (KDOQI: 98/1,000 sessions, HEMO 129.9/1,000 sessions). We registered 13 fatal events with a mean follow-up of 27.12±6.84 months. A greater number of sessions with IDH according to the Nadir90 definition was a predictive factor of mortality (Log rank 5.02, p=0.025), independent according to adjusted models (HR: 3.23 [95% CI: 1.08-9.6], p=0.035). The definitions Nadir100 (HR: 4.54 [95% CI: 1.25-16.4], p=0.02) and Fall30Nadir90 (HR: 3.08 [95% CI: 1.07-8.8], p=0.03) were independent predictors of non-fatal cardiovascular disease in adjusted models. CONCLUSIONS: Intradialytic hypotension, even asymptomatic, is a predictor of mortality and non-fatal cardiovascular disease in prevalent patients on haemodialysis.

La composición corporal influye en la eliminación de toxinas urémicas unidas a proteínas en la hemodiafiltración online / Body composition infuences the elimination of protein-bound uremic toxins in online hemodiafiltration

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Los altos volúmenes convectivos se asocian a la mejoría del perfil metabólico en los pacientes diabéticos en hemodiafiltración online / High convective volumes are associated with improvement in metabolic profile in diabetic patients on online haemodiafiltration

Antecedentes y objetivo: La hemodiafiltración onine (HDF-OL) con altos volúmenes de transporte convectivo mejora la supervivencia en los pacientes en hemodiálisis. Se ha propuesto limitar el volumen convectivo en los pacientes diabéticos por la carga de glucosa administrada con el líquido de sustitución. El objetivo del estudio fue analizar la influencia del volumen de sustitución en la evolución del perfil metabólico y la composición corporal de los pacientes diabéticos incidentes en HDF-OL. Material y métodos: Estudio observacional prospectivo en 29 pacientes diabéticos incidentes en HDF-OL posdilución. Basalmente se recogieron datos clínicos y demográficos, parámetros analíticos metabólicos, nutricionales e inflamatorios, y la composición corporal por bioimpedancia espectroscópica (BIS). Cada 4 meses se recogieron parámetros analíticos y el volumen de sustitución medio por sesión, y en 23 pacientes se realizó otra BIS al menos un año después. Se calcularon variaciones de hemoglobina glucosilada (HbA1c), triglicéridos, colesterol total, c-LDL, c-HDL, albúmina, prealbúmina y proteína C reactiva (PCR) al año, 2 años, 3 años y al final del seguimiento. Se calcularon las variaciones cuatrimestrales y anuales como periodos independientes, y se analizaron los cambios de composición corporal. Resultados: La edad al inicio fue a los 69,7±13,6 años; el 62,1% eran varones, de 72,3 ± 13,9 kg, 1,78 ± 0,16 m2, y con 48 (35,5-76) meses en diálisis. El 81,5% recibía insulinoterapia, el 7,4% antidiabéticos y el 51,9% estatinas. El volumen de sustitución medio fue de 26,9 ± 2,9L/sesión y el periodo de seguimiento (tiempo en HDF-OL) fue de 40,4 ± 26 meses. Se observó una correlación significativa entre el volumen de sustitución medio y un incremento de los niveles de c-HDL (r = 0,385, p = 0,039) y prealbúmina (r = 0,404, p = 0,003) a lo largo del seguimiento. El volumen convectivo se asoció a la reducción de los niveles de PCR al año (r = -0,531, p = 0,005), a los 2 años (r = -0,463, p = 0,046) y al final del seguimiento (r = -0,498, p = 0,007). Los pacientes con volumen de sustitución >26,9L/sesión tuvieron mayor descenso en los niveles de triglicéridos y PCR, y un aumento de las cifras de c-HDL. Estos pacientes con > 26,9 L/sesión finalizaron el estudio con niveles más altos de c-HDL (48,1 ± 9,4mg/dL vs. 41,2 ± 11,6 mg/dL, p = 0,025) y más bajos de PCR (0,21 [0,1-2,22] mg/dL vs. 1,01 [0,15-6,96] mg/dL, p = 0,001), sin diferencias al inicio.Las comparaciones entre el volumen de sustitución y los cambios analíticos por periodos cuatrimestrales [n = 271] mostraron una correlación significativa con un descenso de HbA1c (r = -0,146, p = 0,021), al igual que las comparaciones por periodos anuales [n=72] (r = -0,237, p = 0,045). Un volumen de sustitución medio anual >26,6L/sesión (29,3 ± 1,7L/sesión vs. 23,9 ± 1,9 L/sesión) se asoció a un descenso de HbA1c (-0,51 ± 1,24% vs. 0,01 ± 0,88%, p = 0,043). No se observó correlación entre el volumen de sustitución y las variaciones en el peso, IMC o parámetros de la BIS.Conclusión: No existe suficiente evidencia para limitar el transporte convectivo en los pacientes diabéticos en HDF-OL por el contenido de glucosa del líquido de sustitución

Background and objective: Online haemodiafiltration (OL-HDF) with high convective transport volumes improves patient survival in haemodialysis. Limiting the amount of convective volume has been proposed in patients with diabetes mellitus due to glucose load that is administered with replacement fluid. The objective of the study was to analyse the influence of substitution volume on the evolution of the metabolic profile and body composition of incident diabetic patients on OL-HDF.Material and methods: Prospective observational study in 29 incident diabetic patients on postdilution OL-HDF. Baseline data included clinical and demographic data, laboratory parameters (metabolic, nutritional and inflammatory profile) and body composition with bioimpedance spectroscopy (BIS). Laboratory parameters and mean substitution volume per session were collected every 4 months, and in 23 patients a further BIS was performed after a minimum of one year. Variations in glycosylated haemoglobin (HbA1c), triglycerides, total cholesterol, LDL-c, HDL-c, albumin, prealbumin and C reactive protein (CRP) were calculated at one year, 2 years, 3 years, and at the end of follow-up. Quarterly and annual variations were calculated as independent periods, and changes in body composition were analysed. Results: Age at baseline was 69.7±13.6 years, 62.1% were male, 72.3 ± 13.9 kg, 1.78 ± 0.16 m2, with 48 (35.5-76) months on dialysis. Approximately 81.5% received insulin, 7.4% antidiabetic drugs and 51.9% statins. Mean substitution volume was 26.9 ± 2.9L/session and follow-up period (time on OL-HDF) was 40.4 ± 26 months.A significant correlation was observed between mean substitution volume and the increase in HDL-c (r=0.385, p=0.039) and prealbumin levels (r = 0.404, p = 0.003) throughout follow-up. Moreover, substitution volume was correlated with a reduction in CRP levels at one year (r = -0.531, p = 0.005), 2 years (r = -0.463, p = 0.046), and at the end of follow-up (r = -0.498, p = 0.007). Patients with mean substitution volume > 26.9 L/session had a higher reduction in triglycerides and CRP, and an increase in HDL-c levels. These patients with > 26.9L/session finished the study with higher HDL-c (48.1 ± 9.4 mg/dL vs. 41.2 ± 11.6 mg/dL, p = 0.025) and lower CRP levels (0.21 [0.1-2.22] mg/dL vs. 1.01 [0.15-6.96] mg/dL, p = 0.001), with no differences at baseline.Quarterly comparisons between substitution volume and laboratory changes [n = 271] showed a significant correlation with a reduction in HbA1c (r = -0.146, p = 0.021). Similar findings were obtained with annual comparisons [n = 72] (r = -0.237, p = 0.045). An annual mean substitution volume over 26.6 L/session (29.3 ± 1.7L/session vs. 23.9 ± 1.9L/session) was associated with a reduction in HbA1c (-0.51 ± 1.24% vs. 0.01 ± 0.88%, p = 0.043). No correlation was observed between substitution volume and changes in weight, body mass index or BIS parameters.Conclusion: There is not enough evidence to restrict convective transport in diabetic patients on OL-HDF due to the glucose content of the replacement fluid

Influencia de la concentración de calcio en el líquido de hemodiálisis sobre el control de la tensión arterial / Influence of calcium concentration in haemodialysis fluid on blood pressure control

Introducción: La hipertensión arterial es altamente prevalente en los pacientes en hemodiálisis. Implica un mayor riesgo cardiovascular y es fundamental su control. A pesar de medidas dietéticas, optimización de la pauta de hemodiálisis y tratamiento farmacológico, existe un porcentaje de pacientes en nuestras unidades que continúan hipertensos. Es por ello que nos planteamos que la reducción de calcio en el líquido de diálisis puede ayudar al manejo de los pacientes hipertensos en hemodiálisis. Material y métodos: Se seleccionaron todos los pacientes hipertensos de nuestra unidad de hemodiálisis. Se comprobó estado de normovolemia mediante bioimpedancia espectroscópica y se disminuyó la concentración de calcio del líquido de hemodiálisis a 2,5 mEq/l, con un seguimiento de 12 meses. Resultados: Cumplieron criterios de hipertensión arterial no volumen-dependiente 24 pacientes (edad 61±15 años, varones el 48%, diabetes el 43%). Se observó una disminución significativa en la tensión arterial sistólica y diastólica a los 6 y 12 meses de la reducción de la concentración del calcio de diálisis, sin acompañarse de mayor inestabilidad hemodinámica (tensión arterial sistólica basal 162 ± 14; a los 6 meses 146 ± 18; a los 12 meses 141 ± 21 mmHg; p = 0,001) (tensión arterial diastólica basal 76 ± 14; a los 6 meses 70 ± 12; a los 12 meses 65 ± 11mmHg; p = 0,005) Existió un aumento de los niveles plasmáticos de PTH de forma no significativa. No se evidenciaron efectos secundarios. Conclusiones: La hemodiálisis con calcio en el líquido de 2,5mEq/l es una alternativa terapéutica eficaz y segura para el control de hipertensión arterial de difícil manejo en los pacientes de hemodiálisis

Background: Hypertension is a highly prevalent disorder among patients undergoing haemodialysis. It contributes to greater cardiovascular risk and must be controlled. However, despite dietary measures, haemodialysis regimen optimisation and pharmacological treatment, some patients in our units continue to maintain high blood pressure levels. The objective of the study is to demonstrate that reducing calcium in dialysis fluid can help treat hypertension patients undergoing haemodialysis. Material and methods: We selected all of the hypertensive patients from our haemodialysis unit. We checked their normovolemic status by means of bioimpedance spectroscopy, decreasing the haemodialysis fluid's calcium concentration to 2.5 mEq/l, with a follow-up period of 12 months. Results: A total of 24 patients met the non-volume dependent hypertension criteria (age 61±15 years, males 48%, diabetes 43%). A significant systolic and diastolic blood pressure decrease was observed at 6 and 12 months as a result of reducing the dialysis calcium concentration; this was not accompanied by greater haemodynamic instability (baseline systolic blood pressure: 162 ± 14 mmHg; at 6 months: 146 ± 18 mmHg; at 12 months: 141 ± 21 mmHg; P = .001) (baseline diastolic blood pressure: 76 ± 14 mmHg; at 6 months: 70 ± 12 mmHg; at 12 months: 65 ± 11 mmHg; P = .005). A non-significant increase in plasma parathyroid hormone levels was also found. No side effects were observed. Conclusions: Adding 2.5 mEq/l of calcium to dialysis fluid is a safe and effective therapeutic alternative to control hard-to-manage hypertension among haemodialysis patients

High convective volumes are associated with improvement in metabolic profile in diabetic patients on online haemodiafiltration. / Los altos volúmenes convectivos se asocian a la mejoría del perfil metabólico en los pacientes diabéticos en hemodiafiltración online.

BACKGROUND AND OBJECTIVE: Online haemodiafiltration (OL-HDF) with high convective transport volumes improves patient survival in haemodialysis. Limiting the amount of convective volume has been proposed in patients with diabetes mellitus due to glucose load that is administered with replacement fluid. The objective of the study was to analyse the influence of substitution volume on the evolution of the metabolic profile and body composition of incident diabetic patients on OL-HDF. MATERIAL AND METHODS: Prospective observational study in 29 incident diabetic patients on postdilution OL-HDF. Baseline data included clinical and demographic data, laboratory parameters (metabolic, nutritional and inflammatory profile) and body composition with bioimpedance spectroscopy (BIS). Laboratory parameters and mean substitution volume per session were collected every 4 months, and in 23 patients a further BIS was performed after a minimum of one year. Variations in glycosylated haemoglobin (HbA1c), triglycerides, total cholesterol, LDL-c, HDL-c, albumin, prealbumin and C reactive protein (CRP) were calculated at one year, 2 years, 3 years, and at the end of follow-up. Quarterly and annual variations were calculated as independent periods, and changes in body composition were analysed. RESULTS: Age at baseline was 69.7±13.6 years, 62.1% were male, 72.3±13.9kg, 1.78±0.16m2, with 48 (35.5-76) months on dialysis. Approximately 81.5% received insulin, 7.4% antidiabetic drugs and 51.9% statins. Mean substitution volume was 26.9±2.9L/session and follow-up period (time on OL-HDF) was 40.4±26 months. A significant correlation was observed between mean substitution volume and the increase in HDL-c (r=0.385, p=0.039) and prealbumin levels (r=0.404, p=0.003) throughout follow-up. Moreover, substitution volume was correlated with a reduction in CRP levels at one year (r=-0.531, p=0.005), 2 years (r=-0.463, p=0.046), and at the end of follow-up (r=-0.498, p=0.007). Patients with mean substitution volume >26.9L/session had a higher reduction in triglycerides and CRP, and an increase in HDL-c levels. These patients with >26.9L/session finished the study with higher HDL-c (48.1±9.4mg/dL vs. 41.2±11.6mg/dL, p=0.025) and lower CRP levels (0.21 [0.1-2.22] mg/dL vs. 1.01 [0.15-6.96] mg/dL, p=0.001), with no differences at baseline. Quarterly comparisons between substitution volume and laboratory changes [n=271] showed a significant correlation with a reduction in HbA1c (r=-0.146, p=0.021). Similar findings were obtained with annual comparisons [n=72] (r=-0.237, p=0.045). An annual mean substitution volume over 26.6L/session (29.3±1.7L/session vs. 23.9±1.9L/session) was associated with a reduction in HbA1c (-0.51±1.24% vs. 0.01±0.88%, p=0.043). No correlation was observed between substitution volume and changes in weight, body mass index or BIS parameters. CONCLUSION: There is not enough evidence to restrict convective transport in diabetic patients on OL-HDF due to the glucose content of the replacement fluid.

Influence of calcium concentration in haemodialysis fluid on blood pressure control. / Influencia de la concentración de calcio en el líquido de hemodiálisis sobre el control de la tensión arterial.

BACKGROUND: Hypertension is a highly prevalent disorder among patients undergoing haemodialysis. It contributes to greater cardiovascular risk and must be controlled. However, despite dietary measures, haemodialysis regimen optimisation and pharmacological treatment, some patients in our units continue to maintain high blood pressure levels. The objective of the study is to demonstrate that reducing calcium in dialysis fluid can help treat hypertension patients undergoing haemodialysis. MATERIAL AND METHODS: We selected all of the hypertensive patients from our haemodialysis unit. We checked their normovolemic status by means of bioimpedance spectroscopy, decreasing the haemodialysis fluid's calcium concentration to 2.5mEq/l, with a follow-up period of 12 months. RESULTS: A total of 24 patients met the non-volume dependent hypertension criteria (age 61±15 years, males 48%, diabetes 43%). A significant systolic and diastolic blood pressure decrease was observed at 6 and 12 months as a result of reducing the dialysis calcium concentration; this was not accompanied by greater haemodynamic instability (baseline systolic blood pressure: 162±14 mmHg; at 6 months: 146±18 mmHg; at 12 months: 141±21 mmHg; P=.001) (baseline diastolic blood pressure: 76±14 mmHg; at 6 months: 70±12 mmHg; at 12 months: 65±11 mmHg; P=.005). A non-significant increase in plasma parathyroid hormone levels was also found. No side effects were observed. CONCLUSIONS: Adding 2.5mEq/l of calcium to dialysis fluid is a safe and effective therapeutic alternative to control hard-to-manage hypertension among haemodialysis patients.

Removal capacity of different high-flux dialyzers during postdilution online hemodiafiltration.

INTRODUCTION: The aim of this study is to compare molecule removal and albumin leakage in postdilution online hemodiafiltration with different high-flux dialyzers. METHODS: We studied seven high-flux dialyzers (Polyflux 210H®, Evodial 2.2®, FxCordiax1000®, Elisio21H®, TS-2.1SL®, XevontaHi20®, VitaPES 210-HF®) in 6 patients. The reduction ratio (RR) of small- and middle-sized molecules was calculated. Dialysate samples were collected to estimate the albumin leakage. FINDINGS: Global differences between dialyzers were observed in the RR of ß2 microglobulin (P =0.003) and prolactin (P =0.013). The mean loss of albumin in the dialysate per session varied between 114 ± 67 mg (with Evodial 2.2) and 2621 ± 1363 mg per session (with XevontaHi20). We found global differences between dialyzers in total albumin loss (P = 0.05). DISCUSSION: We demonstrated that the performance of high-flux dialyzers was different among the types and that not all high-flux dialyzers should be considered equal.

Consulta de acceso vascular: resultados antes y después de la instauración de un programa multidisciplinar con realización de ecografía doppler de rutina / Vascular access clinic results before and after implementing a multidisciplinary approach adding routine Doppler ultrasound

ANTECEDENTES Y OBJETIVO: El abordaje multidisciplinar y el uso de ecografía doppler (ED) en la creación y vigilancia del acceso vascular (AV) puede mejorar la prevalencia y permeabilidad de las fístulas arteriovenosas (FAV) para hemodiálisis. El objetivo de este estudio es analizar el impacto de una nueva consulta multidisciplinar (CMD) de AV con ED de rutina. MATERIAL Y MÉTODOS: Evaluamos los resultados de la consulta de AV en 2014 (pre-CMD) y 2015 (CMD), antes y después de la implantación de un equipo multidisciplinar (cirujano vascular/nefrólogo) con ED de rutina en mapeo prequirúrgico y FAV prevalente. RESULTADOS: Se evaluaron 345 pacientes en 2014 (pre-CMD) y 364 pacientes en 2015 (CMD). En ambos periodos se realizó un número similar de cirugías, 172 vs. 198, p = 0,289, con tendencia a aumentar las cirugías preventivas de reparación de FAV en el periodo CMD, 17 vs. 29 (p = 0,098). En FAV de nueva creación (155 vs. 169), disminuyó la tasa de fallo primario en el periodo CMD, 26,4 vs. 15,3%, p = 0,015 y aumentó de forma no significativa la realización de FAV radiocefálicas distales, 25,8 vs. 33,2% (n = 40 vs. 56), p = 0,159. También aumentó la concordancia entre la indicación quirúrgica en la consulta y la cirugía realizada (81,3 vs. 93,5%, p = 0,001). En el periodo CMD se solicitaron menos exploraciones radiológicas desde la consulta, 78 vs. 35 (p < 0,001), con una reducción del gasto sanitario (81.716€ vs. 59.445€). CONCLUSIONES: El manejo multidisciplinar y la utilización del ED de rutina permiten mejorar los resultados de AV, con disminución de la tasa de fallo primario de FAV, más opciones de FAV distal nativa, mejor manejo de la FAV prevalente disfuncionante y menor coste en exploraciones radiológicas

BACKGROUND: A multidisciplinary approach and Doppler ultrasound (DU) assessment for the creation and maintenance of arteriovenous fistulas (AVF) for haemodialysis can improve prevalence and patency. The aim of this study was to analyse the impact of a new multidisciplinary vascular access (VA) clinic with routine DU. MATERIAL AND METHODS: We analysed the VA clinic results from 2014 and 2015, before and after the implementation of a multidisciplinary team protocol (vascular surgeon/nephrologist) with routine DU in preoperative mapping and prevalent AVF. RESULTS: We analysed 345 and 364 patients from 2014 and 2015 respectively. The number of surgical interventions was similar in both periods (p = .289), with a trend towards an increase in preventive surgical repair of AVF in 2015 (17 vs. 29, p = .098). 155 vs. 169 new AVF were performed in 2014 and 2015, with a significantly lower primary failure rate in 2015 (26.4 vs. 15.3%, p = .015), and a non-significant increase in radiocephalic AVF, 25.8 vs. 33.2% (n = 40 vs. 56), p = .159. The concordance between the indication at the clinic and the surgery performed also increased (81.3 vs. 93.5%, p = .001). Throughout 2015 fewer complementary imaging test were requested from the clinic (78 vs. 35, p < .001), with a corresponding reduction in costs (€87,716 vs. €59,445). CONCLUSIONS: Multidisciplinary approach with routine DU can improve VA results, with a decrease in primary failure rate, higher likelihood of radiocephalic AVF, better management of dis-functioning AVF and lower radiological test costs

Vascular access clinic results before and after implementing a multidisciplinary approach adding routine Doppler ultrasound. / Consulta de acceso vascular: resultados antes y después de la instauración de un programa multidisciplinar con realización de ecografía doppler de rutina.

BACKGROUND: A multidisciplinary approach and Doppler ultrasound (DU) assessment for the creation and maintenance of arteriovenous fistulas (AVF) for haemodialysis can improve prevalence and patency. The aim of this study was to analyse the impact of a new multidisciplinary vascular access (VA) clinic with routine DU. MATERIAL AND METHODS: We analysed the VA clinic results from 2014 and 2015, before and after the implementation of a multidisciplinary team protocol (vascular surgeon/nephrologist) with routine DU in preoperative mapping and prevalent AVF. RESULTS: We analysed 345 and 364 patients from 2014 and 2015 respectively. The number of surgical interventions was similar in both periods (p=.289), with a trend towards an increase in preventive surgical repair of AVF in 2015 (17 vs. 29, p=.098). 155 vs. 169 new AVF were performed in 2014 and 2015, with a significantly lower primary failure rate in 2015 (26.4 vs. 15.3%, p=.015), and a non-significant increase in radiocephalic AVF, 25.8 vs. 33.2% (n=40 vs. 56), p=.159. The concordance between the indication at the clinic and the surgery performed also increased (81.3 vs. 93.5%, p=.001). Throughout 2015 fewer complementary imaging test were requested from the clinic (78 vs. 35, p <.001), with a corresponding reduction in costs (€87,716 vs. €59,445). CONCLUSIONS: Multidisciplinary approach with routine DU can improve VA results, with a decrease in primary failure rate, higher likelihood of radiocephalic AVF, better management of dis-functioning AVF and lower radiological test costs.

Is High-Volume Online Hemodiafiltration Associated With Malnutrition?

Chronic malnutrition is a common problem in patients with end-stage renal disease on hemodialysis. Some studies have reported albumin loss into dialysis fluid during postdilution online hemodiafiltration (OL-HDF). The aim of the study was to assess the nutritional status of patients on high-volume OL-HDF and to demonstrate that higher convective clearances are not associated with malnutrition due to possible loss of nutrients with ultrafiltration. Demographic and clinical data, corporal composition with bioimpedance spectroscopy, dialysis features, albumin loss into dialysis fluid and laboratory parameters were collected in twenty-eight patients with ESRD undergoing postdilution OL-HDF with stable convective volumes over 28 L/session. Convective volume (CV) in the last six months was 32.51 ± 3.52 L per session. Cross-sectional analysis of dialysis features showed 32.7 ± 3.34 L of CV and high reduction rates of beta-2-microglobulin (84.2 ± 3.8%) and cystatin-C (81.6 ± 3.47%). Beta-2-microglobulin reduction showed a positive correlation with prealbumin levels (P = 0.048). CV was only correlated with cystatin-C reduction (P = 0.025). Estimated albumin loss into dialysis fluid (1.82 ± 1.05 g/session) was not related to laboratory or bioimpedance nutritional parameters, or to CV. Among patients with higher CV, serum albumin levels maintained more stability during the observational period. High volume OL-HDF results in better convective clearances and is not associated with malnutrition. Albumin and nutrients loss into dialysis fluid should not be a limiting factor of the substitution volume.

Eficacia de los antivirales de acción directa en la infección por el virus de la hepatitis C en pacientes en hemodiálisis / Effectiveness of direct-acting antivirals in Hepatitis C virus infection in haemodialysis patients

La infección por el virus de la hepatitis C (VHC) es muy prevalente entre los pacientes en hemodiálisis y condiciona un peor pronóstico respecto a los que no la padecen. El tratamiento con interferón y ribavirina es mal tolerado y existen pocos datos sobre la experiencia con los nuevos antivirales de acción directa (AAD). El objetivo de este trabajo es estudiar retrospectivamente la prevalencia actual de la infección por el VHC y los resultados de eficacia y seguridad con distintas pautas de AAD en la población en hemodiálisis de 2áreas hospitalarias. Estudio multicéntrico, retrospectivo y observacional en el que se analizan los anticuerpos frente al VHC en 465 pacientes, entre los que 54 de ellos eran positivos (11,6%). Entre estos, 29 casos (53,7%) con genotipos 1 y 4 fueron tratados con distintas pautas de AAD, que incluían combinaciones de paritaprevir/ritonavir, ombitasvir, dasabuvir, sofosbuvir, simeprevir, daclatasvir y ledipasvir, con/sin ribavirina. La edad media era de 53,3+7,9 años, el 72,4% eran varones y la causa más importante de la enfermedad renal crónica eran las alteraciones glomerulares. En el 100% de los casos se obtuvo una respuesta viral sostenida a las 24 semanas independientemente de la pauta de AAD recibida. Los efectos secundarios fueron poco relevantes y ningún caso precisó suspender el tratamiento. En 15 de ellos, se asoció ribavirina a los AAD. En estos casos, el efecto adverso más destacable fue la tendencia a la anemización, reflejada en el incremento de la dosis de agentes estimulantes de la eritropoyesis, aunque ninguno precisó transfusiones. En resumen, concluimos que los nuevos AAD para el tratamiento del VHC en pacientes en hemodiálisis presentan una gran eficacia, con mínimos efectos secundarios, y constituyen un avance muy importante en su manejo, con lo que cabe esperar un pronóstico mucho mejor que el que presentaban hasta muy recientemente (AU)

Hepatitis C virus (HCV) infection is highly prevalent among patients on haemodialysis and leads to a poorer prognosis compared to patients who do not have said infection. Treatment with interferon and ribavirin is poorly tolerated and there are limited data on the experience with new direct-acting antivirals (DAAs). The aim of this study is to retrospectively analyse the current prevalence of HCV infection and efficacy and safety results with different DAA regimens in the haemodialysis population of 2hospital areas. This is a multicentre, retrospective and observational study in which HCV antibodies were analysed in 465 patients, with positive antibody findings in 54 of them (11.6%). Among these, 29 cases (53.7%) with genotypes 1 and 4 were treated with different DAA regimens, including combinations of paritaprevir/ritonavir, ombitasvir, dasabuvir, sofosbuvir, simeprevir, daclatasvir and ledipasvir, with/without ribavirin. Mean age was 53.3±7.9 years, 72.4% of patients were male and the most important aetiology of chronic kidney disease involved glomerular abnormalities. In 100% of cases, a sustained viral response was achieved after 24 weeks, regardless of DAA regimen received. Adverse effects were not relevant and no case required stopping treatment. In 15 cases, ribavirin was combined with the DAA. In these cases, the most significant adverse effect was anaemic tendency, which was reflected in the increase of the dose of erythropoietin stimulating agents, although none required transfusions. In summary, we conclude that new DAAs for the treatment of HCV in haemodialysis patients are highly effective with minimal adverse effects; it is a very important advance in HCV management. These patients are therefore expected to have a much better prognosis than they have had until very recently (AU)

Importance of Body Water in the Efficacy of Convective Solute Transport in Online Hemodiafiltration.

High-volume online hemodiafiltration (OL-HDF) has been associated with improved patient survival compared to conventional hemodialysis in recent trials, where the importance of convective volume (CV) in this benefit is noted. The purpose of this study was to determine the corporal composition parameters influencing the efficacy of CV in the removal of different molecular weight (MW) molecules. Demographic data, corporal composition parameters with bioimpedance spectroscopy, dialysis features and the reduction rates of different MW molecules in a four-hour OL-HDF session were collected in 61 patients. We observed a significant negative correlation of ß2-microglobulin, cystatin-C, myoglobin and prolactin reduction rates with body surface area, weight, total body extracellular (ECW) and intracellular water (ICW), lean tissue mass and body cellular mass. The multivariable regression analysis identified ECW and ICW as the only corporal composition factors independently associated to the relative elimination of ß2-microglobulin (Beta: -0.801, P = 0.002 for ECW and Beta: -1.710, P = 0.001 for ICW), cystatin-C (Beta: -0.656, P = 0.010 for ECW and Beta: -1.511, P = 0.004 for ICW) and myoglobin (Beta: -0.745, P = 0.014 for ECW and Beta: -2.103, P = 0.001 for ICW), in addition to CV. Prolactin reduction was only associated with ICW (Beta: -1.540, P = 0.028). When adjusting CV with ECW and ICW, only the ratio CV/ECW was an independent predictor for higher elimination of ß2-microglobulin, cystatin-C and myoglobin. The corporal composition parameters independently associated to the reduction of medium-sized molecules are the extracellular and intracellular water. The ratio "convective volume/extracellular water" predicts higher efficacy of convective transport. Adjusting the convective volume to patient features could be useful to monitor the efficacy of OL-HDF and to prescribe individualized therapies.

Effectiveness of direct-acting antivirals in Hepatitis C virus infection in haemodialysis patients. / Eficacia de los antivirales de acción directa en la infección por el virus de la hepatitis C en pacientes en hemodiálisis.

Hepatitis C virus (HCV) infection is highly prevalent among patients on haemodialysis and leads to a poorer prognosis compared to patients who do not have said infection. Treatment with interferon and ribavirin is poorly tolerated and there are limited data on the experience with new direct-acting antivirals (DAAs). The aim of this study is to retrospectively analyse the current prevalence of HCV infection and efficacy and safety results with different DAA regimens in the haemodialysis population of 2hospital areas. This is a multicentre, retrospective and observational study in which HCV antibodies were analysed in 465 patients, with positive antibody findings in 54 of them (11.6%). Among these, 29 cases (53.7%) with genotypes 1 and 4 were treated with different DAA regimens, including combinations of paritaprevir/ritonavir, ombitasvir, dasabuvir, sofosbuvir, simeprevir, daclatasvir and ledipasvir, with/without ribavirin. Mean age was 53.3±7.9 years, 72.4% of patients were male and the most important aetiology of chronic kidney disease involved glomerular abnormalities. In 100% of cases, a sustained viral response was achieved after 24 weeks, regardless of DAA regimen received. Adverse effects were not relevant and no case required stopping treatment. In 15 cases, ribavirin was combined with the DAA. In these cases, the most significant adverse effect was anaemic tendency, which was reflected in the increase of the dose of erythropoietin stimulating agents, although none required transfusions. In summary, we conclude that new DAAs for the treatment of HCV in haemodialysis patients are highly effective with minimal adverse effects; it is a very important advance in HCV management. These patients are therefore expected to have a much better prognosis than they have had until very recently.