PubMed · 7430408
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J V Petrucci. 1980. Reference standard for packed cell volume.. https://doi.org/10.1136/jcp.33.9.905-a
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Despite the clearly established relationship between adequacy of dialysis and response to erythropoietin, recent guidelines on anemia management in end-stage renal disease (ESRD) omit mention of dialysis adequacy while advocating the use of large amounts of intravenous iron. To determine the relative effects of adequacy of dialysis and intravenous iron on hematocrit, we studied 309 hemodialysis patients and analyzed data from 141 hemodialysis facilities in New York State (ESRD Network 2), as well as data from all 18 ESRD Networks in the United States, for the last quarter of 1997. Among the 309 subjects, mean hematocrit differed between quartiles of urea reduction ratio (URR; F statistic = 4; P: = 0.008). Patients with URRs greater than 70% were 2.6 times more likely to have hematocrits greater than 33% (odds ratio, 2.6; 95% confidence interval [CI], 1.3 to 5.3; P: = 0.009) after adjustment for other factors. Mean dialysis facility (n = 141) hematocrits correlated directly with mean URRs (r = 0.32; P: = 0.001). Facilities with a mean URR greater than 70% were three times more likely to have a mean hematocrit greater than 33% (odds ratio, 3; 95% CI, 1.2 to 7.5; P: = 0.02). The percentage of patients in each of the 18 ESRD Networks with hematocrits of 33% or greater correlated inversely with the percentage of patients administered intravenous iron (r = -0.53; P: = 0.03) after adjustment for dose of erythropoietin. We conclude that adequacy of dialysis predicts the response to erythropoietin at both patient and dialysis facility levels. Patients with low hematocrits primarily because of inadequate dialysis may inappropriately be administered excess intravenous iron intended as a corrective measure.
Optical sensors have advanced significantly over the past 2 decades leading to today's noninvasive optical measurement capabilities and their widespread applications in renal therapy. These measurements provide significant advantages to the clinician. For example, a given blood constituent can be monitored in real time (continuously, nondestructively), which facilitates the ability to optimally "titrate" the therapy with immediate visual feedback. Optical methods have another intrinsic advantage in that each biologic constituent has its own unique spectral "signature" allowing for simultaneous, multiple, and specific measurements of biologic analytes. Use of this budding spectral technology in renal therapy today provides for increased patient safety (by measuring plasma-free hemoglobin, microemboli, clots, oxygen saturation, blood leaks, and hematocrit), measurements of dialysis dose (dialysate urea levels), dry weight (tissue water monitoring), access viability (recirculation, access blood flow), cardiac status (absolute blood volume, cardiac output), and enhanced continuous fluid management (fluid overload, critical blood volume). As microelectronics and signal processing capabilities continue to advance, so will the future of optical diagnosis and treatment. These capabilities translate directly to improved patient quality of life.
It has been suggested that normalization of haemoglobin with epoetin in anaemic chronic renal failure (CRF) patients might result in even greater benefits than those currently achieved with partial haemoglobin correction. Four prospective randomized trials recently examined this hypothesis. The Scandinavian Multicentre Trial, which was completed in February 1998, included 416 haemodialysis, continuous ambulatory peritoneal dialysis and pre-dialysis patients. Preliminary analysis of the data found no differences with respect to safety between patients treated to achieve subnormal haemoglobin (9.0-12.0 g/dl) and those in whom haemoglobin was normalized (13.5-16.0 g/dl). The Canadian Multicentre Trial included 159 haemodialysis patients with asymptomatic left ventricular (LV) dysfunction. In patients with a normal LV cavity volume at enrolment, the change in LV cavity volume at 48 weeks was significantly greater in the control group (target haemoglobin 9.5-10.5 g/dl) than in the intervention group (target haemoglobin 13.0-14.0 g/dl). The Normal Hematocrit Cardiac Trial in the US included 1233 haemodialysis patients with clinically evident ischaemic heart disease or congestive heart failure. The trial was stopped in 1996 after an interim analysis showed increased mortality in the intervention group (target haematocrit 42%) compared with the control group (target haematocrit 30%). The higher haematocrit values themselves, however, did not appear to be responsible for the differences in mortality, as the mortality rates within each group decreased with increasing haematocrit. Nonetheless, until evidence is available from other trials demonstrating a benefit of normalizing haemoglobin, it has been recommended that a target haematocrit value of 42% be avoided in haemodialysis patients with clinically evident ischaemic heart disease or congestive heart failure. Further studies are also required to determine whether increasing haemoglobin to normal may prove to be beneficial in other patient groups. The Spanish Quality of Life Study of 134 haemodialysis patients found a significant improvement in all quality-of-life parameters when haemoglobin was increased to a mean of 12.5 g/dl. The investigators suggested that in patients without severe co-morbidity, the target haemoglobin should be as close to normal as possible.