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PubMed1999

Dialysis adequacy and homocyst(e)ine concentrations in peritoneal dialysis patients.

INTRODUCTION: Determinants of hyperhomocysteinaemia in peritoneal dialysis patients have been recently reported but there is still conflicting data on the influence of dialysis adequacy on homocysteine (Hcy). METHODS: We studied 46 consecutive new continuous ambulatory peritoneal dialysis (CAPD) patients to determine the variation of Hcy before and 1 and 6 months after dialysis. The variation in Hcy was analysed with respect to dialysis adequacy, factors known to influence its metabolism, and Hcy peritoneal clearance. RESULTS: Hcy was 31.9+/-9 micromol/l before dialysis. It was significantly higher before dialysis than 1 month after the onset of PD (31.9+/-9 micromol/l vs 23.2+/-6.9 micromol/l, P < 0.0005). Weekly PD Hcy clearance was 14.3+/-5.4 1. There was no relationship between pre-dialysis Hcy and 1 month post-dialysis Hcy (r=0.176, P=0.15). There was a strong relationship between PD Hcy clearance and both PD creatinine clearance (r=0.502, P<0.005) and Kt/V (r=0.42, P<0.005). There was no relationship between Hcy and PD creatinine clearance (r= -0.221, P=0.11). In contrast, the decrease in tHcy at 1 month was related to PD Hcy clearance (r=0.487, P<0.01), to PD creatinine clearance (r= 0.349, P<0.02) and to Kt/V (r=0.32, P<0.02). Multivariate analysis confirmed the relationship between the decrease in Hcy and dialysis adequacy. Eleven patients (24%) experienced arteriosclerotic complications. Fasting Hcy concentrations in this population were significantly higher before and 1 month-post-dialysis than in patients without cardiovascular complications. CONCLUSIONS: We observed a significant and prolonged reduction in Hcy concentrations by peritoneal dialysis in end-stage renal disease patients. The decrease in Hcy concentration was positively related to dialysis adequacy. This study suggests the possibility that dialysis adequacy may influence arteriosclerotic outcomes through an Hcy-lowering effect.

Adult↗
PubMed2004

Death after withdrawal from dialysis: the most common cause of death in a French dialysis population.

BACKGROUND: Discontinuation of dialysis is a common cause of death in end-stage renal disease (ESRD) patients in North America and the UK, but appears to be unusual in the rest of Europe. The aim of this retrospective study was to characterize withdrawal from dialysis in a French population cohort. METHODS: We assessed the cause of death, and the medical and social characteristics of chronic dialysis patients in a French population who died in 2001. We compared patients who died after withdrawal from dialysis and patients continuing dialysis until death. We determined the decision-making process when dialysis was withdrawn. RESULTS: In a population cohort of 1436 dialysis patients, 196 died (13.9%). Of them, 40 patients (20.4%) died following withdrawal from dialysis. This was the most common cause of death, followed by cardio-vascular disease (18.4%). Patients withdrawing from dialysis had a significantly higher rate of dementia (17.5 vs 6.4%, P = 0.02), a poor general condition (55 vs 15.4%, P < 0.001), and were dependent in their life for everyday activities in comparison with patients who died from other causes. They were not different in age, sex, duration of dialysis treatment, dialysis technique, cardio-vascular disease, diabetes, stroke or cancer, but the sample size was small. Treatment was more often removed in patients with severe medical complications and/or cachexia (90%). The decision to stop dialysis was made most often by a physician (77.5%). CONCLUSION: Death after withdrawing from dialysis was the most common cause of death in ESRD patients in our French population cohort. The patients who died after discontinuation of treatment were more often in a poor general condition, near the end of life, and most often the physician decided to stop dialysis treatment.

Aged↗
PubMed2004

Renal cell carcinoma co-existent with other renal disease: clinico-pathological features in pre-dialysis patients and those receiving dialysis or renal transplantation.

BACKGROUND: Patients on chronic dialysis are prone to developing acquired cystic kidney disease (ACKD), which may lead to the development of renal cell carcinoma (RCC). The risk factors for the development of RCC so far have not been determined in pre-dialysis patients with co-existent renal disease. The aim of this study was to evaluate the clinico-pathological features of RCC in pre-dialysis patients with associated renal diseases or in those undergoing chronic dialysis and renal transplantation. METHODS: We studied 32 kidneys from 31 patients with RCC and associated renal diseases. Of those, 18 kidneys were from 17 patients not on renal replacement therapy (RRT) when diagnosed with RCC; 14 patients received dialysis or dialysis followed by renal transplantation. Several clinico-pathological features were analysed and compared between the two groups. RESULTS: Overall, there was a preponderance of males (75%); nephrosclerosis was the predominant co-existent disease (31%). The median intervals from renal disease to RCC in the dialysis and transplanted groups were significantly longer than in the pre-dialysis group (15.8+/-1.1 vs 2.4+/-0.7 years, P<0.0001). In contrast to pre-dialysis RCC, the dialysis and transplant RCC groups had greater frequency of ACKD (100 vs 28%, P<0.0001), papillary type RCC (43 vs 11%, P<0.05) and multifocal tumours (43 vs 5%, P<0.05). At the end of the study, 71% of dialysis and transplanted patients and 72% of pre-dialysis patients were alive. CONCLUSIONS: ACKD develops in dialysis patients, as it does in those with renal disease prior to RRT. The duration of renal disease, rather than the dialysis procedure itself, appears to be the main determinant of ACKD and RCC. The RCC occurring in patients with ACKD and prolonged RRT is more frequently of the papillary type and multifocal than the RCC occurring in patients with no or few acquired cysts and a short history of renal disease. Long-term outcomes did not differ between the two groups.

Aged↗
PubMed1993

Variation in the attitudes of dialysis unit medical directors toward decisions to withhold and withdraw dialysis.

Increasingly, physicians who treat patients with renal failure are deciding with patients and families whether to withhold or withdraw dialysis. These decisions as well as those concerning whether medical directors of dialysis units felt prepared to make them were studied using three hypothetical scenarios. A questionnaire survey of 524 physician medical directors of adult chronic dialysis units throughout the United States was conducted. They were asked about decisions to withdraw dialysis from a competent patient and a patient with severe dementia, about decisions to withhold dialysis from a permanently unconscious patient, and also about their use of ethics committees to reach these decisions. Three hundred eighteen (61%) responded. Most, 92%, indicated that their units would usually honor a competent patient's request to stop dialysis. There was less agreement about whether to start dialysis in permanently unconscious patients; 83% would withhold dialysis, and 17% would provide it. There was the least agreement about continuing dialysis in patients with dementia; 32% would stop dialysis, and 68% would continue it. Ninety-four percent of medical directors reported that they felt prepared to decide about withholding and withdrawing dialysis. Eighty percent said they might consult a Network ethics committee for difficult decisions. Almost all medical directors of dialysis units believe that they are prepared to make decisions to withhold and withdraw dialysis. Nevertheless, this study revealed significant variation in their attitudes toward these decisions. Practice guidelines and consultation with ethics committees might assist dialysis unit medical directors in making these decisions more uniformly and in a way that promotes patient benefit.

Attitude of Health Personnel↗
PubMed2004

Compliance with the dialysis regimen in chronic peritoneal dialysis patients: utility of the pro card and impact of patient education.

Noncompliance (NC) with the dialysis prescription has been described as a common problem in dialysis patients. In previous studies, NC in peritoneal dialysis (PD) patients has been assessed by obtaining patient or family histories, using questionnaires, and making home visits. With the use of the HomeChoice Pro Chip Card (PCC: Baxter Healthcare Corporation, Deerfield, IL, U.S.A.), the dialysis staff can monitor the total volume of dialysate used, the frequency of exchanges, and the duration of dialysis in patients maintained on automated peritoneal dialysis (APD). Last year, we reported that the PCC was an effective tool for assessing compliance and noted that more than half of patients had a compliance rate (CR) < 95%. In the present study, we examined the impact of patient education on compliance with the prescribed dialysis regimen. We evaluated our APD patients for CR with their dialysis prescription. The PCC was used to record the duration of dialysis and the actual volume of fluid used. From October 2002 to September 2003, all patients maintained at home for 3 consecutive months on APD in the New Haven continuous ambulatory peritoneal dialysis unit were educated concerning the importance of compliance with their dialysis regimen. They were also educated about the function of the PCC and were informed that the dialysis facility would be monitoring their compliance with the prescribed regimen. Compliance rates were calculated by dividing the delivered dialysis volume by the prescribed dialysis volume and multiplying by 100. We obtained data on 42 APD patients. Of the 42 patients, 35 (83%) had a CR > or = 95%, 3 (7%) had a CR between 90% and 94.9%, and 4 (10%) had a CR < 90%. Those CRs are much better than the ones we had previously reported, before the institution of the patient education program. The PCC can be used to assess compliance in APD patients. Patient education results in an improvement in patient compliance. Further study is required to determine factors that affect CR in APD patients.

Female↗
PubMed2000

Tidal peritoneal dialysis: comparison of different tidal regimens and automated peritoneal dialysis.

BACKGROUND: The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines have suggested minimal weekly Kt/V urea and creatinine clearance goals for peritoneal dialysis patients maintained on continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). Achieving these goals may present problems, particularly in larger patients whose residual renal function declines. Thus, modifications of the dialysis regimen, such as tidal peritoneal dialysis (TPD), have been developed. However, the ability of TPD to improve the efficiency of the dialysis procedure remains uncertain. METHODS: Stable, cycling peritoneal dialysis patients were placed into two groups to study the effectiveness of different TPD prescriptions on peritoneal clearances of urea and creatinine. The volume of dialysis solution used and the duration of therapy were fixed in the two groups. Comparisons were made to conventional APD using multiple hourly cycles in which spent dialysis solution was completely drained with each cycle. Group I patients received a total of 15 L of PD solution over 9.5 hours in the dialysis unit. These patients received 10, 25, and 50% TPD and APD on four separate days. Group II patients received 24 L of PD solution over 9.5 hours. These patients received 25 and 50% APD on separate days in the dialysis unit. Peritoneal dialysis clearances for urea (pKt/V) and creatinine (pCCr) levels were calculated for both groups. The results were then analyzed to determine whether there was any significant difference among the various prescriptions. RESULTS: The data in the group I patients indicated a mean daily pKt/V of 0.22 +/- 0.03 with 10% TPD, 0.23 +/- 0.02 with 25% TPD, 0.25 +/- 0.02 with 50% TPD, and 0.26 +/- 0.02 with APD. Paired t-test analysis for pKt/V demonstrated that 10 and 25% TPD resulted in significantly lower values than 50% TPD and APD (P < 0.05). Mean daily pCCr L/24 h/1.73 m2 was 6.03 +/- 0.72 for 10% TPD, 6.34 +/- 0.83 for 25% TPD, 6.65 +/- 0.51 for 50% TPD, and 7.01 +/- 0.96 for APD; these differences were not significantly different. The data in the group II patients demonstrated a mean daily pKt/V of 0.28 +/- 0.03 with 25% TPD, 0.29 +/- 0.05 with 50% TPD, and 0.30 +/- 0.05 for APD. The mean daily pCCr was 6.69 +/- 0.47 for 25% TPD, 8.09 +/- 1.30 for 50% TPD, and 7.63 +/- 1.13 for APD. There were no statistical differences for pKt/V and pCCr within the 24 L group. CONCLUSION: When the duration of therapy and volume of dialysate volume are kept constant, TPD does not result in an improvement in clearances compared with conventional APD, at least with dialysate volumes up to 24 L.

Creatinine↗
PubMed2004

Body mass index, dialysis modality, and survival: analysis of the United States Renal Data System Dialysis Morbidity and Mortality Wave II Study.

BACKGROUND: The impact of obesity on survival in end-stage renal disease (ESRD) patients as related to dialysis modality (i.e., a direct comparison of hemodialysis with peritoneal dialysis) has not been assessed adjusting for differences in medication use, follow-up > or =2 years, or accounting for changes in dialysis modality. METHODS: We performed a retrospective cohort study of the United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Wave II Study (DMMS) patients who started dialysis in 1996, and were followed until October 31 2001. Cox regression analysis was used to model adjusted hazard ratios (AHR) for mortality for categories of body mass index (BMI), both as quartiles and as > or =30 kg/m2 vs. lower. Because such a large proportion of peritoneal dialysis patients changed to hemodialysis during the study period (45.5%), a sensitivity analysis was performed calculating survival time both censoring and not censoring on the date of change from peritoneal dialysis to hemodialysis. RESULTS: There were 1675 hemodialysis and 1662 peritoneal dialysis patients. Among hemodialysis patients, 5-year survival for patients with BMI > or =30 kg/m2 was 39.8% vs. 32.3% for lower BMI (P < 0.01 by log-rank test). Among peritoneal dialysis patients, 5-year survival for patients with BMI >/=30 kg/m2 was 38.7% vs. 40.4% for lower BMI (P > 0.05 by log-rank test). In adjusted analysis, BMI > or = 30 kg/m2 was associated with improved survival in hemodialysis patients (AHR 0.89; 95% CI 0.81, 0.99; P= 0.042) but not peritoneal dialysis patients (AHR = 0.99; 95% CI, 0.86, 1.15; P= 0.89). Results were not different on censoring of change from peritoneal dialysis to hemodialysis. CONCLUSION: We conclude that any survival advantage associated with obesity among chronic dialysis patients is significantly less likely for peritoneal dialysis patients, compared to hemodialysis patients.

Adult↗
PubMed1994

Dialysis utilization in the Toronto region from 1981 to 1992. Toronto Region Dialysis Committee.

OBJECTIVE: To analyse trends in the demand for and supply of dialysis in the Toronto region and to determine whether planned dialysis expansion will be sufficient to provide for the projected growth of the dialysis population. DESIGN: Descriptive analysis of data reported to the Toronto Region Dialysis Registry between 1981 and 1992, compared with provincial and national equivalents. SETTING: All secondary and tertiary care dialysis programs in the Toronto region participating in the registry. PATIENTS: All 504 existing patients enrolled in dialysis programs in 1981 and all 3794 new patients entering programs from 1982 to 1992. Patients with acute renal failure were excluded. MAIN OUTCOME MEASURES: Demand for dialysis: dialysis population at year end, age distribution, crude mortality rate and transplant rate. Supply of resources: distribution of modality (hemodialysis or peritoneal dialysis), number of patients treated per hemodialysis station, number of hemodialysis stations per million population and hemodialysis utilization index (actual/budgeted treatments). RESULTS: During the study period the number of dialysis patients in the Toronto region went from 504 to 1422, for an increase of 182.1%. The average rate of growth was 9.8% per year. Of the total increment of 918 patients from 1981 to 1992, 390 (42.5%) were 65 years of age or more; none the less, the average annual crude mortality rate remained relatively constant, at 13.8% to 17.3%. The transplantation rate declined from a peak of 20.2% in 1982 to 7.8% in 1992. During the study period the Toronto region had much higher numbers of dialysis patients, and hemodialysis patients, per hemodialysis station than the rest of Ontario or Canada. The region's hemodialysis utilization index was 101% in 1991 and 102% in 1992; the index in individual hospitals varied from 98% to 124% (85% was considered optimal). CONCLUSIONS: The growth of the dialysis population in the Toronto region has caused a critical shortage of resources. This trend can be attributed mainly to a decrease in the transplantation rate and an increase in the number of elderly patients entering dialysis programs, combined with insufficient funding for expansion of facilities. Continuation of this trend would be expected to limit universal access to this expensive, but life-sustaining therapy.

Adolescent↗
PubMed1998

Staphylococcus aureus bacteraemia among patients undergoing dialysis--focus on dialysis catheter-related cases.

BACKGROUND: Central venous catheter-related infections are the most common cause of nosocomial S. aureus bacteraemia in Denmark. Central venous catheters are often used for dialysis, and patients on dialysis often run into staphylococcal infections. The purpose of this study was to investigate S. aureus bacteraemia among dialysis patients, especially those related to dialysis catheters. METHODS: This was a retrospective study of 14,387 consecutive S. aureus bacteraemia cases during the period 1976-93, of which 793 cases occurred among dialysis patients. By reviewing the case records, 65 dialysis catheter-related cases were described more thoroughly. RESULTS: The number of S. aureus bacteraemia cases among dialysis patients as a proportion of all cases in Denmark has increased from 5.2 to 14.7% during the study period, but the annual incidence among these patients has been almost stable during the period (median 5.7% (3.2-9.0%)). Patients on dialysis had a lower mortality than other patients with S. aureus bacteraemia (18.9 vs 29.0%), but a four times higher mortality from central venous catheter-related S. aureus bacteraemia (5.3 vs 1.3%, P < 0.001). The mortality from dialysis catheter-related S. aureus bacteraemia was correlated with greater age (median 71 years (57-73) vs median 56.5 years (15-76), P < 0.01) and with septic shock (55.5 vs 7.1%, P < 0.05). Patients on dialysis had a lower frequency of S. aureus endocarditis (3.3 vs 5.4%, P < 0.01) and of S. aureus bone and joint infections (3.3 vs 8.2%, P < 0.001) than other patients. Patients undergoing dialysis had a later onset of catheter-related S. aureus bacteraemia than other patients (median 15 days (1-145) vs 5 days (1-134), P < 0.05). CONCLUSIONS: Patients on dialysis are at a high risk of S. aureus bacteraemia and they have a four times higher mortality from central venous catheter-related S. aureus bacteraemia than other patients. There is need for prospective studies in which patients as well as catheters are followed more thoroughly to study the pathogenesis of dialysis catheter-related infections.

Adult↗
PubMed2005

The impact of education on chronic kidney disease patients' plans to initiate dialysis with self-care dialysis: a randomized trial.

BACKGROUND: Compared with in-center hemodialysis, self-care dialysis (including home and self-care hemodialysis and peritoneal dialysis) is less resource intensive and associated with similar clinical outcomes. However, utilization of self-care dialysis has been very low. We performed a randomized controlled trial in predialysis patients with chronic kidney disease (CKD) (GFR <30 mL/min) to determine the impact of a patient-centered educational intervention on patients' intention to initiate dialysis with self-care dialysis. METHODS: Seventy patients with CKD who were receiving care in a multidisciplinary predialysis clinic were randomized to receive either (1) a two-phase patient-centered educational intervention (phase 1 included educational booklets and a 15-minute video on self-care dialysis; phase 2 included a 90-minute small group interactive educational session on self-care dialysis) in addition to their regular multidisciplinary care, or (2) ongoing standard care and education in the multidisciplinary predialysis clinic. The primary outcome was patients' intention to initiate dialysis with self-care dialysis, assessed by questionnaire. RESULTS: Thirty-five patients were randomized to standard care; 34 completed the study. Thirty-five patients were randomized to the educational intervention; 30 completed phase 1 and 28 completed phase 2. By study end, significantly more patients in the intervention group (82.1%) intended to start dialysis with self-care dialysis compared with the standard care group (50%, P= 0.015). This difference persisted after controlling for the small baseline differences among patients in the two study groups (P= 0.004). CONCLUSION: A two-phase educational intervention can increase the proportion of patients who intend to initiate dialysis with self-care dialysis.

Aged↗
PubMed2004

[Dilution index as a candidate parameter reflecting dialysis dose in combined peritoneal dialysis and hemodialysis therapy].

Combined peritoneal dialysis and hemodialysis therapy (combined therapy) is recognized as an effective alternate in peritoneal dialysis patients with insufficient water and solute removal, but there is no appropriate index for dialysis dose, as two distinct dialysis procedures are utilized in the same patient. Among several candidate parameters, the dilution index proposed and defined by Yamada, et al as the solute generation rate divided by the distribution volume and time-averaged concentration of the solute might be applicable, because it is unrelated to the method of solute removal. Among 11 patients undergoing combined therapy at Toride Kyodo General Hospital, six patients who had transferred from peritoneal dialysis alone to combined therapy were recruited. All patients received peritoneal dialysis therapy for five consecutive days followed by one day off dialysis before a hemodialysis session on the seventh day every week. Total weekly creatinine and urea removal by residual renal function, peritoneal dialysis, and hemodialysis were measured, and their solute removal on the last(5th) day under peritoneal dialysis was ascertained and correlated with the averaged daily removal of solutes. Hence the value of solute removal obtained on the last day under peritoneal dialysis was multiplied seven times and defined as the weekly solute generation. The distribution volumes of creatinine and urea were defined as 58% of body weight. The time-averaged concentration was obtained from the mean level of a solute before and after a hemodialysis session. During the period followed solely by peritoneal dialysis, the dilution indices for creatinine and urea were 1.22 +/- 0.14 and 1.85 +/- 0.14, respectively. The dilution index after transferring to combined therapy, calculated by the above-mentioned method was increased to 1.72 +/- 0.29 and 2.28 +/- 0.31, respectively. Hence the dilution index may be useful for reflecting dialysis doses even in combined therapy.

Combined Modality Therapy↗
PubMedDate not supplied

Peritoneal protein loss in patients with high peritoneal permeability: comparison between continuous ambulatory peritoneal dialysis and daytime intermittent peritoneal dialysis.

BACKGROUND: Dialysate protein loss is involved in the etiology of hypoalbuminemia and malnutrition on continuous ambulatory peritoneal dialysis (CAPD). Patients with high peritoneal membrane permeability had the lowest serum albumin (Alb) and highest dialysate protein concentrations and achieved higher small solute dialysis/plasma equilibration in a shorter time than patients with low peritoneal transport. The aim of this prospective crossover study was to evaluate whether protein loss might be decreased in patients with high peritoneal permeability on short dwell-time (DT) peritoneal dialysis. METHODS: Five high and nine high-average peritoneal transport patients were subjected to the following sequential dialysis schemes (four exchanges/day, glucose 1.5%): scheme A, three daytime exchanges (4-6 h DT) and one nightly (8-12 h DT) for 2-3 days, scheme B, 3-h DT each and dry peritoneum at night during 5 days, a wash-out period similar to scheme A, and scheme C, 2-h DT each and dry peritoneum the remainder of day and night during 5 days. Dialysate Alb, IgG, IgA, and IgM losses and adequacy of dialysis were evaluated at the end of each scheme. RESULTS: Dialysate IgM was not detected. All protein losses were reduced with the short DT dialysis schemes; however, dialysis CCl and KT/V(urea) were also decreased. In patients with high peritoneal transport type, the 3-h DT dialysis scheme achieved a reduction in Alb loss without significant reduction of adequacy of dialysis. CONCLUSIONS: Peritoneal Alb, IgG, and IgA losses are significantly reduced in patients with high peritoneal permeability on short dwell-time dialysis and extended dry periods. However, a reduction of dialysis contribution to small solute clearances was also observed, Three-hour dwell-time dialysis may be particularly useful in patients with high peritoneal transport type, as it tends to reduce peritoneal protein loss without notably reducing adequacy of dialysis.

Adult↗
PubMed2002

What's new in peritoneal dialysis: biocompatibility and continuous flow peritoneal dialysis.

PURPOSE OF REVIEW: This review examines recent developments in the understanding of the effect of conventional, bioincompatible peritoneal dialysis fluids on structural and functional changes in the peritoneal membrane. Emphasis is placed on the clinically relevant outcome of failure of long-term peritoneal dialysis. Therapeutic strategies to prevent technique failure, including the use of new peritoneal dialysis fluids and continuous flow peritoneal dialysis, are explored. RECENT FINDINGS: Long-term (greater than 6 months) exposure to new peritoneal dialysis fluids with physiologic pH, lower lactate concentrations, or lower concentrations of glucose degradation products results in improved leukocyte cytokine release, ultrafiltration, and mesothelial cell mass, respectively. Continuous flow peritoneal dialysis allows efficient small molecule removal using dialysate with lower glucose concentration and possibly less glucose degradation products. Recent technical advances include creation of a double-lumen peritoneal dialysis catheter, and methods of monitoring intra-abdominal pressure and ultrafiltration. SUMMARY: Though initial reports with biocompatible peritoneal dialysis fluids are promising, the efficacy of these new solutions in preventing long-term peritoneal dialysis failure is unproven. Conditions in which new peritoneal dialysis fluids may be beneficial are suggested. Continuous flow peritoneal dialysis requires substantial technical improvements before this technique can be widely accepted.

Biocompatible Materials↗
PubMed2001

Duration of dialysis and its relationship to dialysis adequacy, anemia management, and serum albumin level.

An analysis of the relationship between intermediate outcomes and duration of dialysis therapy in hemodialysis patients was performed by linking Health Care Financing Administration (HCFA) Core Indicators data with data obtained from HCFA form 2728 at the initiation of dialysis therapy. Patients who recently initiated hemodialysis therapy were less likely to meet Dialysis Outcomes Quality Initiative guidelines than patients with a longer duration of dialysis therapy. For both urea reduction ratio and Kt/V, odds ratios for adequate dialysis were approximately 0.20 for a duration of dialysis therapy less than 0.5 years and 0.42 to 0.63 for a duration of dialysis therapy of 0.5 to 1.0 years compared with a duration of dialysis therapy of 2.0 years or greater. For patients with a duration of dialysis therapy less than 0.5 years (compared with >/=2.0 years), the odds ratio for a hematocrit less than 28% was approximately 3.0, that for a hematocrit 33% or greater was approximately 0.6, and that for a serum albumin level of 3.5 g/dL or greater (bromcresol green method) or 3.2 g/dL or greater (bromcresol purple method) was approximately 0.4. There was a direct relationship between glomerular filtration rate at the initiation of dialysis therapy and both serum albumin and hematocrit values. Patients administered recombinant human erythropoietin (rHuEPO) predialysis were more likely to have greater hematocrits. There also was a direct relationship between hematocrit and serum albumin level. Therefore, several actionable items in regard to attentive overall medical care can result in an improvement in the percentage of patients newly started on hemodialysis therapy who meet intermediate outcomes, including the administration of rHuEPO predialysis, correction of iron deficiency, and timely placement of a permanent dialysis access.

Adolescent↗
PubMed1996

Adequacy of dialysis: trace elements in dialysis fluids.

A number of considerations suggest that trace element disturbances might occur in dialysed patients. These must at least in part be ascribed to the dialysis treatment itself during which these constituents may either be transferred to or removed from the patient. Tap water must be considered as the main source of dialysate trace metal contamination. These can adequately be removed during water treatment provided that, in addition to softening and deionization, reverse osmosis is available. However, even in the presence of the latter devices the possibility of serious contamination of the dialysis fluids leading to either chronic or acute intoxications still exists. The addition of chemical concentrates may also contribute to the increased concentrations of a number of trace metals. The toxic effects of aluminium in dialysis patients are well known and at the present time the element is still responsible for the greater part of trace metal-related problems in dialysis patients. Hence, the need for regular monitoring of aluminium cannot be ruled out at present. Strategies for diagnosis and treatment of aluminium overload have been updated. Recent studies demonstrated the efficacy of low desferrioxamine doses in diagnosis and treatment of aluminium overload, and optimal schedules for administration of the chelator and duration of treatment have been presented. Recently, in an epidemiological survey serum silicon concentrations in dialysis patients were found to be increased up to 100-fold compared to subjects with normal renal function. Moreover, it was noted that silicon concentrations in the dialysis population differ from one centre to another and that increased levels are due to either the use of silicon-contaminated dialysis fluids or an increased oral intake of the element originating from a high silicon content in the drinking water. Besides aluminium and silicon, a transfer towards the patients during dialysis has also been reported for a number of other elements including copper, zinc, nickel, strontium and chromium. The possible consequences of dialysate contamination with these elements will briefly be dealt with in the present paper. In contrast to trace metal accumulation, removal of trace metals during dialysis may at least in part contribute to the relative deficiency of particular essential elements. Selenium deficiency has repeatedly been observed. In view of the element's well-known essential role in glutathion peroxidase activity and the association of its deficiency with the development of some malignant diseases, further studies on the clinical impact of decreased serum selenium in dialysis patients are worthwhile. In conclusion, trace metal dialysate contamination/ depletion may contribute to the disturbed trace element concentration in dialysis patients. Aluminium accumulation is still an important problem in clinical nephrology. The clinical importance of the accumulation/ deficiency of trace elements other than aluminium is not yet fully understood and deserves further investigation.

Aluminum↗
PubMed1998

Rationale for early incremental dialysis with continuous ambulatory peritoneal dialysis.

There are good reasons to suspect that if a weekly Kt/V urea of <2.0 is inadequate for CAPD then it is also inadequate for CRF without dialysis. Spontaneous protein intakes tend to fall below 0.7-0.8 g/kg at these levels in both CAPD and CRF. Low protein intakes can be associated with deterioration in nutritional status and a falling serum albumin. Low serum albumin concentrations at the start of dialysis are associated with increased risk of death during dialysis. Some nutritional problems which develop during conservative management prior to dialysis initiation may not be completely reversible. Since both renal function and CAPD offer nearly continuous urea clearances, it makes sense that targets for adequacy in CAPD should also be targets for initiation of chronic dialysis. At this time, it seems that a weekly Kt/V urea of 2.0 is a reasonable value. There may be reasons why chronic peritoneal dialysis is more suitable than intermittent HD for the initiation of early incremental dialysis. These advantages have to do with the ease of providing small incremental dialysis doses as needed to maintain the Kt/V urea at a level of 2.0 for the kidney and dialysis combined. Early CAPD may be less threatening to residual renal function than HD. Daily CAPD allows early control of sodium and water balance. It also delays the use of blood access sites until larger dialysis doses achieved with HD are absolutely necessary. There may be cost advantages as well. We should abandon the philosophy of initiating dialysis after patients have already suffered the ravages of uraemia and related malnutrition.

Humans↗
PubMed2004

Hemoglobin normalization results in lower dialysis dose, despite high dialysate flow. Single needle offers inadequate dialysis.

Anemia correction by erythropoietin favorably affects dialysis outcome but may also reduce dialysis efficiency increasing morbidity and mortality. Single needle dialysis (SN) and high dialysate flow (DF) are dialysis variations. We studied the effect of hemoglobin (Hb) normalization on dialysis adequacy under high DF. We also compared double needle (DN) and SN dialysis efficiency. Seventeen stable anuric patients (13 M, 4 F), aged 62 (40-90), on hemodialysis for 48 months (8-204), were studied in two, 6 months apart, periods of low (A) and high Hb (B), during a midweek 4 h dialysis with DN and SN. DF was 500 in A and 800 ml/min in B. Rebound urea samples, 20 min post dialysis, were used for computer calculated double pool urea kinetics. Hb levels were 128 +/- 8 g/L (B) vs. 119 +/- 14 g/L (A), P < 0.03. Despite the use of higher DF less dialysis was delivered in B vs. A, under DN or SN (DN: URR 64.8 +/- 5.8 vs. 69.7 +/- 5.2%, Kt/Vequil. 1.09 +/- 0.19 vs. 1.26 +/- 0.21, nPCR 1.37 +/- 0.29 vs. 1.60 +/- 0.36g/kg/day, changes <0.001, SN: URR 49.7 +/- 7.5% vs. 52.6 +/- 8.8%, Kt/Vequil. 0.74 +/- 0.16 vs. 0.82 +/- 0.23, nPCR 1.05 +/- 0.33 vs. 1.20 +/- 0.31, changes NS). SN was found significantly (P < 0.001) less efficient than DN in A and B. Serum creatinine drop was significantly (P < 0.001) less in both periods with SN vs. DN. Hb (SN in B) correlated inversely to Kt/V (r = -0.5705, P < 0.02) and URR (r = -0.6432, P = 0.005). Hb correction to normality is associated with a decrease in dialysis efficiency. The use of high dialysate flow does not compensate for this loss. SN delivers inadequate dialysis independently of dialysate flow or hemoglobin concentration.

Adult↗