bluuebunny/crossref_metadata_2025 huggingface dataset:
Extracorporeal RRT modalities: A systemic review
Authors: Kannaiyan R.S.
Published: January 2005

Objective: 
Hemodialysis (HD), hemofiltration (HF), hemodiafiltration (HDF), and acetate free biofiltration (AFB) are renal replacement therapy (RRT) methods in which impurities are removed from the blood extracorporeally. It has been suggested that HF, HDF, and AFB may have fewer cardiovascular side‐effects than HD and may reduce incidence of dialysis‐related amyloid‐ associated complications due to more effective removal of β2‐microglobulin. Methods: We performed a systematic review of randomized controlled trials (RCTs) comparing these RRT modalities. Out of 1672 abstracts identified by searching MEDLINE, EMBASE, and Cochrane Controlled Trials Registry, 18 trials (588 patients) were included. Our comparisons were convective modalities (HF/HDF/AFB) vs HD (16 trials); HDF/AFB vs HF (no trials); and HDF vs AFB (2 trials). Data were extracted by two reviewers independently on mortality, hypotension episodes, dialysis sessions associated with “adverse symptoms”(headache, nausea, and vomiting), hospital admissions, adequacy of dialysis, number of patients with amyloid related complications, β2‐microglobulin removal, and quality of life (QOL). Results: No significant difference was found with regards to mortality, hospitalization, dialysis‐related hypotension, dialysis‐related symptoms, Kt/V, predialysis β2‐microglobulin values between convective modalities (HF/HDF/AFB) and HD, and HDF and AFB. Quality of life was assessed only in two studies comparing HF/HDF/AFB and HD. One study that used an unvalidated scoring tool showed that patients on convective modalities scored significantly better than those on HD; whereas, another study using a validated scoring system, the Kidney Diseases Questionnaire, failed to show significant differences between the two groups. Conclusions: While this review summarized the best available evidence, it is based on very few trials. The trials included in this review are small and are therefore inadequately powered to detect differences between effects of the relevant treatments. Overall, HF, HDF, and AFB have not been shown to have significant advantage over HD with regard to clinically important outcomes of mortality, dialysis‐related hypotension and manifestations of dialysis‐related amyloidosis, and therefore, it is not possible to recommend the use of one modality in preference to the other.
Clinical and laboratory variables in Type 2 diabetic men with renal failure before and after initiation of hemodialysis
Authors: Bibb J. , Servilla K.S. , Tzamaloukas A.H.
Published: January 2005

Control of certain clinical and laboratory parameters affects morbidity and mortality of type 2 diabetic patients with chronic renal failure (CRF) both before and after initiation of hemodialysis (HD). To identify areas and stage of renal failure where control of these critical variables needs improvement, we compared important clinical and laboratory parameters 6 months before (PRE) and 6 months after starting HD (POST) in 43 type 2 diabetic men with CRF, who were 69.3 ± 10.7 years old at HD initiation. Differences, all at p ≤ 0.05, were found in blood pressure, in mm Hg, at the physician's office, both systolic (PRE 154 ± 16, POST 138 ± 18) and diastolic (PRE 77 ± 13, POST 69 ± 11), serum cholesterol in mg/dL (PRE 206 ± 61, POST 159 ± 40), and serum creatinine in mg/dL (PRE 4.1 ± 1.3, POST 7.0 ± 1.8), while no differences were noted in blood hematocrit (PRE 36 ± 7%, POST 34 ± 9%), blood glycosylated hemoglobin (PRE 7.4 ± 1.7%, POST 6.9 ± 2.3%), serum glucose in mg/dL (PRE 151 ± 67, POST 184 ± 94), serum phosphorus in mg/dL (PRE 4.5 ± 0.8, POST 4.6 ± 1.5), serum calcium in mg/dL (PRE 8.7 ± 0.5, POST 8.5 ± 1.4), and serum albumin in g/dL (PRE 3.2 ± 0.5, POST 3.4 ± 0.6). Compared to the POST category, significantly (p ≤ 0.05) higher percentages were found in the PRE category for systolic blood pressure >150 mm Hg (PRE 58.8%, POST 26.5%), blood glycosylated hemoglobin >8%(PRE 33.3%, POST 13.3%), serum cholesterol >200 mg/dL (PRE 48.4%, POST 19.4%). A lower percentage was found in the PRE category for serum phosphorus >5.5 mg/dL (PRE 13.2%, POST 31.6%), while the corresponding percentages for serum albumin <3.0 g/dL (PRE 21.6%, POST 18.9%) and serum calcium <8 mg/dL (PRE 7.9%, POST 13.2%) did not differ. In patients with type 2 diabetes mellitus and renal failure, control of blood pressure, glycemia, and serum lipids appears to be better; whereas, control of serum phosphorus is worse in the first year after starting chronic hemodialysis than in the preceding year. There is room for improvement, both before and after hemodialysis initiation, in the control of these variables, which affect the clinical outcomes of hemodialysis.
Citrate anticoagulant hemodialysate in renal failure patients at high risk of bleeding
Authors: Baosong G. , Ning N. , Ganglian Y. , Lin G. , Liangqi W. , Ruijun G.
Published: January 2005

Objective: 
The aim of this study was to observe the anticoagulant effect of the new type of citrate anticoagulant hemodialysate in renal failure patients at high risk of bleeding. Methods: 57 patients at high risk of bleeding were given hemodialysis for 4 hours and were divided into 3 groups according to hemodialysis procedures: Group 1 was saline‐flush hemodialysed with bicarbonate hemodialysate. Group 2 was hemodialysed with citrate hemodialysate and with no anticoagulant. Group 3 was hemodialysed with bicarbonate hemodialysate and with nadroparin calcium (a low molecular weight heparin, LMWH) as anticoagulant. Bleeding complication, coagulation of extracorporeal circuit, venous blood pressure, heart rate, QTC, activated coagulation time (ACT), ionized‐calcium (iCa++), total calcium and pH, , Na+, K+, Cl−, BUN, Cr, GPT, GST, TBIL, DBIL, as well as the blood cell counts were monitored during hemodialysis, and a scanning electron microscopic (SEM) analysis was used to investigate the morphology of thrombus formation and cellular aggregation on the interior surface of hemodialysis membranes. Results: During the hemodialysis in Group 1, venous blood pressure increased continuously, resulting in the failure of hemodialysis for 4 out of 19 patients. Hemodialysis for 4 hours in Group 2 were all successfully fulfilled. No bleeding episodes occurred. No severe clotting of dialyzers and blood accesses was observed. ACT was extended and iCa++ decreased obviously in the venous line, but ACT and iCa++ in vivo were normal. pH, tended to increase but not to metabolic alkalosis levels. Na+, K+, Cl−, GPT, GST, TBIL, DBIL, as well as the counts of blood cells were all within the normal range. There was no severe thrombus observed by SEM in the hollow fibers. In Group 3, severe bleeding complication happened to 3 out of 19 patients, and one of them died. ACT was extended obviously at the arterial end. Conclusions: The citrate anticoagulant hemodialysate was proved to be practical, safe and effective. So it is indicated for patients with an active or recently active bleeding focus.
Correction of an anemia in patients with a terminal stage chronic renal insufficiency on haemodialysis
Authors: Ismagilov R.Z. , Dreizin V.J. , Azhitaeva A.S.
Published: January 2005

One of the basic symptoms of a terminal stage chronic renal insufficiency is anemia. From everything, used methods of correction of an anemia, it is considered the most effective application of preparations recombinant human erythropoietin (r‐Hu EPO). Since 1994 in the Scientific Centre of Surgery begins application r‐Hu EPO. Application r‐Hu EPO in patients with a terminal stage chronic renal insufficiency in 90–95% of cases had a positive effect, but 5–10% of patients have intolerance to erythropoietin, that has induced to search of new effective methods of correction of anemia. During research were determined quantity erythrocytes, hemoglobin, reticulocyte in peripheral blood and acid‐alkaline condition of blood. All hematology parameters were defined at the beginning of treatment, over 5 day and for 15 day of stimulation of a bone marrow. For 15 days after stimulation of a bone marrow by the laser there was an authentic increase of quantity erythrocyte, hemoglobin, hematocrit. The initial contents erythrocytes made 2.22 ± 0.1 10 × 12, hemoglobin 67.7 ± 3.2 g/l and hematocrit 18.2 ± 1.2%. During treatment by the laser parameters erythrocytes have increased up to 2.9 ± 0.8 10 × 12, hemoglobin up to 89.6 ± 2.9 g/l and hematocrit up to 28.2 ± 1.3%(P < 0,005). Hematology parameters in blood of control group authentically have not changed.
The use of near infrared interactance in hemodialysis
Authors: Sarhill N. , Mahmoud F. , Khaishgi A. , Sawhney R. , Ahsan A. , Lanning J. , Christie R.
Published: January 2005

Forty‐one consecutive admissions to a hemodialysis center were evaluated. Demographic information including age, gender, race, and diagnosis was collected. Patients, >18 years old, with end stage renal disease and on hemodialysis for at least one year were included. Those with edema or known ascites were excluded. Weight was measured before and after hemodialysis (HD) using a standard scale and by considering the amount of fluid loss by the hemodialysis machine. Body composition including total body water (TBW) was calculated before and after HD using near infrared interactance (NIR). All measurements were completed during half hour before and after HD. Forty‐one patients included: men (n = 26), women (n = 15); median age 58 (range 28–88 years). Twenty‐eight were African American and the rest Caucasians. The amount of intravascular fluid taken after HD (assessed by weight reduction) ranged 0–5 L with median 2.2 L. NIR analysis for the same patients at the same time showed different total body water measurements in 91% of cases (P > 0.05). Moreover, NIR analysis showed increase in total body water in 24% of patients even though the hemodialysis machine showed a loss of total body water; median of 1.3 (range: 0–3L). The error in measuring body composition with NIR was both large and varied (random and not systematic error). We conclude that NIR analysis cannot be considered as a reliable method to evaluate body composition, especially total body water, amongst patients with end stage renal disease undergoing hemodialysis.
Biochemical and imaging alterations of renal bone disease in newly detected predialysis and on maintenance dialysis patients
Authors: Hossain R.M. , Hoque M.E. , Rahman H. , Rashid H.U. , Iqbal M.
Published: January 2005

Objective: 
Bone involvement in chronic renal failure is manifested long before the initiation of dialysis and is more prevalent in patients receiving inadequate conservative phase management. This study aimed at identifying the extent of renal bone disease among pre‐dialysis and maintenance dialysis patients. Method: Thirty‐two patients (gr 1) on maintenance hemodialysis (HD) for variable period of time were compared to twenty newly detected, irregularly treated, (gr 2) pre‐dialysis severe renal failure patients for their clinical, biochemical, and imaging features. Result: Mean age of gr 1 and gr 2 patients was 45 ± 14 vs. 34 ± 15 years (p < 0.05). Comparison of blood biochemistry between group 1 and 2 showed serum creatinine 9.9 ± 2.9 vs. 13.4 ± 4.4 mg/dl (P < 0.01), calcium 10 ± 1.4 vs. 7.4 ± 1 mg/dl (p < 0.001); phosphate 4.4 ± 1 vs. 8 ± 2 mg/dl (p < 0.008); ionized calcium 4.7 ± 0.1 vs. 3.9 ± 0.7 mg/dl (p < 0.05); alkaline phosphatase 116 ± 31 vs. 86 ± 31 IU/l (p < 0.05); and iPTH 72 ± 48 vs. 147 ± 92 pg/ml (p < 0.05). Radiological changes present in the two groups were osteopenia‐63% vs. 65%(P = NS); trabecular resorption‐53% vs. 20%(p < 0.05); soft tissue calcification‐31% vs. 10%(p < 0.05); bone cyst‐16% vs. 25%(P = NS) and subperiosteal bone resorption‐16% vs. 20%(P = NS). Tc 99MDP bone scan combined in both groups of patients (n = 52) showed increased uptake in wrist joint (29%), tibia‐fibula (25%), costochondral junction, vertebral column (15% each), sternum (13%), radius and ulna (10%), and calvaria and mandible (8% each). X‐ray finding was positive for bone involvement in 59% cases and Tc 99 scan was positive in 80%(p < 0.05). Association study showed iPTH had a negative correlation with serum calcium (r = −0.5, p < 0.05) and a positive correlation with serum phosphate (r = 0.7, p < 0.05) and alkaline phosphatase (r = 0.9, p < 0.001). Conclusion: It is concluded that pre‐dialysis newly detected renal failure patients may present with deranged calcium homeostasis and can manifest high prevalence of bone involvement when compared to maintenance hemo‐dialysis patients.
The effect of hemodialysis duration on 703 hemodialysis patients in our center
Authors: Özdemir F.N. , Arat Z. , Akcay A. , Erdem A. , Aǧca E. , Sezer S. , Haberal M.
Published: January 2005

There are limited data on demographics, long‐term follow‐up, and iron/rHuEPO requirements of hemodialysis (HD) patients in Turkey. The aim of the study was to analyze the effects of the HD duration, primary illness, blood pressure, and age on serum albumin, CRP, blood pressure, iron/rHuEPO requirements, PTH, and HCV positivity of HD patients. 703 patients (280 women, 423 men, aged 47.8 ± 15.5 years) from 4 HD units were included and grouped according to the duration on HD. The demographic, clinical, and biochemical data of the last 3 months for each patient were recorded retrospectively. When the groups were compared, patients with a longer HD duration were younger and percentage of diabetic patients decreased as the duration increased. Serum albumin and CRP levels were similar between the groups. When the groups were compared according to the blood pressure profiles, after the 5th year, a decline in the systolic blood pressures was observed. Diastolic blood pressures were similar across the years. There was no significant difference in need of antihypertensive medicines. Iron requirements showed a fall after the 5th year, and an increase in after the 10th year. There was a decline in the hematocrit levels by the duration on HD but there was no change in rHuEPO requirements over the years. Parathyroid hormone levels and HCV positivity tended to increase across the years. Our results revealed that during the first 10 years, age, etiology (diabetes, hypertension), and blood pressure control seemed to be important factors affecting survival. Whereas, after the 10th year, patients seemed to be more prone to the long‐term complications of HD, such as HCV infection, anemia, secondary hyperparathyroidism.
The relationship of insulin resistance and body fat in chronic kidney disease patients.
Authors: Satirapoj B. , Supasyndh O. , Boonyavarakul A. , Luesutthiviboon L. , Chuvicheer P.
Published: January 2005

Background: 
Insulin resistance has been associated with type 2 diabetes, hypertension, central obesity, and dyslipidemia, all of which are important risk factors for progression of chronic kidney disease (CKD). A greater degree of insulin resistance may predispose to renal injury by worsening renal hemodynamics through the elevation of glomerular filtration fraction. However, there are sparse data on the relationship between insulin resistance, glomerular filtration rate (GFR), and total body fat or phase angle in CKD without diabetes. Methods: We examined 84 non‐diabetes CKD patients according to the K/DOQI definitions; only 79 patients were enrolled into the study (GFR between 15 and 90 ml/min/1.73 m2). The value of insulin resistance was obtained by homeostasis model assessment (HOMA). Bioelectrical impedance analysis was performed to determine the percentage of total body fat or phase angle. GFR was calculated by the average of creatinine and urea clearances. Results: The correlation analysis showed that HOMA‐insulin resistance was positively correlated with phase angle (r = 0.35, P < 0.01), percentage of total body fat (r = 0.27, P < 0.01), body mass index (r = 0.48, P < 0.01) and serum triglyceride levels (r = 0.32, P < 0.01), but not significantly correlated with gender (r = −0.07, P > 0.05), age (r = 0.05, P > 0.05), GFR (r = −0.006, P > 0.05), and mean arterial blood pressure (r = 0.11, P > 0.05). Conclusion: In non‐diabetic chronic kidney disease patients, the major risk factor for insulin resistance is the amount of total body fat. The insulin level is not dependent on the GFR in these patients.
Long slow night hemodialysis and quality of life
Authors: Hakkarainen P. , Kapanen S. , Honkanen E. , Löflund E.
Published: January 2005

Background: 
Long slow hemodialysis (LS‐HD) improves many biochemical parameters compared with conventional HD. However, its influences on quality of life are less well known. Aims: The objective of this study was to examine the quality of life of patients on LS‐HD performed overnight compared to the patients on standard hemodialysis. This extends the previous study, conducted in 2001, which examined the LS‐HD patients, quality of life. Patients and methods: We sent questionnaires to 12 LS‐HD (overnight, treatment time 8 h × 3/wk) patients and 15 day HD (4.5 h × 3/wk) patients, all being treated using the limited care method. Data was collected using two different structured questionnaires. One was constructed for a previous study (2001) and the other one was a standardized set of questionnaires (RAND‐36). Research material was collected from patient documents, such as the essential biochemical parameters, blood pressure, weight gain, and weekly EPO doses were recorded. Ten of the LS‐HD patients (83%) and 13/15 (87%) of day HD patients returned the questionnaires. Three day hemodialysis patients returned empty questionnaires, which were disqualified. Results: Based on the medical facts, the results showed that the patients of LS‐HD felt better than the patients in another group. Patients on the LS‐HD had higher Kt/V (2.623 vs. 1.577) and Hb (118 vs. 111) and lower Pi (1.36 vs. 1.63) and EPO dose (epoietin‐beta 2667 ky/week vs. 5833 ky/week; darbepoetin 16 ky/week vs. 37 ky/week). However, their predialysis BP as well as the weight gain between treatments and salt and fluid balances caused problems furthermore. The experiences of the therapy of the LS‐HD patients were more positive than of the control group: they felt their medical condition was better than of the patients on day HD. However we didn’t observe significant differences in the replies showing physical or psychosocial conditions between the two groups. Conclusions: The study suggests that when patients can themselves make the choice between treatment modalities, it improves the quality of life of the patients. Control of anemia is improved in LS‐HD overnight patients with lower doses of EPO. The LS‐HD gives the patients more freedom of diet. However, more attention must be paid to salt and fluid restriction. The LS‐HD makes it possible for many patients to work normally.
CQI in the acute dialysis setting
Authors: Margarita P. , Ilumin UC.
Published: January 2005

When the acute dialysis program became an in‐house operation, the development and implementation of a CQI program was a priority. Quality indicators were identified. Clotting in the dialyzer, treatment delays, and catheter‐related infections were tracked. Based on our CQI data, it was clear from the beginning that there was a high incidence of dialyzer clotting, particularly on our patients on Extended Daily Dialysis (EDD) who were on heparin‐free dialysis. Heparin‐free dialysis is prescribed for high bleeding risk patients and for patients with heparin‐induced thrombocytopenia. There was a need to explore an effective way to maintain patency and longevity of the extracorporeal circuit as clotting not only results to blood loss but to loss of treatment time, which affects the efficiency and adequacy of the dialysis therapy. Our policy on no‐heparin dialysis was modified. Hourly saline flushes were changed to a more aggressive every‐15‐to‐30 minute flushes. In addition, “heparin rinse” or priming the extracorporeal circuits with 5000 units of heparin added to 1‐liter bag, except for HIT positive patients, was immediately implemented. After 2 months, clotting in the dialyzer on Extended Daily Dialysis was significantly reduced from 24% to 2%. Conclusion: CQI in the acute dialysis setting is critical for a continuous cycle of evaluating and improving patient outcomes. Through the process of CQI, we were able to identify dialyzer clotting with our EDD as a quality of care problem and implemented a solution that was effective.
Studies of phosphate dynamics during hemodialysis
Authors: Kjellstrand C.M. , Odar‐Cederlof I. , Ing T.S. , Blagg C.R.
Published: January 2005

Regulation of phosphate (PO4) in hemodialysis patients is very difficult and ideal levels are rarely maintained. A high removal and a normal phosphate level is important, as high and low levels are both associated with morbidity and a very high mortality.

We studied phosphate dynamics and its relation to other small “uremic” molecules in 48 patients by measuring pre‐ and postdialysis levels and all removed phosphate, urea and creatinine (creat) in all dialysate during 455 dialyses done at different frequencies (freq): 3.7 ± 1.2, range 3–6 treatments per week and durations of dialysis (t): mean: 196 ± 95, range 80–560 min and with high (HF) and low flux membranes.

Kt/V‐PO4, Kt/V‐urea and Kt/V‐creat, volumes (Vr) for all solutes and their relationships to frequency and duration of dialysis, urea clearance and predialysis phosphate were calculated.

Factor/solute:
PO4
Urea‐N
Creatinine

Predialysis mg/dl
5.7 ± 1.9
73 ± 24
12 ± 3

Postdialysis mg/dl
3.0 ± 1.0
33 ± 15
6 ± 2

100 × Vr/BW
63 ± 78
58 ± 24
41 ± 15

Kt/V
1.01 ± 0.66
1.04 ± 0.32
0.97 ± 0.26

Weekly stdKt/V
1.75 ± 0.81
2.12 ± 0.68
1.96 ± 0.71

Removed gm/week
3.1 ± 1.3
56 ± 23
6.2 ± 2.5

Vr = removed solute ÷ (predialysis minus postdialysis concentration.); BW = body weight. Uf = ultrafiltration. Results: Vr as a percentage of BW for PO4 was dependent on predialysis PO4 and rose steeply as predialysis PO4 decreased: Vr% BW = 212 − 88 × ln (predialysis PO4), (r = 0.39, p < 0.0001). There was no such relationship for Vr for urea or creatinine and no relation between urea and PO4 Vr, (r = 0.07, p = 0.141).

In stepwise multiple regression analysis:

Mg PO4 removed per week = t × 6.5 + freq × 387 + Uf × 140 + pre‐PO4 × 273 + PO4 stdKt/V × 343 − HF × 375 − 1824, (r = 0.73, p < 0.0001). Blood flow(QB) and dialysate flow (QD), urea weekly stdKt/V were not significant variables in the model.

Pre‐dialysis PO4 = 6.8 − Hrs/week × 0.07 − QB × 0.003 + Uf ×  0.26. QD, membrane type or dialyses/week did not enter the model. Only patients dialyzing>28 hrs/week could stop phosphate binders within 3 weeks. Conclusions: Phosphate shows a highly variable dynamic during dialysis. Apparently, the body maintains extracellular PO4 concentration by releasing PO4 from unknown compartments when the blood concentration of PO4 decreases. Vr for phosphate thus varies not only from patient to patient but also in a patient, depending on blood concentration of PO4. Kt/V for urea and creatinine are inaccurate in describing PO4 removal. To remove PO4 efficiently it is most important to use long and daily dialysis. QB, QD and membrane type are relatively unimportant in phosphate removal.
Catheter‐related bacteremia in a pediatric hemodialysis unit
Authors: Onder A.M. , Chandar J. , Coakley S. , Abitbol C. , Montane B. , Zilleruelo G.
Published: January 2005

Tunneled‐cuffed hemodialysis catheters are frequently used as long‐term vascular access in children due to the technical difficulties in constructing a fistula. Catheter‐related bacteremia (CRB) is still a major complication contributing to patient morbidity and loss of vascular access. Objective: To investigate the microbiological characteristics of CRB in children on hemodialysis. Methods: Chart review of 63 children who received hemodialysis with a tunneled‐cuffed catheter between January 1999 and December 2003 was performed. CRB was diagnosed when positive blood cultures were obtained in patients with symptoms of bacteremia, and without an identifiable source. Results: During the 5 year period, a total of 251 CRB were detected with 313 bacterial and 2 candidal growths in the blood cultures. The distribution of gram positive (Gr+) and gram negative (Gr−) microorganisms and their sensitivity patterns are shown in the table. Coagulase negative Staphylococcus was the most common microorganism, and constituted 62% of all bacterial isolates. All Gr+ microorganisms were sensitive to vancomycin except one isolate of Enterococcus fecalis. Enterobacter cloacae was the most common Gr− microorganism, followed by Klebsiella pneumonia. The sensitivity of Gr− microorganisms to levofloxacin was 100%. The treatment course was complicated by the growth of a second microorganism in subsequent blood cultures in 24% of infections; 54% of these consisted of both Gr+ and Gr− isolates. The etiology of ESRD or the use of immunosuppressive agents had no effect on the occurrence of CRB. The average number of infections were 5.8/1000 catheter days, and the recurrence of CRB was more likely in patients who had two or more CRB in a year.

1999
2000
2001
2002
2003

Gr+ growth
80%
88%
87%
85%
73%

Oxacillin resistance
84%
73%
82%
68%
75%

Gr− growth
20%
12%
13%
15%
27%

Tobramycin resistance
21%
50%
25%
20%
13%

Conclusions:
Empiric initial treatment for CRB should include both Gr+, and Gr− coverage. Oxacillin and first generation cephalosporins are not good choices due to high incidence of resistance. Levofloxacin is a good alternative for Gr CRB. Novel preventive measures should be sought in patients who have a tendency to have recurrent CRB.
Single‐dose pharmacokinetics (PK) of ferric gluconate (FG) in iron‐deficient pediatric hemodialysis patients
Authors: Warady B.A
Published: January 2005

Purpose:
Limited information exists on the use of any intravenous iron preparation in pediatric HD patients. This study was designed to describe the PK parameters of FG, now approved for use in children on HD. Methods:Iron‐deficient pediatric HD pts (≤15 yr) were randomized to 2 doses of FG. Blood samples taken during a 1 hr infusion and at intervals over 48 hrs were analyzed for total iron, transferrin‐bound iron (TBI), and FG‐bound iron (FGI). Results:49% of pts were male, 88% white, 57% age 6–12 yr, wt 16.3–63.2 Kg, ht 100–177.5 cm. Mean serum iron concentrations (total iron and FGI) rapidly increased in a dose‐dependent manner, approximately proportional to the FG dose administered. A rapid rise in total serum iron was followed by a slower, less prominent rise in TBI. Single‐dose PK of FGI was adequately described using non‐compartmental analytical methods. A standard 2‐compartment NONMEM model successfully fit the data and accurately described the time‐course of FGI concentrations.

Pharmacokinetic Parameter
1.5 mg/kg FG (n = 22)
3.0 mg/kg FG (n = 26)

Cmax(mean ± SD, mcg/dL)
1287 ± 285
   2283 ± 637

AUC0–48(mean ± SD, mcg·hr/dL)
9327 ± 4038
16,830 ± 6526

AUC0–∞(mean ± SD, mcg·hr/dL)
9499 ± 4089
17,087 ± 6776

Tmax(mean ± SD, hrs)
   1.1 ± 0.23
   1.1 ± 0.19

t1/2(mean ± SD, hrs)
   2.0 ± 0.7
   2.5 ± 1.8

Kel(mean ± SD, hr−1)
  0.43 ± 0.30
  0.39 ± 0.27

Cl (mean ± SD, L/hr)
  0.69 ± 0.50
  0.66 ± 0.52

Vd(mean ± SD, L)
   1.6 ± 0.6
   1.9 ± 1.1

Conclusions:
Cmax values in pediatric HD population were similar to Cmax values previously reported with similar FG doses in healthy iron‐deficient adults (Ferrlecit® prescribing information). In contrast, mean AUC0−∞ values were approximately 2 times greater, and mean Cl rates were 5.4 times slower in pediatric pts.
Use of argatroban for hemodialysis and continuous veno‐veno hemodialysis in a patient with heparin‐induced thrombocytopenia
Authors: Lau K.K.
Published: January 2005

Objective:
To describe the use of argatroban in a post‐cardiac operation patient with heparin‐induced thrombocytopenia requiring hemodialysis and continuous veno‐veno hemodialysis (CVVH). Case Summary:A 23‐year‐old Caucasian female with heparin‐induced thrombocytopenia developed acute renal failure after cardiovascular surgery. Argatroban was used as a substitute for heparin during hemodialysis and CVVH. Both activated partial thromboplastin time (aPTT) and activated clotting time (ACT) were used to guide the dosage of argatroban. The patient was successfully dialyzed without clotting of the circuit. The dosage required in our patient was much lower than the manufacturer's recommendation. Discussion:Argatroban is a thrombin inhibitor that does not cross react with heparin. It is metabolized by the liver, and dosage adjustment is recommended in patients with severe hepatic impairment. The correct dosage for patient with unstable hemodynamics is not known. Our patient had apparently normal hepatic function at the initiation of dialysis, but the dosage of argatroban recommended by the manufacturer resulted in prolonged elevation of the aPTT and ACT with associated gastrointestinal bleeding. This may be related to hepatic congestion secondary to poor cardiac function and/or severe anasarca. And the dosage of argatroban required during dialysis was much lower than the recommendation. Conclusions:Argatroban is an effective alternative of heparin for CVVH. The correct initial dosage in patients with mild hepatic impairment and unstable hemodynamics is still unclear.
Citrate anticoagulation for pediatric continuous venovenous hemodiafiltration
Authors: Watanabe A. , G.C. Dantas , Troster E.J. , Koch V.H.K.
Published: January 2005

Objective:
Feasibility and safety evaluation of citrate anticoagulation for hemodiafiltration (CVVHD) procedure in a pediatric critical care unit. Patients and Methods:From 08–2002 to 12–2003, five patients were treated by CVVHD with regional citrate anticoagulation, age range 1.4–16 yrs, body weight 6.7–38 kg. Inclusion criteria: oligoanuria and hypervolemia and/or uremia, hemodynamic instability, and impossibility of peritoneal dialysis. The patient's primary diseases were: liver disease (4/5) and chronic renal disease (1/5). All patients were on mechanical ventilation and on vasopressor support and presented with thrombocytopenia. Hepatic dysfunction was observed in four patients. The CVVHD prescription was: blood flow rate: 2–5 ml/min, dialysate and replacement flow rate: 3000 ml/1.73 m2/h. Citrate regional anticoagulation (4% trisodium citrate) was used according to a previously described protocol (Bunchman et al., Pediatr Nephrol 2002: 17:150–154). The duration of each individual procedure was 9–72 hours, and the total time range of CVVHD was 2 to 19 days. A bicarbonate based solution (Na 140 mEq/L and bicarbonate 35 mEq/L) was prepared in our hospital pharmacy. Prisma system (GAMBRO) and polycrylonitrile M‐60 Pre‐set hemofilter was used in 4/5 patients and M‐10 Pre‐set hemofilter in one patient. Results:The use of M‐10 filter was associated with a higher rates of ACD‐A and calcium infusion (ml/h). Metabolic alkalosis was observed in one patient and hypernatremia in three patients. All patients died of causes other than renal failure (sepsis and multiple organ dysfunction syndrome). No bleeding related to citrate occurred. Conclusion: Citrate anticoagulation proved to be feasible with minor side effects in pediatric ICU patients. The high mortality can be related to the severity of multiple organ failure.
Marked functional improvement in a pediatric patient treated with hemodialysis for scleroderma related renal failure
Authors: Benador N.M. , Grimm P.C. , Reznik V.M. , Mendoza S.A. , Ferrara E.
Published: January 2005

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibrosis and vasculopathy of the skin and visceral organs. Scleroderma renal crisis (SRC), the most acute and life threatening complication, occurs in 10–20% of adult patients with SSc and has not been reported in children. A 10‐year‐old girl was diagnosed with SSc when she presented with weakness and skin thickening. She had positive ANA and anti‐Scl 70. Renal function, urinalysis, and blood pressure were normal. She was treated with steroids, penicillamin and methotrexate as well as amlodipine for Raynaud's phenomenon, but her diffuse skin thickening and contractures progressed and she became wheelchair bound and had poor growth despite nutrition through a G‐tube. At age 15 (weight 28 kg), when evaluated for abdominal pain, she was found to have acute renal failure (BUN 54 mg/dl, creatinine 2.2 mg/dl) and hypertension. Despite therapy with enalapril, serum creatinine continued to rise and she became oligoanuric, requiring initiation of hemodialysis. BP was controlled with enalapril and dialysis but she remained dialysis dependent. Steroid therapy was discontinued and replaced by low dose cyclosporine. Enalapril was replaced by losartan because of leukopenia and BP remained normal. Over the next 2 years, she was treated with hemodialysis and did not experience any complications. She progressively had an outstanding overall clinical improvement, marked skin softening, and was able to walk independently. Renal function did not improve. 28 months after the SRC, she received LRD renal transplant. Immunosuppression included cyclosporine, mycophenolate and prednisone. Creatinine 2 months post‐transplant is 0.7 mg/dl. SRC in children may progress to end‐stage renal disease but can be treated successfully with dialysis and transplantation without significant complications.
Not Presented  Puncturing your own fistula
Authors: Krutzen L.
Published: January 2005

When you are working with home HD education you often meet patients who are very afraid of the moment when they are going to puncture the fistula themselves. Our experience is that the patient sometimes can’t concentrate on anything but this moment. For this reason we let the patient try to puncture as soon as possible. We also get many questions from colleges, doctors, and nurses on how to do it. Most of the patients are very successful and prefer to puncture themselves after having tried it. They say that it is less painful if you puncture yourself and we also have a feeling that it is very rare that they are unsuccessful. To get proof for these feelings we made a small inquiry among our patients, asking about how it is to puncture yourself. We sent the inquiry to 30 patients. We also decided to make a film showing how to puncture yourself. We asked some of our home HD patients if they wanted to contribute. The result of this is a video, which is 9 min long, showing how to puncture in different types of fistulas, underarm, overarm, and grafts.
Venous needle dislodgement during hemodialysis: An unresolved risk of catastrophic hemorrhage
Authors: Sandroni S.
Published: January 2005

Venous line disconnection or needle dislodgement during hemodialysis with resultant hemorrhage is a potentially lethal event. The risk is compounded by the frequent failure of standard dialysis machines to detect the event, as blood flow through the venous needle typically creates enough back pressure to prevent venous pressure alarms even if the needle is completely out of the patient's AV access. Manufacturers are well aware of the risk and device literature contains specific warnings about it. The FDA publishes reports on its website about these events; so far this year there have been seven reported events with five deaths. Informal sources indicate that the actual (unreported) occurrence is much more frequent; we are aware of four additional events within our region alone. Efforts to reduce the risk include protocols requiring the access needles to always be visible, and use of enuresis detection devices. Anecdotal experience with these efforts suggests they are not highly effective. Protocols requiring documentation of more frequent needle site checks or alternate methods of securing the needles have not been formally evaluated. However, such efforts do not address the primary problem: there is a need for an engineered solution to this problem. Requirements for such a solution include: reliable detection of needle position and blood flow discrepancies, a useful alarm, and feedback to stop the blood pump. Persistence of this problem raises issues of regulatory oversight.
Intima‐media thickness of radial artery is associated with early access failure in hemodialysis patients
Authors: Kim Y.O. , Choi Y.J. , Kim J.I. , Shin M.J. , Kim B.S. , Song H.C. , Yoon S.A. , Kim Y.S. , Kim S.Y. , Choi E.J. , Chang Y.S. , Bang B.K.
Published: January 2005

Objective: 
We have reported that intimal hyperplasia, which is the pathologic change of the radial artery, is associated with early failure of arteriovenous fistula (AVF) in hemodialysis (HD) patients (Am J Kidney Dis, 41:422–428, 2003). Intima‐media thickness (IMT), which represents the whole thickness of arterial wall, can be easily measured by ultrasonography, unlike intima thickness. This study was performed to investigate the impact of IMT of radial artery on early failure of AVF in HD patients. Methods: Ninety HD patients undergoing radiocephalic AVF operation were included in this study. The AVF was constructed in an end vein–to–side artery fashion at the wrist by one vascular surgeon. During the operation, 10‐mm long partial arterial walls were removed with elliptical form for microscopic analysis. Specimens were stained with trichrome and examined by a pathologist blinded to the clinical data. AVF patency was prospectively followed up for 1 year after the operation. Results: Mean age of the patients was 56 ± 13 years and the number of females was 44 (48.9%). Mean IMT was 430 ± 132 μm (133–760 μm). Of the total 90 patients, 31 patients (34.4%) had AVF failure within 1 year after the operation. Mean IMT was higher in the failed group (n = 31) than in patent group (n = 59)(486 ± 130 μm vs. 330 ± 178 μm, p = 0.004). Using a threshold of 500 μm of IMT, AVF patency rate was compared between these two groups using Kaplan‐Meier method with log rank test. The AVF patency rate within 1 year after the operation was higher in patients with IMT ≥ 500 μm (n = 26) than in patients with IMT < 500 μm (n = 64)(p < 0.001). The patients with IMT ≥ 500 μm were older and had higher incidence of diabetes mellitus, compared to the patients with IMT < 500 μm. There was no difference in sex, smoking, hypertension, total cholesterol and albumin levels between the two groups. Conclusion: Our data suggest that increased intima‐media thickness of radial artery is associated with early failure of radiocephalic arteriovenous fistula in hemodialysis patients.
Estimation of backfiltration flow rate in commercially available high flux dialyzers: Importance of water purification system for dialysate
Authors: Mineshima M. , Ishimori I. , Akiba T.
Published: January 2005

Several types of high flux dialyzers were developed and introduced for clinical applications to improve solute removal efficiency. In these dialyzers, internal filtration/backfiltration (IF/BF) is induced by pressure drop of blood and dialysate flow in a countercurrent manner under less net filtration. Higher IF/BF flow rate increased convective transport of the solute in addition to diffusive transport. In previously published papers, we reported the effects of IF on solute removal efficiency of the dialyzer during an analytical and an experimental study and the measurement of the internal filtration flow rate (QIF) by Doppler ultrasonography. Average blood flow rate (QBav) at a cross‐sectional plane was measured by pulse Doppler and the longitudinal QBav profile along the dialyzer was obtained using a probe slider that can move the probe in parallel along the dialyzer. This is a suitable method for a bedside monitoring of the IF/BF flow rate of dialyzers because it is noninvasive to the patient and produces reliable data with higher reproducibility. Internal backfiltration flow rate (QBF) in six types of commercially available high flux dialyzers, having a higher 50 ml/min of β2‐microglobulin clearance (CL‐β2 m), were examined by Doppler ultrasonography under 10 ml/min/m2 of net filtration flow rate. As a result, a wide range of QBF value, 12.1–28.4 ml/min, was obtained among those dialyzers. It means a fair amount of BF, 2.9–6.8 liter per session, occurs in a typical hemodialysis treatment. Strict management of dialysate purification is required for a dialyzer with a relatively larger BF. On the other hand, no correlation between the CL‐β2 m value and the QBF value was seen because the CL‐β2 m value depends on not only the IF/BF flow rate but also diffusive property of the membrane. The BF flow rate in every dialyzer should be examined to avoid suffering from the invasion of endotoxin and its fragment for safety.
The effects of exercise during hemodialysis on adequacy
Authors: Caner C. , Ozlem S. , Yavuz Y. , Ali Riza S. , Ozlen P. , Beyhan I. , Sema O.
Published: January 2005

Pedalling during hemodialysis (HD) has been shown to increase solute clearance in a previous study. In the present study, we aimed to test whether an easy to perform exercise program, not requiring a special device, could yield similar outcomes. Fifteen HD patients with the mean age of 48.4 ± 3.8 years were enrolled into the study. Patients with significant access recirculation (>10%), moderate to severe coronary artery disease, moderate to severe heart failure, severe chronic obstructive lung disease, and history of lower extremity surgery during last three month period were excluded. All patients were studied on two consecutive HD sessions with identical prescriptions. At the first session, standard HD was applied without exercise, whereas in the second session lower extremity exercise of 30 minutes duration was added. Reduction rates and rebound for urea, creatinine, and potassium and Kt/V were calculated. Wilcoxon signed rank test was applied in analysis and p < 0.05 was accepted as significance level. All patients completed the study. When both sessions were compared, mean arterial blood pressure (97 ± 3 mmHg vs 120 ± 4 mmHg, p < 0.001) and heart rate (77 ± 1 beats/min vs 92 ± 3 beats/min, p < 0.001) were higher in the exercise group. On the other hand, urea reduction rates, rebound values of urea, creatinine, and potassium were similar in both groups. Conclusion: In the study, we did not observe any changes in solute rebound and clearance with the exercise. Shorter duration of the exercise may be the explanation of failure to achieve desired outcomes. Increasing patients’ tolerance and fitness levels by means of steadily increasing exercise programs may be of help. Additionally, mode of exercise may also be responsible for different outcomes.
Changing hemodialysis machine data into a usable patient care with Diascan
Authors: Paille L. , Nikl K.
Published: January 2005

K/DOQI has set the national standard of adequacy in dialysis. Clinical practice assesses these standards using ‘routine’ blood work schedules that vary from every 4–6 weeks and calculates these results using different urea kinetic formulas. This variance may result in under‐dialysis of our patients that may not be detected until the next routine blood work. Comparing Kt/V blood work results using ‘snapshot’ laboratory results versus total run trending using Integra Diascan monitoring may help us define adequacy and may identify potential cost savings to the medical system and the hemodialysis patient. Diascan offers more than on‐line Kt/V monitoring of clearances; it also reports patient serum plasma conductivity. Serum plasma monitoring helps to identify potential excess fluid gains which may compromise dialysis treatments leading to poor clearances, which in turn leads to increased morbidity and mortality, as well as increasing costly dialysis interventions and potential emergent treatments. The small sampling of patients compared use a variety of vascular accesses and were examined for some of the barriers to effective ‘snapshot’ monitoring of Kt/V or PRU versus trending adequacy to explore the potential benefits and efficacy of the data obtained.
Tandem dialyzers with dual monitors to meet Kt/V targets
Authors: Sridhar N. , Hurst C. , Hayes P.
Published: January 2005

Objective: 
A large body mass and/or a poorly functioning vascular access predispose to inadequate Kt/V. Double dialyzers in parallel and tandem have been shown to enhance Kt/V to levels recommended by K/DOQI. We experienced difficulties with unintended excessive ultrafitration (UF), positive transmembrane pressure (TMP)‐triggered pump stoppage, need for large volume saline infusion (inflating Kt/V), and a high incidence of clotting of the second dialyzer in tandem. Since blood and dialysate flow rates are higher in the tandem configuration, Kt/V should be theoretically higher. We developed a technique of using the tandem configuration with two monitors in which all the UF could be limited to the second dialyzer, the TMP of the two dialyzers independently controlled, TMP reversal eliminated, and saline infusion and unintended UF minimized. Methods: 3 large male patients with AV grafts (AVG) and 2 with tunneled catheters (TC) had 7 treatments (with Kt/V and URR calculated using the stop‐flow technique in the last 5) sessions of each of single, double parallel, and tandem configurations. Blood (Qb) and dialysate‐flow (Qd) were halved with Y‐connectors in the parallel configuration. Qb through both dialyzers and Qd through the second were controlled with the first monitor and Qd (TMP set to near zero) through the first dialyzer controlled with the second monitor using recirculating saline through its blood pump (with the “venous” pressure adjusted using an air‐filled syringe) in the tandem configuration. The patient's blood did not circulate through the blood‐pump of the first machine. Qd was 500 ml/min through each dialyzer in the single and tandem and 250 ml/min in the parallel configurations. Processed blood volume (dialysis time) was exactly 85 L with AVG and 60 L with TC. Heparin dosage was constant. ANOVA, 2 × k tables, and Neuman‐Keuls test were used in analyzing data. Results: Mean Kt/V (%URR) increased from 1.15 (62) with single to 1.35 (68) with parallel (p < 0.02) and 1.48 (71) with tandem (p < 0.001) dialyzers in patients with AVG but not TC [1.05 (58), 1.02 (55), and 1.25 (64) with single, parallel, and tandem, respectively]. Tandem dialyzers met targets for URR (p < 0.001) and Kt/V ( p < 0.05) more frequently than parallel with AVG but not TC. Conclusions: Tandem dialyzers with 2 monitors are more successful than parallel dialyzers in delivering target Kt/V and URR when Qb is not compromised.
Impact of flow and surface area on middle molecule clearance
Authors: Eloot S. , De Vos J.Y. , Hombrouckx R. , Verdonck P.
Published: January 2005

Urea is still clinically applied as standard marker to quantify dialysis adequacy. The removal of middle molecules has however been proven in some studies to have a long‐term effect on mortality. Therefore, the present study is aimed at investigating the impact of blood and dialysate flow, and membrane surface area on middle molecule removal in low flux Fresenius F6HPS dialyzers. Blood and dialysate flows were varied within the clinical range of 300–500 mL/min and 500–800 mL/min, respectively, while ultrafiltration rate was kept constant at 0.1 L/h. Single pass tests were performed in vitro in a single dialyzer (3 tests) and in serially (5 tests) and parallel (3 tests) connected dialyzers. The blood substitution fluid consisted of bicarbonate dialysate in which radioactive labeled vitamin B12 (MW1355) was dissolved. Middle molecule concentrations of samples taken at the inlet and outlet blood line were derived from radioactivity measurements and were applied to calculate the dialyzer clearance as well as the reduction ratio. For the latter, the surrogate middle molecule vitamin B12 was assumed as distributed according to a two‐pool kinetic model. Adding a second dialyzer in series or parallel ameliorates significantly overall dialyzer clearance and reduction ratio, except for the highest applied blood flow rate of 500 mL/min. Better solute removal is also obtained with higher dialysate flows, while the use of higher blood flows seemed only advantageous when using a single dialyzer. Analysis of the ultrafiltration profiles in the different configurations illustrated that enhancing the internal filtration rate ameliorates the convective transport of middle molecules. In conclusion, adequate solute removal results from a number of interactions, as there are, blood and dialysate flow rates, membrane surface area, filtration profile, and concentration profiles in the blood and dialysate compartment.