Download EXTRACORPOREAL DIALYSIS: TECHNIQUES AND ADEQUACY

Nephrology Dialysis Transplantation 28 (Supplement 1): i202–i213, 2013
doi:10.1093/ndt/gft116
EXTRACORPOREAL DIALYSIS:
TECHNIQUES AND ADEQUACY - A
SP397
IMPROVEMENT IN TECHNOLOGY: EVALUATION OF THE
BIOFEEDBACK ON TMP ON TWO DIALYSIS SYSTEMS
Denis Steckiph1, Giovanni Calabrese2, Andrea Bertucci1, A. Mazzotta2, G. Vagelli2
and Marco Gonella2
1
Gambro Hospal s.p.a. Bologna Italy, 2Nephrology and Dialysis Unit Casale
Monferrato Italy
Introduction and Aims: The biofeedback on TMP, as UltraControl (UC, Gambro),
enhances and automatically adjusts the convective volume in hemodiafiltration online
(OL-HDF). Moreover, the results of recent RCTs on postdilution OL HDF, such as
CONTRAST and TURKISH, suggest that OL-HDF with high convective volume can
improve the patient survival. This study evaluated the convective performances of UC
in post-dilution OL-HDF on two dialysis machines: AK200 ULTRA S (AK) and
ARTIS.
Methods: We enrolled 14 stable pts (63±12 yrs), already treated by OL-HDF, in a
sequential design study of two weeks for each monitor. Both monitors automatically set
the infusion volume by a biofeedback on TMP (described by Teatini et al. Blood Purif
2011), while AK measures the TMP value by 3 points formula (Pre-filter, venous and
inlet dialysate pressure) and uses a TMP step of 25mmHg, ARTIS works with 4 points
(Pre-filter, venous, inlet and outlet dialysate pressure) and TMP step of 20mmHg. For
each patient the remaining technical parameters were kept unchanged. The infusion
volume, TMP and Pre-filter pressure (PFP) were hourly collected. All the pts were
treated with 2.1 m2 Polyflux H (Gambro). The descriptive analysis was based on the
mean ± standard deviation. Inferential statistics included two tailed t-test for paired
data, considering a probability value of less than 0.05 as significant.
Results: No differences were found on main dialytic parameters, such as Qb (371±10
vs 370±12 ml/min, p=0.978), treatment time (265±16 vs 266±16 min, p=0.334) and
total weight loss (1.8±0.7 vs 1.8±0.7 L, p=0.739), between the two periods. The ARTIS
system reached a smooth higher infusion volume (27.0±2.5L vs 25.8±2.3L, p<0.01)
with a different pressure trend (see figure 1). The intra-patient coefficient of variability
on infusion volume was lower with ARTIS machine than AK machine (7.8±3.4 vs 6.4
±3.4%).
Conclusions: UltraControl reached high convective volumes (>20 L) in postdilution
OL HDF with AK and ARTIS machine. The introduction of 4 points TMP measuring
and a smaller increment TMP step resulted in more optimize TMP setpoint, leading to
an increase of infusion volume and reduction of the intra-patient variability on ARTIS
machine. Therefore UltraControl system on ARTIS seems to be the best technique for
Postdilution OL-HDF.
SP398
DESIGN, REALIZATION AND PRELIMINARY EXPERIMENTAL
EVALUATION OF A NOVEL MAGNETIC FILTER FOR
UTILIZATION IN MAGNETICALLY-ASSISTED
HAEMODIALYSIS
Dimosthenis Stamopoulos1, Efthymios Manios1, Nikolaos Papachristos1,
Eirini Grapsa2, Georgios Papageorgiou1 and Vassiliki Gogola1
1
Institute of Advanced Materials, Physicochemical Processes, Nanotechnology
and Microsystems National Center for Scientific Research 'Demokritos' Athens
Greece, 2Dialysis Unit General Hospital of Athens 'Aretaieion' Athens Greece
Introduction and Aims: Although Haemodialysis (HD) has become a mature
replacement therapy it still has disadvantages such as slow toxin-removal kinetics
(imposed by the underlying diffusion/convection processes) and non-selective action
(undesired toxins cannot be distinguished from biomolecules that should be
preserved). The so-called Magnetically Assisted Haemodialysis (MAHD) introduces
fast kinetics and selective action. Specifically, MAHD is based on core-shell conjugates
(Cs) of two ingredients: a ferromagnetic particle (FP), the core that ensures the fast
kinetics and a biocompatible substance (BS) of high affinity for specific toxins, the shell
that among others guarantees selectivity. The Cs should be administered to the patient
timely prior to the MAHD session, so that they will collect toxins while circulating in
the cardiovascular system. Ultimately the Cs are removed, together with the collected
toxins, by the so-called Magnetic Filter (MF) that is incorporated at the extracorporeal
circulation line (ECL). Here we introduce a novel MF.
Methods: Among others, the design of the MF was based on two main requirements:
(a) production of intense magnetic force to achieve high efficiency on the removal of Cs
and (b) absolute safety protecting the patient from the reentry of Cs into the
cardiovascular system. Software packages (Finite Element Method Magnetics and
Origin®) were used for the simulation of the magnetic field produced by the employed
permanent magnets.
Results: Based on the above requirements a prototype MF was realized: a compact disc
of diameter 13 cm with 10 permanent magnets (NdFeB, grade N42) of cylinder form
(diameter 5 mm, height 5 mm) embedded uniformly along its periphery wherein a
track also exists suitable for the adjustment of the rigid tube of a modified ECL. The
tube is adjusted in such a manner so that its outer surface is always in contact with the
top surface of the magnets. The disc rotates around its axis by electronically-controlled
means with angular velocity that can be synchronized to the blood flow in the adjusted
tube. This ensures the magnetic trapping of FPs flowing in the ECL that are
subsequently guided to an isolation point, where farther processing can be performed.
The MF was experimentally tested with physiological saline as blood substitute in
which FPs of iron (Fe) or iron oxide (Fe3O4) were dispersed. The MF removed
completely the FPs of Fe in a single round, while it needed a second round for the FPs
of Fe3O4.
Conclusions: The MF introduced here can remove efficiently and safely FPs of Fe and
Fe3O4 from an ECL. This opens interesting perspectives for its utilization in
near-future in vitro experiments in the dialysis machine.
SP399
CONTROL OF PLASMA PHOSPHATE ON THRICE WEEKLY
IN-CENTRE HAEMODIAFILTRATION
Beng So1, Vishal Dey1 and Elaine M. Spalding1
John Stevenson Lynch Renal Unit Crosshouse Hospital Kilmarnock United
Kingdom
1
Introduction and Aims: Adequate control of plasma phosphate without phosphate
binders is difficult to achieve on a thrice weekly haemodialysis schedule without
compromising nutritional intake. The use of frequent nocturnal dialysis has been
shown to be an effective strategy but this is not practical in the in-centre setting. A
thrice weekly nocturnal dialysis shift has recently been established in our centre and
since inception 14 patients have participated in the program. Over 1000 individual
sessions have been carried out to date.
Methods: The duration of dialysis was increased from a median of 4.5 hours to 8
hours, Qb was reduced to 200ml/min and Qd reduced to 300ml/min. All patients
continued on post-dilution haemodiafiltration with a dialysate calcium concentration
of 1.75mmol/l and potassium adjusted according to pre-dialysis levels. Dialysis
adequacy and bone chemistry were reviewed at monthly QA meetings. A reduction in
plasma phosphate was anticipated so all phosphate binders were stopped before the
switch to nocturnal dialysis.
SP397
© The Author 2013. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: [email protected]
Abstracts
Nephrology Dialysis Transplantation
Results: Within 1 month of commencing on nocturnal dialysis the weekly Kt/V had
increased from to 2.23±0.23 to 2.66±0.23 ( p<0.001) and plasma phosphate had
reduced from 1.70±0.50mmol/l to 1.20±0.33mmol/l ( p<0.01). Despite all phosphate
binders being stopped all patients continue to have a plasma phosphate below
1.7mmol/l and in several patients it has been necessary to increase dietary phosphate in
order to keep the pre-dialysis plasma phosphate within the normal range.
Conclusions: To our knowledge this is the first time control of phosphate without the
use of binders has been reported on a thrice-weekly in-centre haemodialysis program.
In addition to the improvement in the phosphate control there has been a significant
financial saving from the cessation of binders.
SP400
THE EFFECTS OF DIFFERENT DIALYSIS TREATMENTS ON
GLYCEMIC EXCURSIONS AND INFLAMMATION IN PATIENTS
WITH END-STAGE RENAL DISEASE WITH AND WITHOUT
TYPE 2 DIABETES MELLITUS
Carmelo Libetta1, Pasquale Esposito1, Elisabetta Margiotta1, Pamela Maffioli2,
Aldo Bonaventura2, Lucio Bianchi2, Davide Romano2, Teresa Rampino1
and Giuseppe De Rosa2
1
Nephrology, Dialysis and Transplantation IRCCS Policlinico S.Matteo and
University of Pavia Pavia Italy, 2Department of Internal Medicine and Therapeutics
IRCCS Policlinico S. Matteo and University of Pavia Pavia Italy
Introduction and Aims: It is known that hemodialysis dialyzes out blood glucose, and
that hemodinamic change during session induces stress hormones and inflammatory
citokines.The aim of this study was to evaluate the glycemic excursions and the
changes of various inflammatory parameters in type 2 diabetic patients affected by
end-stage renal disease undergoing bicarbonate dialysis (BHD) and hemodiafiltration
(HDF) compared to euglycemic patients.
Methods: Twenty patients (11 affected by type 2 diabetes mellitus, and 9 not diabetic
patients) were evaluated. We measured, before and after dialysis, these parameters:
body mass index (BMI), glycated hemoglobin (HbA1c), fasting plasma glucose (FPG),
fasting plasma insulin (FPI),HOMA-IR, lipid profile, homocysteine (Hcy), high
sensitivity C-reactive protein (hs-CRP), fibrinogen, lipoprotein (a) [Lp(a)],
metalloproteinases-2, and -9 (MMP-2 and MMP-9), interleukins 6 (IL-6), and -8
(IL-8), and soluble receptor for advanced glycation end products (sRAGE). All patients
underwent glucose continuous monitoring system, using The iPro Continuous Glucose
Monitor System (Medtronic MiniMed) starting just before the bicarbonate dialysis, and
ending five days later, after the HDF dialysis.
Results: We observed a significant decrease of glycemic excursions during BHD
respect to HDF. We also observed a statistically significant decrease of MMP-9
( p<0.001) after bicarbonate dialysis, but not after HDF. Considering only type 2
diabetic patients, we observed a decrease of sRAGE with bicarbonate dialysis ( p<0.01),
but not with HDF. Moreover, in type 2 diabetic patients, there was a significant
correlation between glycemia and MMP-9 (r=0.5689, p<0.05). On the other hand, in
not diabetic patients, there was a positive correlation between glycemia and Lp (a)
(r=0.3785, p<0.05), and between glycemia and MMP-9 (r=0.2792, p<0.05).
Conclusions: We can conclude that bicarbonate dialysis seems reduce glycemic
excursions during the treatment respect to HDF, and induces decrease of inflammatory
markers, therefore more adapted to the treatment of type 2 diabetic uremic patients.
SP401
CLINICAL PERFORMANCE COMPARISON OF REVACLEAR®
DIALYZER VERSUS LARGER-SURFACE AREA DIALYZER
Astrid Mauric1, Ulrike Haug3, Günter Enzinger2, Elke Kern-Derstvenscheg2,
Andrea Sluga2, Christiane Ausserwinkler2, Werner Beck3
and Alexander R. Rosenkranz1
1
Clinical Division of Nephrology Medical University of Graz Graz Austria, 2Dialysis
Institute Gießauf Graz Austria, 3Medical Safety Office Gambro Dialysatoren GmbH
Hechingen Germany
Introduction and Aims: A new high-flux dialyzer, Revaclear® (Gambro Dialysatoren
GmbH), had been designed to provide high performance despite smaller membrane
surface area, by optimizing membrane hollow fiber dimensions and packing density.
Expected advantages compared to larger-surface area dialyzers are high
biocompatibility due to reduced blood-dialysis membrane contact area, and cost
savings with respect to logistics, storage and waste management. A clinical study was
set up aiming at showing equivalent removal capacity compared with a larger surface
dialyzer.
Methods: The prospective, multicenter, randomized cross-over study (NCT01722695)
was approved by competent authorities and reviewed by the local ethics review board.
Thirty stable hemodialysis (HD) patients were enrolled after giving written informed
consent. Applied dialyzers were Revaclear® 200 (1.2 m2) or Revaclear® 400 (1.8m2)
(Gambro, Hechingen, Germany) and FX60 (1.4m2) or FX100 (2.2 m2) (Fresenius
Medical Care, Bad Homburg, Germany). Patients underwent 3 consecutive HD
sessions with Revaclear® 200 or Revaclear® 400 followed by 3 HD sessions with FX60 or
FX100 or vice versa. Treatment time was 240 min, dialysate flow rate 500 mL/min and
blood flow rate ≥ 300 mL/min. In each session HD dose, removal rates and total
removal of urea, creatinine, phosphate and ß2-microglobulin were assessed from preand post-dialysis blood samples and an integrated dialysate sample. Primary endpoint
Volume 28 | Supplement 1 | May 2013
HD dose was statistically tested for equivalence, whereas the other parameters were
explored for differences.
Results: Interim data from 20 patients are reported: 11 male, age 64.2 ± 14.9 years, dry
weight 71.9 ± 12.2 kg and dialysis vintage 6.5 ± 6.5 years. HD dose Kt/V with
Revaclear® vs. FX was 1.5 ± 0.2 vs. 1.5 ± 0.2 ( p=0.0084 for equivalence). Reduction rate
(%) was 72.3 ± 4.9 vs. 72.0 ± 5.0 for urea ( p=0.8689), 64.1 ± 5.6 vs. 65.1 ± 5.3 for
creatinine ( p=0.8173), 55.8 ± 6.5 vs. 57.2 ± 5.2 for phosphate ( p=0.7414), and 66.3 ±
5.3 vs. 64.5 ± 4.4 for ß2-microglobulin (corrected for hemoconcentration) ( p=0.2761).
Total removal (g) was 25.09 ± 5.63 vs. 26.47 ± 6.35 for urea ( p=0.4384), 1.66 ± 0.61 vs.
1.72 ± 0.62 for creatinine ( p=0.7697), 2.91 ± 0.44 vs. 2.96 ± 0.54 for phosphate
( p=0.8173) corresponding to 0.95 ± 0.14 vs. 0.97 ± 0.18 for phosphorus, and 0.17 ±
0.06 vs. 0.14 ± 0.05 for ß2-microglobulin ( p=0.2098).
Conclusions: The presented study data demonstrate that the Revaclear® dialyzer
provides similar clinical performance when compared to the larger-size FX dialyzer. In
addition, by its smaller design, the Revaclear® dialyzer offers beneficial features with
respect to cost and environmental aspects, i.e. logistics and waste management.
SP402
COMPARING UREMIC SOLUTES REMOVAL FOR HIGH-FLUX
HEMODIALYSIS, HEMODIAFILTRATION AND HIGH-FLUX
HEMODIALYSIS WITH EXERCISE DURING DIALYSIS
Vaibhav Maheshwari1, Sabrina Haroon2, Yijun Loy2,
Lakshminarayanan Samavedham1, Gade P. Rangaiah1 and Titus Lau2
1
Chemical and Biomolecular Engineering National University Singapore Singapore
Singapore, 2National University Health System Singapore Singapore
Introduction and Aims: Efficacy of high flux hemodialysis (HD) and convection based
dialysis, namely, hemofiltration and hemodiafiltration (HDF) is restricted by
inter-compartmental resistance due to cellular membrane and/or capillary
endothelium. This resistance results in significant post-dialytic rebound or reduced
solute removal. Exercise during dialysis is suggested to remove solutes from remote
inaccessible compartments owing to better perfusion of remote skeletal muscles and
decreased inter-compartmental resistance. In this clinical research, we have compared
the toxin removal outcome by high flux HD, stand-alone HDF and intra-dialytic
exercise during high flux HD.
Methods: Recruited patients underwent 3 parallel dialysis sessions: (1) HD, (2) HDF,
(2) HD with exercise (HD-Ex). Dialysis prescription was same for all the three sessions.
HD and HDF sessions were conducted using Fresenius 4008S and Gambro AK200
ULTRA machine, respectively. All HDF sessions were performed in pressure-control
mode. In HD-Ex, exercise was prescribed in three bouts of 20 min each, with 30 min
gap between successive bouts using static cycler (Monark 861E). Blood samples were
collected and analyzed for concentrations of urea, creatinine, and β2-microglobulin at
three time points: t = 0 min ( pre-dialysis), t = 240 min (end-dialysis) and t = 360
( post-rebound). The percentage rebound is calculated to adjudge the quantum of
removed solutes. Intra-dialytic blood samples were also collected every 30 mins.
Results: Total 9 stable patients (5 males) on maintenance hemodialysis were studied.
The convective volume achieved in HDF was 20 ± 2.9L. Kt/V achieved was 1.46 ± 0.27
and 1.50 ± 0.29 for HD and HD-Ex respectively. The % rebound for urea is 14.09 ±
3.23 (HD), 14.38 ± 5.29 (HDF), and 13.03 ± 4.07 (HD-Ex); for creatinine is 23.5 ± 4.00
(HD), 23.53 ± 5.10 (HDF), and 21.99 ± 4.05 (HD-Ex); and for β2-microglobulin is
29.28 ± 8.45 (HD), 24.56 ± 2.51 (HDF), and 26.03 ± 5.69 (HD-Ex). The results are
presented as mean ± SD. Intra-dialytic serum urea, creatinine and β2-microglobulin
levels were significantly higher in the intra-dialytic period for HD-Ex than HDF and
HD. There were no adverse events in any of the treatment sessions.
Conclusions: The results of the post dialysis solute rebound indicate that HD-Ex than
HDF and HD in terms of small small solute clearance. For middle molecular weight
solute ie β2-microglobulin, HDF is superior in clearance compared to HD and HD-Ex,
but HD-Ex outperforms HD. The increased serum solute concentration during HD-Ex
session suggests that exercise mobilizes the solutes from remote inaccessible
compartments to intravascular compartment and hence, contributed to increased
removal during dialysis. Intra-dialytic exercise can enhance solute removal and can be
a routine part of dialysis treatment.
SP403
TRANSIENT LOSS AND COMPLETE RECOVERY OF THE
POPULATION OF PLATELETS DURING THERAPEUTIC
PLASMA EXCHANGE
Dimosthenis Stamopoulos1, Nerantzoula Mpakirtzi2, Maria Panagiotou3,
Despina Barbarousi4, Charis Matsouka4 and Eirini Grapsa5
1
Institute of Advanced Materials, Physicochemical Processes, Nanotechnology and
Microsystems National Center for Scientific Research 'Demokritos' Athens Greece,
2
Department of Nephrology General Hospital of Athens, 'G. Gennimatas' Athens
Greece, 3Dialysis Unit General Hospital of Athens 'Alexandra' Athens Greece,
4
Department of Haematology General Hospital of Athens 'Alexandra' Athens
Greece, 5Dialysis Unit General Hospital of Athens 'Aretaieion' Athens Greece
Introduction and Aims: In therapeutic plasma exchange (TPE) thrombocytopenia is
observed in some patients. Usually this is ascribed to the unintentional removal of
Platelets (Plts) with the plasma that is rejected at the centrifugation stage. Except for
this possibility other mechanisms could be at play: mechanical stress (MS) experienced
doi:10.1093/ndt/gft116 | i
Abstracts
Nephrology Dialysis Transplantation
by cells during the relatively intense centrifugation and biochemical shock (BS) exerted
from the replacement medium can deconstruct Plts. To explore these issues, we studied
intact Plts (iPlts) of TPE patients with standard clinical techniques and advanced
microscopes.
Methods: During the TPE sessions the 15 patients studied here were given a
combination of colloid and crystalloid media (Human Albumin 5%, Hydroxyethyl
Starch 6% and saline NaCl 0.9%). The Cobe® Spectra and Spectra Optia® units were
employed. For the determination of the TPE dose and replacement-medium volume
the standard Nadler and Allen formula was used. The iPlts investigation was conducted
comparatively in samples drawn simultaneously from the venous and arterial branches
at both the beginning and end of the TPE session. In addition to the standard clinical
tests two powerful Microscopes, the Scanning Electron (SEM) and the Atomic Force
(AFM) were employed.
Results: Discrepancies were observed in the registration of Plts across the
extracorporeal circuit. Specifically, the combined clinical and microscopy data revealed
that in 5 out of 15 TPE patients the Plts exhibited a statistically significant ( p<0.05)
intense reduction in the venous branch and complete recovery in the arterial branch in
the samples obtained at both the beginning (venous:80.6±114.0x103/μL and
arterial:221.8±49.1x103/μL) and end (venous:44.8±41.5x103/μL and arterial:199.6
±29.3x103/μL) of the TPE session. No statistically significant ( p>0.05) difference
between the beginning and end of the TPE session in both the venous (beginning:80.6
±114.0x103/μL and end:44.8±41.5x103/μL) and arterial (beginning:221.8±49.1x103/μL
and end:199.6±29.3x103/μL) branches was observed.
Conclusions: In some cases across the extracorporeal circuit Plts may transiently be
deconstructed due to MS and BS. A possible consequence is to observe discrepancies in
the complete blood count since automated analyzers do not count particles of size
below a threshold such as granules of deconstructed Plts. The transiently deconstructed
Plts can be efficiently reformed while circulating in the biochemically fertile
environment of the patient cardiovascular system.
SP404
ELEVEN KEY AREAS OF RENAL NURSE RESPONSIBILITY THE FOUNDATIONS OF QUALITY PATIENT DIALYSIS
OUTCOMES
Archie Dumdum Bunani1,2
1
Clinical Services DaVita USA Lehbi Care Center Riyadh Saudi Arabia,
2
Nephrology DaVita USA Lehbi Care Center Riyadh Saudi Arabia
Introduction and Aims: Renal nurses develop their expertise over time and in the
exercise of their professional skills deliver the essence of safe, competent, and
compassionate care. The knowledge, attitude and skills of a nurse develop progressively
where complexities of clinical procedures and experiences are intertwined.
Objective This study identifies whether Quality Patient Dialysis Outcomes (QPDO)
were directly affected by eleven key areas of nurse responsibility used when evaluating
renal staff competency (SC).
Methods: 59 Staff Nurses were appraised evaluating SC while 525 hemodialysis
patients were evaluated using the QPDO parameters. Univariate linear regression and
Pearson rho moment correlation were used to build relationships.
Results: Data indicated both increase and decrease trends in relation to staff
competency. Competencies related to Health Education (↑172.6), Communication
(↑147.5), Records Management (↑141.6), Safe and Quality Nursing Care (↑135.0), and
Management of Resources (↑133.5) demonstrated increase trends. Competencies
related to Research (↑-35.2), Quality Improvement (↑-12.3), and Legal Responsibility
(↑-6.68) were relatively decreased as the period of competency evaluation progressed. It
was notable that QPDO related to Kt/V, Albumin, Hemoglobin, and Hematocrit Levels
were directly proportional to increasing extent of SC ρ=(+0.61) while calcium and
phosphorus levels were directly associated to areas where staff were demonstrated an
decreasing trend ρ=(+0.66).
Conclusions: The eleven key areas of responsibility used to measure SC in a periodic
evaluation demonstrated a strong correlation to the increasing extent of QPDO.
Additionally, as the nurses progressed to becoming expert a direct correlation to the
QPDO was notable. The study became the foundation for staff training and developing
a competency appraisal framework in renal nursing practice thereby promoting quality
assurance procedures while attaining QPDO.
SP405
IMPACT OF THE TYPE OF DIALYZER ON ENDOTHELIAL
FUNCTION AS MEASURED BY ENDOGENIC NITRIC OXIDE
SYNTHASE AND ASYMMETRIC DIMETHYLARGININE LEVEL
IN CHRONIC HEMODIALYSIS PATIENTS AFTER SINGLE
DIALYSIS SESSIONS
Mariusz Kowalczyk1, Piotr Bartnicki1, Maciej Banach1 and Jacek Rysz1
Department of Nephrology, Hypertension and Family Medicine Medical University
of Lodz Lodz Poland
1
Introduction and Aims: High concentration of asymmetric dimethylarginine
(ADMA), an endogenous inhibitor of nitric oxide synthase (NOS), is found in patients
with chronic kidney disease and correlates with vascular disease and cardiovascular
mortality. The aim of the study was to investigate the effect of two different type of
dialyzer on plasma ADMA and NOS concentration after single HD session.
Methods: Twenty-six HD patients were randomly divided into two groups depending
on the type of dialyzer (synthetic ELISIO 190M, Med Flux and cellulose based
SureFlux 170N, Low Flux dialyzer). In the blood samples collected before HD and after
HD, endogenous NOS and ADMA level was estimated using ELISA kit. The results
were compared with the results of 11 CKD patients in the pre-dialysis phase and 12
healthy subjects.
Results: In CKD patients, before HD, NOS and ADMA level was comparable to the
pre-dialysis group but in contrast to the control group NOS level was significantly
lower and ADMA level significantly higher. After HD, both NOS and ADMA level
decreased.Change in NOS and ADMA level depending on the dialyzer is shown in
table 2.
SP405
Before HD
ELISIO 190M Dialyzer
NOS pg/ml
ADMA µmol/l
SureFlux 170N Dialyzer
NOS pg/ml
ADMA µmol/l
Me(25%-75%) NS not significant
After HD
4000 (3380-5339) 2963 (1252-3298) NS
0.85 (0.53-1.13)
0.36 (0.22-0,46)
P=0.0046
2963 (1099-4888) 1091 (761-3422)
0.76 (0.58-0.90)
0.47 (0.36-0.59)
NS
P=0.0012
Conclusions: Both of the dialyzers reduced to a similar degree NOS and ADMA
level, however, a significant decline was observed only for ADMA level. In both
types of the dialyzers, there was no correlation between reduction rate of ADMA
and NOS. Despite different biocompatibility and flux, none of these dialyzers
showed superiority when comparing all results. High level of ADMA and low
level of NOS in comparison to healthy subjects, supports the presence of
endothelial dysfunction in CKD patients regardless of the chosen method of
treatment.
SP406
BASELINE RENAL CYSTS VOLUME PREDICTS THE
RECOMBINANT HUMAN ERYTHROPOIETIN REQUIREMENT
IN AUTOSOMAL DOMINANT POLYCISTIC DISEASE
Paolo Lentini1, Luca Zanoli2, Antonio Granata3, Andrea Contestabile1,
Anna Basso1, Graziella Berlingo1, Valentina Pellanda1, Massimo de Cal4,
Virzi Grazia4, Anna Clementi3, Monica Insalaco3 and Roberto Dell'Aquila1
1
Nephrology S. Bassiano Hospital Bassano Del Grappa (VI) Italy, 2University of
Catania Catania Italy, 3Nephrology S. Giovanni Di Dio Hospital Agrigento Italy,
4
Nephrology S. Bortolo Hospital Vicenza Italy
Introduction and Aims: Prevalence of anaemia in patients with autosomal dominant
polycystic kidney disease (ADPKD) increases according to the severity of chronic
kidney disease (CKD). However,little is known about the relationship between kidney
structure modification and recombinant human erythropoietin(rHu-EPO)
requirement in these patients( pts). Aim of this study was to evaluate the role of renal
SP405
Healthy subjects P
pre-dialysi phase N = 11
Age
Female N (%)
NOS pg/ml
ADMA µmol/l
57.7 +/- 9.3
7 (58.3%)
10000 (4306-10000)
N = 12
*70 +/-12.0
11 (42.3%)
*13833 (1411-5064)
*21389 (846-3391)
Patients
N = 26
*75 +/-10.2
6 (54.5%)
*3380 (2302-4490)
0.36 (0.29-0.40)
*0.77 (0.55-0.97)
0.038 (0.28-0.53)
*0.63 (0.42-0.72)^
before HD
after HD
*P=0.0009
*1P=0.0518
*2P=0.0074
*P=0.0002
^P=0.032
Me (25%-75%) *vs healthy subjects ^vs patients before/after HD
i | Abstracts
Volume 28 | Supplement 1 | May 2013
Abstracts
Nephrology Dialysis Transplantation
cysts and kidney size on rHu-EPO requirement in severe CKD and naive chronic
hemodialysis (HD) patients.
Methods: A total of 43 pts with ADPKD and anemia treated with alfa-erythropietin
(rHU-EPO)were enrolled(16 pts with CKD Stage 4 and 28 naive chronic HD pts),the
total volume of the four largest cysts (cysts-Vol) and the mean antero-posterior renal
diameter (AP) were prospectively followed-up for 18months with kidney ultrasound.
Results: Mean age was 65±13yrs. At baseline, AP was 19.4±2.1cm, cysts-Vol 407 ±
369cm3. During the 18months follow-up, haemoglobin (Hb) was 10.8± 0.7g/dl,
rHu-EPO dose was 14403 ± 7518UI/week,and rHU-EPO/Hb ratio was 1379±780.In
fully adjusted model,baseline cysts Vol and AP predict EPO dose and EPO/Hb ratio
and explain a large amount of variability.
SP406
Dependent variable: EPO, UI/Week
Cysts Vol (100cm3)
AP (cm)
Model R2=0.46
Dependent variable: -EPO/Hb ratio
Cysts Vol (cm3)
AP (cm)
Model R2=0.51
Beta (95%CI)
P
R2 incr.
870 (250-1480)
1146 (68-2223)
<0.05
<0.05
0.11
0.06
104 (43-165)
109 (3-215)
<0.05
<0.05
0.14
0.05
Conclusions: Cysts volume is useful to predict prospectively the rHu-EPO
requirement.This assumption is valid even in chronic dialysis patients, where the renal
function is completely lost.
was based on clinical, laboratory and patient's questionnaire survey outcomes. The
scoring system of the questionnaires ranged from 0-10. Statistical analysis was
performed using Medcalc software version 10.4.0.
Results: The results of this study show the effective role of online HDF on improving
the clinical outcomes, adequacy of dialysis and laboratory results. Patients were much
more satisfied with online HDF when compared with patients treated with
conventional HD. Data are summerised in the following table.
SP407
Parameter
Systolic BP (mmHg)
Diastolic BP (mmHg)
Hypotension during dialysis
Cramps
Itching
Skin colour
Online HDF
106±5.4
68±1
93±7
99±13
51±26
22±21
HD (Control)
112.7±9.5
69±1
39±12
26±12
12±4
10±1
P Value
<0.0002
NS
<0.0001
<0.0001
<0.0001
<0.0001
Kt/V
Phosphorus (mg/dl)
Calcium (mg/dl)
PTH (pg/ml)
Albumin (g/dl)
Hb (g/dl)
Beta 2-microglobulin (mg/l)
Erythropoetin dose
1.26±0.15
4.5±0.4
8.9±0.5
386±143
3.6±0.35
10.3±0.5
22.4±3.8
78%
0.94±0.12
4.6±1.5
8.4±0.3
532±281
3.3±0.37
9.9±0.7
36.6±8.7
75%
<0.0001
<0.035
NS
<0.015
<0.0001
<0.01
<0.0001
NS
Fatigue (general)
Fatigue (post dialysis)
Compliance
Body energy
General mood
Appetite
Taste
Social activity
Sport activity
Professional activity
95±7
91±9
82±10
79±17
88±14
39±16
71±19
82±9
65±14
81±7
29±9
19±4
14±8
13±17
10±3
10±2
10±5
15±8
10±3
10±4
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
Conclusions: In conclusion, our results show that online HDF treatment was
associated with significant improvement in clinical outcomes, dialysis adequacy,
biochemical results and quality of life of ESRD dialysis-treated patients.
SP408
EXTENDED NOCTURNAL HEMODIALYSIS: SINGLE CENTER
EXPERIENCE
Ana R. Martins1, Lucia Parreira1, Ana S. Duque1 and Ilidio Rodrigues1
Nephrocare Barreiro Fresenius Medical Care Barreiro Barreiro Portugal
1
SP406
SP407
ONLINE HAEMODIAFILTRATION: DIALYSIS QUALITY
IMPROVEMENT
Ayman Karkar1 and Mohammed Abdelrahman1
1
Department of Nephrology Kanoo Kidney Centre Dammam Saudi Arabia
Introduction and Aims: Haemodialysis (HD) treatment had over many years
improved the survival rate of patients with end-stage renal disease (ESRD). However,
conventional HD prescription has high rates of morbidity and mortality with poor
quality of life. Online haemodiafiltration (HDF) offers the most physiologic clearance
profile for a broad size range of toxic molecules together with better haemodynamic
stability. Our aim was to investigate, in a prospective randomized study, the effect of
online HDF on dialysis clinical and biochemical outcomes and patient's quality of life.
Methods: Seventy two patients, with 58% males and mean age of 54±12 year, had
similar comorbidities, AV Fistula rate (80%), blood flow rate (324±30 ml/min), dialysis
adequacy (0.94±0.08), biochemical results and duration on HD (51±3 months). They
were randomized into two groups. Group 1 (n=36) was maintained on conventional
HD and group 2 (n=36) treated by online HDF and both were followed up for 24
months. Prescription of HD and HDF included similar 4h dialysis duration performed
3 times/week using high-flux dialysers. The reverse osmosis treated water that was used
for both groups contained <0.1 CFU/ml and <0.01 endotoxin unit/ml. Group 2
received an average of 18.9±2.4 L/4h as post-dilution replacement fluid. Assessment
Volume 28 | Supplement 1 | May 2013
Introduction and Aims: Despite advances in dialysis, this therapy is still associated
with high morbidity, mortality and costs.
Methods: The mortality, morbidity, hypertensive profile, bone mineral disease,
anemia, efficacy of dialysis and nutrition were evaluated in 14 patients undergoing
extended nocturnal hemodiafiltration (HDF) mean time 18,5 hours/week. Among this
patients 5 were male, 1 had diabetes mellitus and 3 had cardiovascular disease. The
software used was SPSS version19.
Results: We report the results of an extended nocturnal hemodiafiltration (HDF)
program in a group of 14 patients, mean dialysate flow was 275 ml/minute, mean blood
flow 275mL/m, with dialysate concentrate of HCO3 32 meq/l, Ca2+ 3, Na+ 138, K+ 2
and glucose 100 mg/L. The mean age was 53.14 years ± 10,34. At admission, average
time of renal replacement therapy was 7.43 ± 4.7 years. The follow-up period was 13,6
± 2.5 months. During the follow up period one patient died and one received a kidney
graft. In all patients there was an improvement of dialysis efficiency (eKT/v 4,6 ± 6,1vs
0,7 ± 0,8 wk, p 0,000). Although hemoglobin levels (11,5 ± 0,8 vs 11,3 ± 0.7 g/dl, pns)
remained unchanged, there was a significant reduction in erythropoiesis stimulating
agent (ESA) consumption (121,1 vs 80,7 IU/kg/wk, p 0.000). Iron consumption (40.4 ±
25,3 vs 34,05 ± 37,9 mg/wk, pns) and ferritin values (434,2 ± 305,2 vs 392,9 ± 162,3 ng/
ml, p 0,003) significantly decreased and nutritional parameters improved (nPCR 1,1 ±
0,1 vs 1,2 ± 0,7 g/kg/d, p 0,000). Serum calcium levels increased (8,2 ± 0,7 vs 8,9 ± 0,4
mg/dl, p 0.001) and there was a reduction in phosphatemia (4,8 to 4,5 mg/dl) allowing
phosphate binder suspension in 4 patients and those reduction in 3; PTH values (688,2
± 599,2 vs 560,9 ± 310,2 pg/ml, pns) were not affected. Both pulse pressure (67,6 ± 15,8
vs 63,5 ± 17,3 mmHg, p 0,035) and diastolic blood pressure (BP) (71,9 ± 7,3 vs 62,1 ±
13,6 mmHg, p 0,014) were significantly lower; antihypertensive medications
consumption decreased (1,9 ± 1,4 vs 0,9 ± 0,8, p 0,008). Left ventricular (LV) mass,
posterior wall and LV fractional shortening had a non significant reduction.
Conclusions: This extended nocturnal HDF program had good patient adherence,
showed an improvement in dialysis efficacy, BP control, nutritional parameters and
inflammatory markers, and lower consumption of erythropoiesis stimulating agents
and of antihypertensive and phosphate binder medication.
doi:10.1093/ndt/gft116 | i
Abstracts
SP409
BIOFILTRATION FREE ACETATE WITH SUBSTITUTION OF
BICARBONATE OF SODIUM AT 84‰: 20 YEARS AFTER
Nephrology Dialysis Transplantation
SP411
PROSPECTIVE EVALUATION OF HYDRATION STATUS IN
PATIENTS REQUIRING CRRT
Anis Baffoun Baffoun1, Mohamed Ali Youssfi2, Aicha Sayeh1, Maher Béji1,
Ramzi Ben Khadra1 and Jalel Hmida1
1
Dialysis Research Unit Military Hospital of Tunisia Tunisia Tunisia, 2Pharmacy
Department Military Hospital of Tunisia Tunisia Tunisia
Flavio Basso1, Marzena Wojewódzka-Żelezniakowicz1, Dinna Cruz1,
Anna Giuliani1, Lourdes Blanca Martos1, Pasquale Piccinni2 and Claudio Ronco1
1
Nephrology, Dialysis and Transplantation San Bortolo Hospital Vicenza VI Italy,
2
Intensive Care Unit San Bortolo Hospital Vicenza Italy
Introduction and Aims: In order to overcome the disavantages of hemodialysis with
bicarbonate (HDB), several techniques of renal replacement therapy have been
developed. These techniques have not become widespread because of their high costs.
Thus the idea of developing a technique that would improve the safety of HDB without
raising the cost is born. This technique was called biofiltration free acetate with
substitution of sodium bicarbonate at 84‰ (BSA at 84‰).
Methods: The BSA at 84‰ is a dialysis technique using a bath-free buffer (acetate or
bicarbonate). The correction of metabolic acidosis of the patient is ensured by
providing a solution of molar sodium bicarbonate (84‰) at the venous bubble trap of
extra corporeal blood circuit. The generator used is similar to that used with the
technique of HDB. The injection of the buffer solution is provided using an infusion
pump with adjustable flow. The flow rate used is about 3.5 to 4.5 ml/kg/hour. The
volume injected during a session of 4 hour varies between 900 and 1000 ml. This
volume is ultrafiltered through the dialyzer membrane in addition to the desired weight
loss. Therefore, it is possible to use the same filters as for HDB.
Results: Studies shows that the BSA at 84‰ technique: * Improved clinical tolerance,
reducing the frequency of hypotension and other clinical manifestations of intolerance
in both patients with acute renal failure and chronic dialysis patients. * A good
correction of metabolic acidosis, both at short and long term, without the risk of post
dialysis hyperbasemia. This is most probably related to the balance established between
intake and elimination of bicarbonate by the filter and the richness in the dialysate on
chloride ion which is at the origin of a better correction of metabolic acidosis in
intracellular by transfer of bicarbonate from extracellular to intracellular sector.
However, the likely benefits of hyperchloremia should not lose sight of its deleterious
effects: acidosis of extracellular medium and hemolysis. Moreover, the risk of
hyperbasemia is not zero if the volume of bicarbonate molar infused is greater than 4.5
ml/ kg/ hour. * A lower cost compared to the technique of HDB due to the low cost of
the concentrate of biofiltration and the low amount of concentrate used in BSA at 84‰
(4-5 versus 8-9 liters). The generalization of the technique, remains dependent on the
marketing of a module of BSA at 84 ‰ integrated to conventional hemodialysis
generator, may minimize the cost of dialysis in the order of 1€ per session.
Conclusions: The good clinical and hemodynamic tolerance of BSA at 84‰, the best
correction of metabolic acidosis and its lower cost, give this technique a pride of place
in the therapeutic arsenal of chronic renal failure.
Introduction and Aims: Disorder of fluid balance is an important risk factor for
morbidity and mortality in critically ill patients. Total body fluid status is particularly
important, butit has been poorly studied in patients requiring CRRT. Our aim is to
evaluate the variation of hydration status, measured by Bioelectric Impedance Vector
Analysis (BIVA) in critically ill patients at the beginning of CRRT, in the following days
and at the discontinuation of treatment.
Methods: This is a prospective cohort study. 86 BIVA measurments were
peerformedfor 20 patients under the treatment for at least 48 hat beginig and during
treatment every day for 5 days. Patients were considered normohydraed if BIVA was
between 72.7% and 74.3% of body water, fluid overloaded if BIVA> 74.3% and
dehydrated if BIVA <72.7%.
Results: The most common indication for CRRT has been the state of fluid overload
with oliguria (13 of 20 patients), followed by sepsis (11 of 20 patients). It was be found
that a level of overhydration with a median of 82.4% of total body water at the
beginning of treatment and with overhydration of 4.3 liters.The variation of body
hydration status is shown in figure 1 and 2. It is interesting to note a gradual increase in
body hydration with a median 6% higher at fifth day than the day of beginig of the
treatment despite removal of fluids through CRRT. The discontinuation of CRRT was
performed for diuresis recovery and improvement of renal function or for resolution of
the state of shock, patients had however a state of overhydration with a median of
87.2% of total body water.There was no statistically significant difference in survival
between patients with overhydration and normohydrated, probably due to the limited
sample number and a mild degree of fluid overload in all patients.
Conclusions: In conclusion, a fluid overload is common in critically ill patients in
CRRT, and this condition persists during treatment. This suggests an inadequacy of the
protocols of fluid balance probably related hemodynamic instability of patients
requiring CRRT. BIVA may, therefore,be a valuable additional diagnostic method to
monitor the hydration status in critically ill patients in intensive care unit.
SP410
ARTIFICIAL LIVER SUPPORT SYSTEM USING HIGH VOLUME
HEMODIAFILTRATION
Mayumi Akazawa1, Hayato Horiuchi1, Yuki Hori1, Asuka Yamada1, Hiroshi Satou1,
Sou Odamaki1, Sota Nakai1, Kanako Satou1, Kanako Aoki1, Ikuo Saito1,
Yuka Kamijo3, Satoshi Ogata2 and Yoshitaka Ishibashi3
1
Clinical Engineering Japanese Red Cross Medical Center Shibuya-ku, Tokyo
Japan, 2Hepato-Biliary-Pancreatic Surgery and Transplantation Japanese Red
Cross Medical Center Shibuya-ku, Tokyo Japan, 3Nephrology Japanese Red
Cross Medical Center Shibuya-ku, Tokyo Japan
Introduction and Aims: Fulminant hepatitis: (FH) is an intractable disease caused by
various etiological agents. Artificial liver support: (ALS) is a symptomatic treatment
used to control serious symptoms, such as impairment of coagulation status, hepatic
coma, and brain edema. Plasma exchange in combination with high-volume
hemodiafiltration using an high performance membrane has become the standard ALS
system. It is safe, efficiently removing more low and middle molecular weight toxic
substances than other methods because of the large volumes of buffer (more than 200L
per session), resulting in recovery from coma in patients with severe fulminant
hepatitis, a status comparable with the ahepatic state.
Methods: In our hospital, plasma exchange: PE (PE or PE+HD or PE+HDF), and high
flow-volume continuous hemodiafiltration: HFV-CHDF are provides for patients of
FH and liver failure. We will report that therapeutic method and the treatment result of
liver failure patients who underwent ALS and compared laboratory data (Total
Bilirubin, D/T ratio, PT-INR and MELD) and fluid replacement volume per an hour
between four groups of alive, transplantation, death and alive (FH) in the past 5 years
(2008-2012).
Results: There were 43 liver failure patients (including 11 patients which had a
diagnosis of FH) during a period, and provided ALS for 227 times. Of which FH
patients, 56 times(average 5.0±3.1 times) of plasma exchange and 63 times(average 5.6
±3.5 times) of HFV-CHDF were provided. The efficacy rate of ALS treatment for FH
patients were 63.6%. When include 3 cases which were able to save by live donor liver
transplant, the lifesaving rate became 90.9%.
Conclusions: Plasma exchange in combination with high volume hemodiafiltration is
an effective method for purifying the blood of patients with fulminant hepatitis and
liver failure.
SP411
SP411
i | Abstracts
Volume 28 | Supplement 1 | May 2013
Abstracts
Nephrology Dialysis Transplantation
SP412
AUTOSUB+: A SOPHISTICATED INNOVATIVE TOOL FOR A
SIMPLIFIED OL-HDF PRACTICE
Jacky Potier1, Guillaume Queffeulou1 and Julien Bouet1
1
Nephrology Hemodialysis CHPC Cherbourg France
Introduction and Aims: The optimization of convective volumes (Vconv) delivered in
Post ol-HDF (POST) allows to remove the Medium Molecules (MM) and especially
those with the highest Molecular Weight (MW). Membrane permeability is preserved
thanks to automated Vconv. The 5008 dialysis machine (Fresenius) was, up to the
recent launch of its new CorDiax version, equipped with a module AUTOSUB (AS)
enslaving convective rate (Qconv =Qs + UF; Qs=Substitution Rate and
UF=Ultrafiltration for Weight gain) to plasmatic water rate (Qpw). Recently
AUTOSUB+ (AS+) uses an innovative technology regulating Qconv according to the
harmonic analysis at the venous pressure sensor of the blood pomp generated
vibrations according to the principle of “la transformée de Fourier”. The aim of our
study was to compare Vconv obtained with AS versus AS+ in POST.
Methods: 24 patients (Age: 73.6 ±11.9; AVF=19 and Catheter=5) were included in this
monocentric crossover study. They were treated during a 240min/session on the same
day of 2 consecutive weeks with 3 different Qb(mL/min) groups: Qb300, Qb350 and
Qb380. AS was set with hematocrite (ht) given by the BVM and the level of he latest
measured Total Proteins (TP). Statistical analysis (StatView) was performed with
Student's paired test for mean values of AS and AS+. Correlation between ht and TP
with the global Filtration Ratio (FR=Vconv/Total Blood Processed) was also analysed.
Results: No significant difference between the two methods for Vconv. Table1. Vconv
(L/session) obtained with AS versus AS+ according to 3 different Qb
SP412
AutoSub (AS)
AutoSub+ (AS+)
Qb300mL/min
24.8±3.1
23.9±1.2
Qb350mL/min
27.8±3.0
27.2±1.9
Qb380mL/min
28.8±2.4
28.5±2.1
No correlation between ht (34.7±3.14%) and AS or AS+. The most important
correlation between TP and FR with AS (R=-0.8; P<0.0001) versus AS+ (R=-0.5;
P=0.012) explains the less dispersion for Vconv values with AS+ (versus AS). AS is no
more dependant on the great variations of TP from one patient to another (6.7± 5.7g/
dL). The interception of the 2 regression lines between TP and FR for AS and AS+
predicts Vconv efficiency more favorable for AS when TP<7.0g/dL and for AS+ when
TP>7.0g/dL.
Conclusions: AS+ using innovative technological approach allows, without any
knowledge of ht and TP, identical Vconv to those generated by AS. In practice, using
the default values of ht and TP decreases the accuracy of AS. In these conditions,
optimizing Vconv without any biological value, makes AS+ a real innovation in the
automation and simplification of OL-HDF. This study confirms the relevance of AS to
optimize Vconv when it is correctly set with the BVM ht values and with the latest
patient's TP values. Finally, AS remains as an effective tool for practicing POST both
efficient and safe for those not yet equipped with the 5008 CorDiax machine.
SP413
CITRATE DIALYSIS FLUID AND CALCIUM MASS BALANCE
A. Nilsson1, J. Sternby1, G. Grundström1 and M. Alquist1
1
Gambro Lundia AB Lund Sweden
concentration 2.4 mM (mmol/l), blood flow rate 300 ml/min, dialysis fluid flow rate 500
ml/min, urea KoA 1000 ml/min, calcium concentrations in dialysis fluid without citrate
1.0, 1.25, 1.5 and 1.75 mM, and citrate levels in the dialysis fluid 0.25 – 2 mM.
Results: The need for extra calcium in the dialysis fluid increases almost linearly with the
citrate level. Each mM of citrate requires an additional 0.15 mM of calcium to maintain
the same calcium mass balance. Other settings of blood and dialysis fluid flow rates, urea
KoA, and total calcium concentrations in plasma gave the same result.
Conclusions: For each mM of citrate in the dialysis fluid the calcium level should be
increased by 0.15 mM to maintain the calcium transport during the treatment.
SP414
Martina Ferraresi1, Maria C. Di Vico1, Federica N. Vigotti1, Maria Deagostini1,
Stefania Scognamiglio1, Valentina Consiglio1, Roberta Clari1, Irene Moro1,
Elena Mongilardi1 and Giorgina B. Piccoli1
1
Department of Clinical and Biological Sciences, University of Turin SS Nefrologia,
ASOU san Luigi Gonzaga Orbassano Torino Italy
Introduction and Aims: The present revival of interest in home haemodialysis (HHD)
is due to lower costs and more frequent/efficient or “intensive” treatments.
Nevertheless, HHD is still underdeveloped and development strategies are needed. Aim
of the study is to report on the results obtained in the period 2010-2012 with a new
flexible HHD program, open also to fragile and elderly patients.
Methods: The program is characterized by flexibility of training (duration and number
of caregivers); implementation of daily dialysis, and individualized schedules;
personalization of controls; easy access to hospital facilities; no discrimination for age
or comorbidity. The study reviews the patient's charts, as for ESRD, comorbidity,
reasons of choice, reasons of drop-out.
Results: In the period 2010 (start of the program) 2012, 19 patients were enrolled, 2 are
waiting to join the program; 12 were sent on HHD (1 died), 1 will start in February
2013. Six patients dropped-out from training: 3 for unavailability of the partner; 2 for
difficulties in the a-v fistula; 1 for housing problems ( presently hosted by relatives); 4/6
perform self-care dialysis in the Center. The patients who dropped out from the
training were younger (median: 44.5 (24-63)) only 1 had comorbidity (vascular). The
patients who completed the training were older (median 58 (38-76)), 2/13 only without
comorbidity (multiple in 4: 6 cardio-vascular, 3 diabetes, 2 collagen diseases, 2
neoplasia, 3 other); 10 patients had contraindications (in 3 temporary; 2 BMI >33; 1
recent angioplasty) for wait-listing for a kidney (or kidney-pancreas) graft. Main
reasons for choice were: easier adaptation to the working schedule (5 patients); family
choice for spending more time together (5 cases); easier travelling (3 cases). The
partner was the wife-husband in all but 1 case who employed a payed nurse. Dialysis is
started with incremental schedules, usually together with the training. Training lasted
3-12 months; schedules ranged from 2 to 7 sessions/week, 2.5-6 hours/session (last
median equivalent renal clearance: 14.5 mL/min).
Conclusions: When HHD is offered with a flexible, open selection, it may represent a
good choice for elderly patients and for patients with multiple comorbidities (often
considered as "the last" candidates for HHD), not suitable for a kidney graft. Working
and family reasons, in particular in elderly couples, are the main driving forces for this
choice. Attention to “the last ones”, and flexibility in facing their needs, may improve
the development of HHD.
SP415
Introduction and Aims: Citrate-containing concentrates have in recent years been
introduced for use in hemodialysis. Citrate entering the blood will form complexes
with calcium and some of the protein bound calcium will then be released to maintain
the equilibrium between protein bound and free ionized calcium. Both free and citrate
bound calcium can pass the dialysis membrane which increases the calcium transport
from the blood. We developed an algorithm to calculate the mass balance of calcium
transfer over the dialysis membrane. The objective was to establish what calcium
concentration in citrate containing dialysis fluid gives the same total calcium mass
transfer as a citrate-free dialysis fluid. The algorithm takes into account the complex
formation between citrate and calcium and also includes other known calcium
complexes present in the dialysis fluid, as well as in the blood.
Methods: The mass transfer area coefficients for ions and complexes were assumed
proportional to their diffusive mobility. The electrical potential across the membrane
(membrane potential) was considered by requiring electroneutrality. As the transfer of
complexes across the membrane affects the concentration gradients for both complexes
and individual ions, we included chemical equilibrium equations in the calculations. Each
albumin molecule in the blood can bind a large number of (pH dependent) ions like
hydrogen, calcium and magnesium with different equilibrium constants. The binding of
calcium and magnesium ions to bicarbonate and citrate was also included in the
calculations. The dialyzer was considered being composed of a number of serial
subsegments. For each segment the transport of each solute and each complex were
calculated separately, taking the membrane potential into account. With the given inlet
concentrations for each solute the outlet concentrations for a dialyzer segment were
calculated from the transports. The total concentration of each compound was calculated
by summing the free concentration and the concentrations of all complexes where they
appear. From the total concentration a new distribution between free concentration and
complexes was calculated. The recalculated concentrations were used as input to the next
subsegments. The following parameters were used: Initial total calcium plasma
Volume 28 | Supplement 1 | May 2013
“THE LAST WILL BE FIRST…”. A FLEXIBLE APPROACH FOR
RESTARTING HOME HEMODIALYSIS
CITRATE REDUCES COMPLEMENT AND LEUKOCYTE
ACTIVATION IN VITRO IN HUMAN BLOOD
Viktoria Hancock1, Shan Huang2, Anders Nilsson1, Gunilla Grundström1
and Kristina Nilsson Ekdahl2
1
Therapeutic Fluid Research Gambro Lundia AB Lund Sweden, 2School of Natural
Sciences Linnæus University Kalmar Sweden
Introduction and Aims: Acetate as acidifier in haemodialysis fluid is known to induce
negative effects, such as nausea and increased inflammatory response. Although
modern haemodialysis fluids contain relatively low levels of acetate compared with
previously used fluids a few decades ago, the levels are far from physiological – raising
concerns in particular for the older, more co-morbid and more vulnerable dialysis
population. Haemodialysis fluid where acetate is substituted, in part or completely, by
citrate was developed recently and has so far only been used to a limited extent in
haemodialysis. Citrate-containing dialysis fluids have shown promising results in terms
of improving clearance and treatment tolerance. In the present study, the
biocompatibility of citrate was examined by investigating the effects of citrate on
complement and leukocyte activation in human whole blood.
Methods: Human whole blood from healthy donors was mixed with small aliquots of
citrate to final concentrations of 0 to 6 mM citrate. After 1 hour of incubation at 37°C,
complement activation was measured as generation of C3a, C5a and terminal
complement complex C5b-9 (TCC), and leukocyte activation was measured as
up-regulation of CD11b expression on granulocytes.
Results: Complement activation was significantly reduced in the presence of citrate.
C5a and TCC showed a reduction of 38% and 27%, respectively, already in the presence
of 0.25 mM citrate compared with control without citrate, and the reduction was
further enhanced at higher citrate concentrations up to 74% and 70%, respectively, in
doi:10.1093/ndt/gft116 | i
Abstracts
the presence of 6 mM citrate. C3a showed significant reduction only at the higher
concentrations of citrate, by 41-59% in the presence of 4-6 mM citrate. Leukocyte
activation was reduced significantly in the presence of 1.5 mM citrate and above,
measured as a reduction in expression of CD11b by 19% with 1.5 mM citrate up to 78%
at the highest citrate concentration, 6 mM.
Conclusions: In conclusion, citrate is a potent reducer of leukocyte and complement
activation in human whole blood in vitro. Complement and leukocyte activation was
significantly reduced at relatively low citrate concentrations (0.25 mM and 1.5 mM,
respectively), similar to those currently employed in citrate haemodialysis.
Mathematical modelling indicates that during a typical dialysis treatment with a fluid
containing 1 mM citrate the blood returning to the patient contains about 0.66 mM
citrate. The systemic citrate concentration is highly dependent on the patient's citrate
metabolism; mathematical modelling indicates a systemic concentration of 0.1-0.4 mM
citrate after 4 hours of dialysis, which is in agreement with our measured systemic
concentrations of around 0.3 mM citrate post dialysis. Our results reveal that
substituting acetate for citrate in dialysis fluids might contribute to a more
biocompatible dialysis by reducing activation of the innate immune response.
SP416
CITRATE VS. ACETATE DIALYSATE-REINFUSATE IN ON-LINE
POSTDILUTION HDF
Giovanni Calabrese4, Denis Steckiph2, Andrea Bertucci2, Claudio Baldin1,
Michele Petrarulo3, Domenico Mancuso4, Giuseppe Vagelli4 and Marco Gonella4
1
Biochemistry Laboratory, Ospedale S. Spirito, ASL AL Casale Monferrato Italy,
2
Gambro-Hospal S.p.A. Bologna Italy, 3Renal Stones Laboratory, AO Mauriziano
Turin Italy, 4Nephrology and Dialysis Unit, Ospedale S. Spirito, ASL AL Casale
Monferrato Italy
Introduction and Aims: Previous papers showed a higher acetate body gain during
convective treatments than in bicarbonate hemodialysis. Since the detrimental effects of
acetate on vascular instability and inflammation are well known, a citrate-based
concentrate was recently marketed. In the present study some biochemical and clinical
effects were evaluated in a group of patients undergoing on-line postdilutional HDF
while using either acetate (AC-HDF) or citrate (CIT-HDF) concentrate.
Methods: In 18 patients on long term OL-HDF with 2.1 m2 Polyamide membrane,
acetate dialysate (3.5 mmol/l) was substituted with citrate dialysate (1 mmol/l), while
keeping unchanged, for each patient, the therapy and the remaining technical
parameters, including dCa (1.5 mmol/l), dHCO3 (31±11 mmol/l), dNa (133±2 mmol/
l) and Heparin ( 4300±1900 u/session). The following pre-postdialysis parameters were
evaluated during a single session for each patient using either acetate or citrate
dialysate: blood pressure, dialysis efficiency, clotting parameters, serum Albumin, PTH
and CRP. In addition, total and ionized calcium, and acid-base balance, were evaluated.
Results: No significant difference between AC-HDF and CIT-HDF was found in the
following parameters: Kt/V (1.6±0.3 vs. 1.7±0.4); sCr, sPi, sβ2M, sHCY removal; serum
Albumin (4.1±0.4 vs. 4.2±0.4 g/dl), clotting parameters (aPTT, Platelet count), CRP (0.6
±0.3 vs. 0.5±0.2 mg/dl), Hb (11.7±1.6 vs. 11.6±1.7 g/dl), pre and post-dialytic BP, as well
as the technical parameters [TMP, infusion volume (24.4±3 vs. 24.2±4 l/session),
pre-filter pressure]. A significant difference resulted in the following parameters between
the two techniques: in AC-HDF total sCa increased from 9.3±0.4 to 10.5±0.6 mg/dl
(p<0.0001), sCa++ from 1.13±0.05 to 1.22±0.03 mmol/l (p<0.0001), sPTH decreased
from 279±203 to 198±238 pg/ml (p<0.05), sHCO-3 increased from 23±2 to 28±2 mmol/l
(p<0.0001), sCitrate remained stable (0.13± 0.02 to 0.11±0.03 mmol/l). In CIT-HDF: sCa
++
increased from 9.5±7 to 9.7±0.4 mg/dl (NS); sCa decreased from 1.12±0.07 to 1.07
±0.03 mmol/l (p<0.0008); sPTH increased from 320±246 to 444±411 pg/ml (p<0.005);
sHCO-3 increased (less than in AC-HDF) from 23±1 to 26±1 mmol/l (p<0.001); sCitrate
increased from 0.12±0.05 to 0.40±0.10 mmol/l (p<0.000).
Conclusions: Ongoing studies are evaluating the potential benefits of Citrate vs. Acetate
in hemodialysis concentrate for what concerns inflammation. In case of positive data, Ca
balance and sPTH behaviour should be reassessed in the middle term in order to
optimize concentrate Ca level, and/or to adjust oral Ca supplements. Moreover, on the
basis of the increase in sCitrate, the possibility of reducing heparin dose should be
considered.
SP417
CITRATE REGIONAL ANTICOAGULATION REDUCES BLOOD
TRANSFUSION REQUIREMENT IN SURGICAL CRITICALLY ILL
PATIENTS UNDERGOING CONTINUOUS RENAL
REPLACEMENT THERAPIES
Paola Inguaggiato1, Giorgio Canepari1, Graziella Gigliola1, Carlo Ferrando1,
Silvio Meinero1, Carmelo Sicuso1 and Alfonso Pacitti1
1
Nephrology and Dialysis Unit S.Croce & Carle Hospital Cuneo Italy
Introduction and Aims: Citrate regional anticoagulation (CRA) is increasingly
adopted during continuous renal replacement therapies (CRRT) in critically ill patients
( pts) with acute kidney injury requiring extracorporeal depuration. In our hospital we
use CVVHD with CRA since 2008, and now it represents almost 50% of treatments
(about 500/year). Cost analysis of CRRT includes not only direct costs (disposable,
nurse workload) but also indirect variable costs (drugs and blood or plasma
derivatives). In literature there are conflicting data about blood transfusion need with
different types of anticoagulation during CRRT. In this retrospective study we
evaluated the impact of CRA on blood transfusion requirement, focusing on those pts
who underwent main surgery.
i | Abstracts
Nephrology Dialysis Transplantation
Methods: Over a two-year period (1/2011 – 12/2012) 293 pts underwent CRRT in our
hospital. After exclusion of pts treated with both CRA and standard methods (STD,
heparin or nothing) during the CRRT period, pts who did not undergo main surgery,
and cases of CRRT duration ≤2 days, we considered 63 pts for our purposes. The
choice of anticoagulant was made for clinical reasons (active bleeding or high
hemorrhagic risk). For each group we evaluated: age, hospital length of stay (LOS),
CRRT duration, hospital mortality (HM), hemoglobin values at start (Hb-S) and stop
of CRRT (Hb-E), number of blood transfusions administered during CRRT period/
CRRT days (CRRT-BT) and number of blood transfusions administered during the
whole hospital stay/LOS (tot-BT). Statistical analysis was made with Student's T test.
Results: In CRA group there were 50 pts, for a total of 500 CCRT days; mean age 72.8
years (M 82%); mean LOS 35.9 days; mean CRRT duration 10 days; HM 40%; mean
Hb-S and Hb-E respectively 9.36 g/dl and 9.43 g/dl ( p=NS); mean CRRT-BT 0.56,
mean tot-BT 0.45. In STD group there were 13 pts, for a total of 132 CRRT days; mean
age 68.5 years (M 77%), mean LOS 26.7 days, mean CRRT duration 10.2 days, HM
69%, mean Hb-S and Hb-E respectively 10.4 g/dl and 9.2 g/dl ( p<0.05), mean CRRT/
BT 1.08, mean tot-BT 1.48. Tot-BT and CRRT-BT were significantly lower in CRA
group than in STD group.
Conclusions: In our experience critically ill surgical pts requiring extracorporeal blood
purification who are at high risk of bleeding are treated with CVVHD with CRA. This
approach would ensure significantly lower need of blood transfusion and more stable
values of Hb during CRRT. Moreover, HM is much lower in CRA group in absence of
significantly different LOS and CRRT duration.
SP418
EXTRACORPOREAL CIRCULATION IN HAEMODIALYSIS
DOES NOT IMPAIR RED BLOOD CELLS: EVIDENCE FROM
BIOPSY OF BLOOD SAMPLES COLLECTED PRIOR AND
AFTER DIALYSIS WITH ADVANCED MICROSCOPES
Dimosthenis Stamopoulos1, Nerantzoula Mpakirtzi2, Efthymios Manios1,
Nikolaos Afentakis2 and Eirini Grapsa3
1
Institute of Advanced Materials, Physicochemical Processes, Nanotechnology
and Microsystems National Center for Scientific Research 'Demokritos' Athens
Greece, 2Department of Nephrology General Hospital of Athens, 'G. Gennimatas'
Athens Greece, 3Dialysis Unit General Hospital of Athens 'Aretaieion' Athens
Greece
Introduction and Aims: In haemodialysis (HD) blood cells are possibly subjected to
both mechanical stress and biochemical activation during the extracorporeal
circulation due to the unavoidably imperfect biocompatibility of the employed
materials. To resolve information on these issues at the cellular level we surveyed intact
red blood cells (iRBCs) of HD patients at the beginning and end of dialysis.
Methods: We comparatively studied iRBCs coming from 11 HD patients subjected to
standard 4-hour dialysis thrice a week under various membranes ( polysulfone,
polyester-polymer alloy, cuprophan, acrylonitrile-sodium methallylsulfonate
copolymer and ethylene-vinyl-alcohol copolymer) with Nikkiso® DBB-06 units. The
iRBCs refer to freshly collected RBCs (in EDTA tubes) that are deposited onto glass
slides in single-layered form without farther treatment except for mild centrifugation
(120xg, 5 min) for the collection of plasma and reduction of Hct at the value of 10%.
The iRBCs were studied with the Atomic-Force Microscope (AFM) and
Scanning-Electron Microscope (SEM) that can morphologically survey both entire
cells, at the micrometer scale (1 μm=10-6 m) and cell membrane at the nanometer scale
(1 nm=10-9 m). In particular, we studied iRBCs both prior to (N=306) and after
(N=305) the dialysis session. These results were contrasted to data obtained on iRBCs
(N=310) of 11 healthy donors as well.
Results: Both the AFM and SEM data show that the membrane of iRBCs displays
morphological abnormalities (MA) that reminisce of circular and linear ulcers (cUMA
and lUMA, respectively). The cUMA and lUMA have typical size 100-2000 and
500-3000 nm, respectively and population 5.24 and 0.25 per iRBC, respectively. The
percentage change of the cUMA and lUMA population per iRBC during the dialysis
session is not statistically significant ( p>0.05), attaining values -9.2% and 12.0%,
respectively. When compared with the healthy donors, the cUMA population observed
in HD patients presents an intense increase, 55% ( p<0.001). The lUMA population
does not present statistically significant ( p>0.05) difference between the two groups.
Conclusions: Nowadays HD has become a mature method in which the employed
materials and methods exert only minor, if any, mechanical stress and biochemical
activation on RBCs, at least for the typical duration of 4 hours commonly employed in
clinical practice. Thus, the extracorporeal circulation can be safely excluded from the
possible mechanisms that influence RBCs thus motivating and/or promoting their
premature elimination by the reticuloendothelial system ultimately contributing to
chronic anaemia.
SP419
A COMPARISON OF SOLUTE REMOVAL ABILITIES BETWEEN
PD, HD AND ON-LINE HDF USING SUPER HIGH FLUX
MEMBRANE
Tadashi Tomo1, Kazuhiro Matsuyama2, Takaeshi Nakata1, Kaede Ishida1,
Takashi Takeno1, Jun-ichi Kadota3 and Jun Minakuchi4
1
Department of Nephrology Oita University Hospital Iadai-ga-oka 1-1　Hasama-machi　Yufu City Oita Japan, 2Oita Nephro Internal Medicine
Matsuyama Clinic 457-1 Tajiri, Oita City Oita Japan, 3Department of Internal
Medicine 2 Oita University Iadai-ga-oka 1-1　Hasama-machi　Yufu City Oita
Volume 28 | Supplement 1 | May 2013
Abstracts
Nephrology Dialysis Transplantation
Japan, 4Kidney Center Kawashima Hospital Kitasako ichibannchou 1-39　Tokushima City Tokushima Japan
Introduction and Aims: Former it was recognized that removal performance of low
molecular weight protein of PD was higher than HD. However, higher performance
dialysis membrane called as super high flux membrane was developed in recent years.
The super high flux membrane has higher solute removal characteristics than high flux
membrane, especiously low molecular weight protein. Then we carried out
comparative evaluation of solute removal between PD, HD and on-line HDF using
super high flux membrane.
Methods: It is targeted at three chronic maintenance dialysis patients who are
enforcing a PD+HD combined therapy. HD using super high flux dialyzer
FB-210UHalpha-eco (Nipro Corporation, Osaka, Japan.) for 4 hours and pre-dilution
on-line HDF, whose replacement volume was 60 litters for 4 hours using MFX-21Ueco
(Nipro Corporation, Oasaka, Japan) and PD were treated. The object solute was used as
urea nitrogen, creatinine, inorganic phosphorus, beta-2 microglobulin, alpha-1
microglobulin, and albumin. and dialyzate drain was computed among HD and HDF
by storing partially and all PD dialyzate drain was collected for 4 times per day. The
solute removal amount of each therapy was calculated with solute concentration and
the amount of drain.
Results: The average removal amount of three patients by each blood purification
therapy per one day was compared. In PD, when the average value of solute removal
was 3263 mg, 508 mg, 199 mg, 21 mg, 22 mg, and 2993 mg at the order of UN, Cre, iP,
beta-2MG, alpha-1MG, and albumin, respectively. In HD, it was 12017 mg, 2196 mg,
849 mg, 234 mg, 174 mg, and 3488 mg, respectively. In HDF, it was set to 12638 mg,
2412 mg, 932 mg, 208 mg, 150 mg, and 2676 mg, respectively. When it calculated what
time there would be one HD treatment and one HDF treatment compared with PD, it
differed for every solute. In HD, it became 3.7 times, 4.3 times, 4.3 times, 11.2 times, 7.8
times, and 1.2 times by each solute. On the other hand, in HDF, it became 3.9 times,
4.7 times, 4.7 times, 9.9 times, 6.7 times, and 0.9 time in a similar manner.
Conclusions: The removal amount of low molecular weight protein under HD and
on-line HDF with a super high flux membrane were much larger than that under PD
for one day. Moreover, since the removal amount of low molecular weight protein by
these therapies with one session was equivalent to 7 day sessions of PD therapy. So at
the time of HD and PD combined therapy, choosing the super high flux membrane
strongly supports the lack of removal amount by PD, not only small molecular
substance but also low molecular weight proteins.
SP420
ZERO EMISSION DIALYSIS CLINIC - A CONCEPT STUDY
SP420
SP420
by using a photovoltaic system. The photovoltaic system (112 kWp) on the building
roof substitutes the exact amount of CO2, which is emitted by the building during
operation:
Conclusions: The concept study demonstrated that it is possible to run a dialysis clinic
in complete CO2 neutral way.
Juergen Kastl1, Maria Merello1, Carlo Boccato1 and Guido Giordana1
1
NephroCare Coordination EMEALA, Fresenius Medical Care Deutschland GmbH,
Bad Homburg, Germany
Introduction and Aims: Haemodialysis treatment is an energy resource demanding
treatment, requiring 15-20 kWh total energy per treatment, which is significant CO2
emissions. With this concept study we demonstrated that it is possible to run a dialysis
clinic carbon neutral.
Methods: We analysed two clinics in Germany and Portugal, representing typical
dialysis clinics in different climate zones. We selected the state of the art technologies to
increase energy efficiency. To achieve carbon neutral operations, we calculated the
needed energy compensation and arranged suitable photovoltaic panels on the roof of
the building. The concept study was performed with the help of our project partner
DENA (German Energy Agency).
Results: Comparison of the two existing dialysis clinics in the two different climate
zones:
SP420
Size of the dialysis clinic
No of treatment p.a.
Year of construction
Energy consumption per
square meters (m²) and
year (a)
Energy consumption per
dialysis station
Energy consumption per
dialysis treatment
Portugal (Coimbra)
2,123 m²
22,576
2005
179 kWh/(m²a)
Germany (Cologne)
1,460 m²
12,534
2005
127 kWh/(m²a)
13,138 kWh/(station x a)
6,000 kWh /(station x a)
17 kWh/treatment
14 kWh/treatment
The energy efficiency of a standard dialysis clinic (1,000m²; single floor; ˜12,500
dialysis tr.p.a.; located in Germany, Cologne) can be reduced to 7 kWh/tr. using the
following features: 1. Building envelope: a well-insulated envelope can save up to 40 %
of heating- and cooling energy 2. Daylight concept: Daylight reduces the energy
demand for lighting and cooling load for the HVAC systems 3. Lighting concept: The
electric power demand for lighting is minimized by an efficient lighting concept
4. Mechanical ventilation: a centralised ventilation system with a heat recovery rate of
85% can reduce ventilation heat losses 5. Chilled and heated ceiling with capillary tubes
are linked to the heat pump system 6. Heat pump: A reversible heat pump (15 kWh)
provides heating and cooling energy. It uses warm waste water from dialysis as a
heating and cooling source.The carbon dioxide (CO2) emissions can be compensated
Volume 28 | Supplement 1 | May 2013
SP421
PAPERLESS DIALYSIS PATIENT MANAGEMENT SAVES
THOUSANDS OF TREES EVERY YEAR
Stefano Mazzone1, Victor Moscardo1, Juergen Kastl1 and Guido Giordana1
NephroCare Coordination EMEALA, Fresenius Medical Care Deutschland GmbH,
Bad Homburg, Germany
1
Introduction and Aims: We want to calculate and demonstrate the environmental
impact of modern data management systems in dialysis.
Methods: We analyzed the paper saving options of a patient data management system
(EuCliD) in a multinational dialysis network.
Results: EuCliD is a database which unifies medical and economic information. Since
it is specially designed for dialysis it enables us to constantly analyze the collected data
for further improvement. At the end of 2012 more than 600 clinics of our
multinational dialysis network are equipped with this data collection system. Our
target is to provide dialysis treatments achieving an internally developed “gold
standard”. The focus on data collection and its analysis has always been a priority for a
multinational commercial dialysis network. Before the introduction of EuCliD relevant
data like the prescription, therapy plans and diagnostic reports was printed on paper.
With the increase of dialysis patients, the amount of documents raised resulting in a
SP421
doi:10.1093/ndt/gft116 | i
Abstracts
huge amount of paper produced every day. Considering basic patient documentation
like dialysis prescription and diagnostic reports needed during a year the amount of
paper counts 200 pages. The documentation of our current number of dialysis patients
sums up to almost 10 million sheets of paper per year. Without EuCliD our
multinational commercial dialysis network would have needed 49 tons of paper for its
patient documentation per year (standard A4 sheet 80gr/m2 ). This equals the amount
of more than 1.000 trees. According to a Claudia Thomson research: “Recycled Papers:
The essential guide” (Cambridge, MA: MIT Press, 1992), 24 trees, 13 m high and 18
cm thick, are needed to produce 1 ton of common paper. Considering the 49 tons of
paper needed for the 2012 our activities, EuCliD allowed the saving of 1.171 trees.
From the introduction of EuCliD in 2004 our multinational dialysis network saved
6658 trees till end of 2012.
Conclusions: The use of modern patient data management systems is mostly
considered as a safety and management tool, but it has a significant impact on the
environment as well. EuCliD adoption allowed data to run faster and safer between
overall clinics and headquarter. These aspects firstly provide a safer and efficient
patients service, allowing headquarter medical board and all network management to
constantly assist clinics for any needs or issue. EuCliD makes also possible to analyze
historical data in order to produce market forecast and to guide clinics management to
the right way. In this context the adoption of a paperless technology allowed the
dialysis network to save a big amount of trees, 13 hectare of wood equivalent.
SP422
QUANTITATIVE DIFFERENCES BETWEEN THE PRESCRIBED
DIALYSIS EFFICIENCY AND THE THERAPEUTICALLY ACTIVE
EFFICIENCY
Bertold Reinhardt1, Rüdiger Knaup2 and Wolfgang Krüger3
1
Scientific Consulting Reinhardt, Steinbach, Germany, 2Dialysezentrum, Bad
Laasphe, Germany, 3Dialysezentrum, Bad Harzburg, Germany
Introduction and Aims: To define dialysis efficiency, mainly parameters from past
dialysis sessions have necessarily to be used. Those parameters are for example Kt/V,
blood flow, dialysis time and urea clearance. But in the results of these parameters there
is more or less no information for a prospective creation of a higher efficiency in the
next dialysis session. Furthermore, the quantification of parameters which are lowering
the dialysis efficiency below the prescribed aim is demonstrated.
Methods: The dialysis efficiency of 236 patients was examined, using blood flow,
dialysis time and urea clearance. Lowering dialysis efficiency parameters were
examined: total recirculation, postdialytic rebound, the distribution volume, the
relation between prescribed and effective blood flow and clearance as well as the effect
of the vascular access (catheter or shunt).
Results: In 387 dialysis sessions of the 236 patients, the average prescribed blood flow
was 288 ml/min (±41 ml/min), the calculated average effective blood flow however, was
246 ml/min (± 72ml/min). Thus only 85% of the prescribed blood flow was realized.
The difference becomes even clearer, if the maximum values of the frequency
distribution are compared. The maximum of the prescribed blood flow was 300 ml/
min while the maximum effective blood flow reached only 220 ml/min. Analogous to
the blood flows, the clearance values produced the following picture: The average
clearance prescription was 232 ml/min (±29 ml/min) and the effective clearance which
really became valid in the dialyser was 197 ml (±37 ml/min), being 15% below the
prescription. Similar to the blood flows, the scattering of the effective clearance is much
larger, as the standard deviation shows. With an average dialysis time of 4 hours and 20
minutes, the average prescribed Kt/V value was 1,59 (±0,30) while the average effective,
therapeutically active Kt/V was only 1,23 (±0,33). Thus the effective Kt/V was 33%
below the prescribed values. The difference between the prescribed Kt/V and the
therapeutically active Kt/V is depending on the blood flow, the clearance, the
distribution volume, the recirculation and the rebound. The average recirculation of the
236 patients was 19%. Only 39 patients had no recirculation and 32 patients a total
recirculation under 10%, but 55 patients had a total recirculation between 25 and 30%
(total recirculation = shunt and cardiopulmonary recirculation). The average
distribution volume of the patients was 35 l (±6,49 l). The average postdialytic urea
rebound was 6,03 mg/dl. Patients with catheter showed inconstant values for Kt/V,
clearance and blood flow from session to session.
Conclusions: The prescribed dialysis is mostly reduced by patient related parameters.
To improve the efficiency it seems to be more important to respect and to improve the
patients individual situation rather than the change of external parameters.
SP423
RATIOS OF PLASMA BICARBONATE INCREASE TO
DIALYSATE-PLASMA BICARBONATE GRADIENT AT EARLY &
LATE HEMODIALYSIS (HD) ON HIGH & LOW DIALYSATE
BICARBONATE CONCENTRATIONS
David Tovbin1, Seungjin Kim2, Lone Avnon3, Moshe Zlotnik1 and Shimon Storch4
1
Nephrology, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel,
2
Medical School for International Health, Ben-Gurion University, Beer-Sheva,
Israel, 3Pulmonary Soroka Medical Center, Ben-Gurion University Beer-Sheva
Israel, 4Nephrology, Bnai-Zion Medical Center, Haifa Israel
Introduction and Aims: Acidosis correction in hemodialysis (HD) is essential and
requires bicarbonate (BIC) transfer to the expanded extra-plasma compartments
i | Abstracts
Nephrology Dialysis Transplantation
through the "narrow" conduit of the plasma compartment. BIC transfer depends on the
gradient between dialysate BIC concentration (DBIC) and plasma BIC level (PBIC).
Intra-dialytic increase in PBIC, which reach alkalotic range, counteracts the gradient
and limits BIC transfer to the body & acidosis correction. We hypothesized that in
“acidotic” patients ( pre-HD PBIC <22 mEq/L on currently used DBIC (CDBIC) of
33.5-34 mEq/L), high DBIC (HDBIC) of 40 mEq/L corrects inter-dialytic acidosis
while inducing limited intra-dialytic PBIC increase and alkalosis. Thus, we assessed
intra-dialytic PBIC increases and their relations & ratios with DBIC-PBIC gradients on
HDBIC & CDBIC.
Methods: In a prospective bi-center study, 15 patients were assessed for 3-week periods
on CDBIC and afterwards HDBIC. Blood gases & electrolytes were assessed weekly at
start, after 2 hours (mid-HD) and end of HD. 3rd week data is presented as mean (SD).
Statistical evaluation used non-parametric tests.
Results: On CDBIC, pre-HD & mid-HD PBIC were 21.5 (2.7) & 27 (1.9) mEq/L,
respectively. Initial 2 hours PBIC increase was 5.5 (1.9) mEq/L and correlated with initial
DBIC- PBIC gradient (r=0.71, p<0.005). Mid-end PBIC increase was 1.3 (2) mEq/L. On
HDBIC, pre-HD & mid-HD PBIC were 24.7 (2.3) & 33.2 (2) mEq/L, respectively. Initial
2 hours PBIC increase was 8.5 (1.7) mEq/L and correlated with initial DBIC- PBIC
gradient (r=-0.85,p<0.05). Mid-end PBIC increase was 1.75 (2) mEq/L. In the 8 acidotic
patients, on CDBIC pre-HD, mid-HD & end- HD PBIC were 19.3 (1.5), 26 (2) & 28 (2.9)
mEq/L and on HDBIC 24 (2.6), 33.2 (2.4) & 34.9 (3.2) mEq/L, respectively. Intra-dialytic
ratios of PBIC increases to DBIC-PBIC gradients decreased significantly from early to late
HD on both CDBIC & HDBIC {0.4357 (0.1124), 0.1634 (0.2834) & 0.5589 (0.1061),
0.2778 (0.3457), respectively, both p<0.05}.
Conclusions: HDBIC corrects inter-dialytic acidosis. However, acidotic patients develop
mid-HD alkalosis even on CDBIC and augmented intra-dialytic alkalosis on HDBIC, as
early PBIC increase is correlated with initial DBIC-PBIC gradient. Late HD decrease in
ratio of PBIC increase to DBIC-PBIC gradient, may indicate that for the same
DBIC-PBIC gradient more BIC is transferred then from plasma to extra-plasma
compartments. To initiate this process earlier and thus increase its magnitude and
improve acidosis correction, earlier PBIC increase and induction of plasma extra-plasma
BIC gradient will be beneficial. To achieve this goal while avoiding excessive intra-dialytic
alkalosis, we suggest initial HDBIC for <2 hours with subsequent DBIC reduction.
SP424
REAL-TIME MONITORING OF POLYVINYLPYROLIDONE
ELUTING FROM DIALYZER MEMBRANE
Koichi Umimoto1, Yoshimasa Shimamoto1, Miyuki Suyama1 and Masahiro Miyata1
Biomedical Engineering Osaka Electro-Communication University Shijonawate
Osaka Japan
1
Introduction and Aims: Polysulfone(PS) dialysis membrane hydrophilized by
blending polyvinylpyrolidone(PVP) are wellknown to have excellent biocompatibility
in clinical use. PS has some uncomfortable side effects, such as anaphylaxis and skin
lesions, which are supposedly caused by PVP.Generally, method for measuring PVP
eluted from dialysis membrane are X-ray photoelectron spectroscopy and colorimetric
assay, however, ultraviolet(UV) spectroscopy offers an alternative approach for clinical
analysis. This approach is reagentless, thereby permitting real time analysis. In this
study, we investigated to measure PVP directly by optical measurement.
Methods: PVP·K-90 (Wako chemicals, Ltd. Japan) was dissolved at a concentration of
1-100 ppm in physiological saline solution. The spectral measurement was performed
by UV spectrophotometer and those spectra were recorded in the 190-340 nm
wavelength range. The concentration of PVP was extracted from spectrum based on
the absorption band and the actual concentration was also determined by autoanalyzer.
PVP sample was collected from the physiological saline passed through the blood side
of PS dialyzer(PS1.6UW Fresenius). The concentration of PVP was measured by
optical measurement and chemical analyzer using Muller method.
Results: The absorption band of PVP·K90 was determined at 203 nm based on the peak
of its spectra. The predicted concentrations of PVP·K90 almost matched the actual
concentrations. There were significant correlation between actual and predicted
concentration of PVP·K90 (r=0.993, P<0.001) . However, the correlation between the two
at a concentration less than 10 ppm was r=0.974(P<0.001). The spectra of PVP eluted
from PS dialyzer were almost similar to those of PVP·K-90. There were significant
correlation between predicted and actual concentrations of eluted PVP (r=0.965 P<0.01).
Conclusions: Although the measurement precision declines with low concentration
slightly, it is possible to determine the concentration of PVP eluted from PS dialyzer
based on the spectral values using UV spectrophotometer. This indicates that optical
measurement proposed as a method for providing real time monitoring of eluted PVP
during priming a dialyzer.
SP425
DIALYSIS DOSE IN CONVENTIONAL HEMODIALYSIS:
COMPARISON OF KT/V, KT BY GENDER AND BODY
SURFACE AREA
Elvira Bosch Benítez-Parodi1, Eduardo E. Baamonde Laborda1, German Perez1,
Jose Ignacio Ramirez1, Ana Ramirez Puga2, Rita Guerra2, Cesar Garcia Canton2,
M. Mar Lago Alonso2, Agustin Toledo2 and M. Dolores Checa Andres2
1
Centro de Hemodiálisis Avericum Las Palmas de Gran Canaria Spain, 2Servicio
de Nefrología Hospital Universitario Insular de Gran Canaria Las Palmas de Gran
Canaria Spain
Volume 28 | Supplement 1 | May 2013
Abstracts
Nephrology Dialysis Transplantation
Introduction and Aims: Studies have demonstrated that measuring the dialysis dose
by using individualized Kt adjusted for gender and body surface area (BSA) allows for
better discrimination of adequacy than Kt/v. To evaluate Kt as an indicator of dialysis
dose, to compare the degree of compliance with different indexes and to identify factors
involved in the administered dialysis dose.
Methods: This retrospective study included 103 patients (66% male, average age 62 ±
12 years, 53.4% with diabetic nephropathy, 35% BMI>30; 66% with arteriovenous
fistula (AVF)) who were on conventional hemodialysis treatment with ionic dialysance
monitor (Hospal). Monthly average Kt values by gender and BSA were recorded during
one year. Kt/v 2nd generation daugirdas and Percentage Urea Reduction (PUR) were
calculated every two months. Compliance with different recommendations (Kt ≥
H:45L/M:50L; Kt/v ≥ H: 1.3/M: 1.6; PUR ≥70%; Kt per BSA-Lowrie) and influencing
factors were analyzed.
Results: The average Kt dose was 46.8 ± 6.1 L, the average Kt/v was 1.5 ± 0.2 and the
averagePUR was 2.1 ± 7 %; 81.1% of patients received an optimal dose of Kt/v adjusted
for gender and 73.8% of patients presented PUR ≥70%; 54% of patients reached a
minimum Kt of 45L although only 38% of them reached the target Kt adjusted for
gender and 31% adjusted for BSA. Univariant analysis showed that Kt was higher in
patients with higher weight values, lower age, male gender, non-diabetic, with AVF,
higher blood flow (Qb) and longer time in dialysis. Kt/v was higher in male patients,
patients with lower BMI and longer time in hemodialysis. Kt-BSA was higher in
patients with AVF, lower age and higher Qb. Multivariant analysis showed significant
results for Kt with body weight and Qb, for Kt/v with BMI and for Kt ASC with Qb.
Conclusions: 1) Kt appears to be the most exacting marker of dialysis dose. While only
81% of patients received a minimum Kt/v dose adjusted for gender, only 38% reached
target Kt adjusted for gender. 2) Kt adjusted to BSA appeared to be still more exacting
than Kt by gender. Due to the high prevalence of obesity in our sample, studies are
needed to determine the optimal Kt adjusted for BSA in our population. 3) Qb,
effective time in dialysis and vascular access are factors influencing the adequate
dialysis dose.
SP426
DIALYSIS TUNNELED VASCULAR CATHETER FAILURE: THE
EFFICACY OF DRUG THERAPY IN REDUCING CATHETER
OCCLUSION RATE
Farah E. Latif1
1
Department of Nephrology and Transplant University Hospital of Wales Cardiff
United Kingdom
SP427
Yasuhiro Mochida1, Kana Matsumoto2, Kunihiro Morita2, Daimu Tsutsumi1,
Kuihiro Ishioka1, Kyouko Maesato1, Machiko Oka1, Hidekazu Moriya1,
Sumi Hidaka1, Takayasu Ohtake1 and Shuzo Kobayashi1
1
Department of Nephrology, Immunology, and Vascular Medicine Shonan
Kamakura General Hospital Kamakura City Kanagawa Prefecture Japan,
2
Depatment of Clinical Pharmacy Doshisha Women's College of Liberal Arts
Kyoutabe City Kyouto Prefecture Japan
Introduction and Aims: In critically ill patients with severe infection, adequate
administration of antibiotics is crucial. Therefore, evidence of antibiotic
pharmacokinetics for critically ill patients should be accumulated. Meropenem
(MEPM) is an antibiotic with broad spectrum, and has been often used as first-line
therapy for critically ill patients in Japan. However, pharmacokinetics of MEPM in
septic patients undergoing continuous hemodialfiltration (CHDF) has not been fully
elucidated.
Methods: We evaluated the pharmacokinetics of MEPM to clarify the optimal dose
and times of infusion in patients under standard CHDF therapy in Japan. Eight
patients with multiple organ failure and anuria due to sepsis who needed CHDF
treatment were injected 0.5 gram of MEPM twice daily. Among 8 patients, 4 patients
used polysulfone (PS) membrane and 4 patients used polymethyl methacrylate
(PMMA) membrane, and blood concentrations of MEPM were sequentially evaluated.
In all 8 patients, condition of CHDF was blood flow rate of 100 mL/minute, dialysate
flow rate of 300 mL/hour, and replacement flow rate of 300 mL/hour, respectively.
Time above MIC was evaluated, and whether blood concentrations differ between PS
and PMMA was also evaluated.
Results: Time above MIC (%T>MIC) of MEPM more than 50 % is usually thought to
be effective and sufficient to sterilize bacteria. In our study, drip infusion of MEPM 0.5g
twice daily under CHDF therapy as mentioned above could achieve effective
therapeutic dose (% T > MIC more than 50 %) if the MIC of bacteria against MEPM
was below 4 μg/mL. Blood concentrations of MEPM did not differ between PS and
PMMA group.
Conclusions: For patients on CHDF condition as mentioned above,injection of 0.5
gram MEPM twice daily was thought to be effective to eradicate bacteria if the MIC of
MEPM for bacteria were below 4 μg/mL.
SP428
Introduction and Aims: Haemodialysis tunneled catheters are an integral part of the
delivery of haemodialysis. Recent advances in catheter technology, access techniques,
and choice of access sites have improved outcomes associated with haemodialysis
catheters. National vascular access guidelines recommend that no more than 10% of
permanent access be in the form of catheters; in many dialysis centers the percentage
remains higher. While current tunneled catheters possess many of the characteristics of
the ideal catheter, the long-term problems of thrombosis have not been conquered to
date and catheter occlusion rate remains higher than recommended. The use of
anticoagulation to reduce the failure rate of dialysis tunneled vascular catheters,
remains under debate. Current national guidelines recommend the use of unfractioned
heparin or LMWH during dialysis in patients with no bleeding risks, to prevent
clotting of the extracorporeal system. However, there remain conflicting theories
regarding the long-term use of antiplatelet therapy or the use of low dose Warfarin to
prevent dialysis access failure. A study was conducted to evaluate the effect of patient
long-term anticoagulation with low dose warfarin, and/or the use of antiplatelet
therapy in the form of Aspirin 75mg once daily, and the effect on dialysis tunneled
vascular catheter occlusion rate.
Methods: A retrospective analysis of the total number of tunneled dialysis vascular
catheters inserted between 01/08/2010 and 30/11/2011, at the regional dialysis unit was
undertaken. The data was collected from patient notes, day case diary, and the
departmental vascular-access electronic database. For each dialysis tunneled vascular
catheter inserted, the use of anticoagulation with Warfarin, the patients' average INR,
the use of antiplatelet therapy with Aspirin, the use of a thrombolytic agent with a
Urokinase infusion following line occlusion and the number of line occlusion days
were collated.
Results: A total number of 183 (84 Male and 99 Female) primary tunneled vascular
catheters were inserted. Tunneled vascular catheters for dialysis where concurrent use
of Aspirin and low dose Warfarin had the longest functional longevity (Median = 79
days, Interquartile Range 61 to 98, ANOVA p = 0.02). The use of a Urokinase based
infusion in occluded tunneled vascular catheters prolonged the line functional
longevity (Median = 86 days, Interquartile Range 75 to 108, ANOVA p = 0.03). No
abnormal bleeding episodes were recorded in any of the studied case notes.
Conclusions: The failure rate of dialysis tunneled vascular catheters remains higher
than recommended by current national guidelines. The problem is multi-factorial, and
no clear precipitant has been identified. This analysis shows that the concurrent use of
antiplatelet therapy and low dose Warfarin can potentially prolong access survival and
warrants further research. Standardisation in drug therapy use for line patency can
improve dialysis outcome and optimise patient care.
Volume 28 | Supplement 1 | May 2013
MEROPENEM PHARMACOKINETICS IN CRITICALLY ILL
PATIENTS ON CONTINUOUS HEMODIAFILTRATION
FEASIBILITY OF HIGH CONVECTION VOLUMES IN ON-LINE
HAEMODIAFILTRATION (HDF)
Alain Ficheux1, Nathalie Gayrard1, Flore Duranton1, Caroline Guzman1,
Ilan Szwarc2, Johanna Bismuth-Mondolfo2, Philippe Brunet3,
Marie-Françoise Servel2 and Àngel Argilés1,2
1
RD – Néphrologie and Université Montpellier 1, EA7288 Montpellier France,
2
Néphrologie Dialyse St Guilhem Centre de Dialyse de Sète Sète France, 3Service
de Néphrologie Hôpital de La Conception – Université Aix-Marseille Marseille
France
Introduction and Aims: Recent randomised controlled prospective trials suggest that
on-line hemodiafiltration (HDF) improves survival, provided that it reaches high
convective volumes. However, while these results await confirmation, there is scant
information on the consequences of modifying convection volumes in vivo. We wanted
to evaluate the consequences of increasing convection volumes in the feasibility of the
prescribed treatment in on-line post-dilutional HDF.
Methods: Twelve stable dialysis patients were treated with XEVONTA Hi 18
Amembris® dialysers, and increasing or decreasing convection flows (QUF) defined
according to the values obtained at the maximum in vivo ultrafiltration coefficient
(KUF max). Dialysis, 40% under KUF max, KUF max and 40% over the KUF max
setting, for 1 week each were assessed. Transmembrane (TMP), venous and arterial
pressures, infusion flow as well as alarms were continuously recorded. Convection was
limited according to the European Best Practice Guidelines (EBPG) (<30% blood flow /
300 mmHg of TMP). Total convection volume achieved, mean TMP, number of
alarms/session were analysed.
Results: The obtained convection volumes added to the dialysis setting were 13±0.3
(under), 21.7±0.4 (KUF max) and 24.3±0.6 (over) L/session respectively ( p<0.001).
Mean TMP of the recorded values during the session (˜400 measurements) were 79±2,
121±2, 185±4 and 242±4 mmHg respectively ( p<0.001). The mean number of alarms/
session was 0, 0, 0.06±0.04 and 0.97±0.13 respectively ( p<0.001). The number of
dialysis sessions achieving the prescribed convection volume was 100, 100, 94 and 33%
respectively ( p<0.001).
Conclusions: Setting an HDF system at the QUF of KUF max resulted in convection
volumes over those recommended by the recent RCTs (> 20L). Higher convection
volumes provoke alarms, and have an associated discomfort for the patient and nursing
staff and more rarely achieve the prescribed convection volumes. Using on-line HDF at
the KUF max allows achieving high convection volumes with no supplementary
concern. Beyond KUF max the instability of the system makes the benefits of
convection less clear.
doi:10.1093/ndt/gft116 | i
Abstracts
SP429
SODIUM AND ULTRAFILTRATION PROFILING: IMPACT OF AN
ALTERNATIVE MODEL IN HEMODIALYSIS HYPOTENSION
Nikolaos Tsikliras1, Sophia Mademtzoglou1 and Elias Balaskas1
1
Dialysis Unit “Akesios” Dialysis Center Kavala Greece
Introduction and Aims: To study the impact of two different models of ultrafiltration
rate and sodium concentration in hemodynamic stability during hemodialysis, in
patients with end stage renal disease (ESRD).
Methods: Six patients, which experienced frequent episodes of hypotension during
haemodialysis, were included in the study. Two models were scheduled, each one for
four sessions. The first one with constant sodium concentration in dialysate (=145meq/
L) and constant ultrafiltration rate (UFR). The second one with linearly increasing
sodium concentration (from 140 to 150meq/L) and linearly decreasing UFR (sodium
and ultrafiltration profiling). Signs and symptoms of blood volume reduction were
evaluated and a total score of gravity was estimated for each session. The number of
nursing interventions for blood volume preservation was also computed. Finally,
patients' thirst after each session, body weight difference between two consecutive
sessions and blood pressure (BP) in next session were estimated.
Results: Nursing interventions were significantly fewer in sessions that profiling was
used ( p=0,035). The percentage reduction in BP was significantly lower in the 4th hour
of the session when profiling was used ( p=0,039). Thirst was reported to be
significantly more in profiling model ( p=0,030). Body weight difference between two
sessions and BP in next session were not influenced by the model used.
Conclusions: Sodium and UFR profiling,with linearly increasing sodium
concentration and linearly decreasing UFR, is a safe and efficient method for the
prevention of blood volume reduction and hypotension during hemodialysis in ESRD
patients.
SP430
EFFECT OF EMPIRICAL REDUCTION OF DIALYSATE SODIUM
ON HYPERTENSION AND BODY COMPOSITION IN EGYPTIAN
HEMODIALYSIS PATIENTS
Montasser Zeid1, Amira Mostafa2, Mohammed N. Mowafy2, Ehab I. Abdo3
and Omnia M. Al Amin2
1
Nephrology Faculty of Medicine Alexandria Egypt, 2Nephrology Medical Research
Institute Alexandria Egypt, 3Biophysics Medical Research Institute Alexandria
Egypt
Introduction and Aims: Sodium balance plays a central role in dialysis treatment and
should be considered first when we study cardiovascular stability. A negative sodium
balance may contribute to low cardiovascular stability during HD treatment, while, a
positive sodium balance can reduce intradialytic symptoms but aggravates other
symptoms as thirst, weight gain, hypertension and eventually development of
cardiomyopathy . To reduce all these complications we must reach zero balance where
amount of sodium removed during dialysis equals the amount accumulated during
interdialytic period. Empirical reduction of dialysate sodium below plasma sodium
enhances sodium removal by diffusion, and may lead to a reduction in total body
sodium. However, this may be intolerant to some patients. Although most studies show
that this approach results in improvements in blood pressure (BP), reductions in
weight gain and fewer symptoms of thirst, others do not report such differences or find
the reverse. The present study was aiming to study the effect of empirical reduction of
dialysate sodium on hemodynamic stability during dialysis, body composition,
inter-dialytic weight gain and hypertension in hemodialysis patients.
Methods: Twenty hypertensive patients with CKD stage 5-D on HD for more than six
months were included in the study. They were subjected to the following: Confirmation
of the dry weight by clinical examination and bioimpedance study, adherence to low
sodium diet during all the period of the study, progressive reduction of dialysate
sodium concentration after each two weeks( for a total of eight weeks) . For every
dialysate sodium concentration changes, the following data was collected: Pre, post and
intradialytic BP, start and end plasma sodium, Symptoms and episodes of intradialytic
hypotension (IDH), Thirst score was completed every week. At the beginning and at
the end of the study, measurement of all body water compartments was done using
bioimpedance.
Results: By empirical reduction of dialysate sodium we achieved significant reduction
of post dialysis plasma sodium, predialysis blood pressure, post dialysis systolic blood
pressure, post dialysis diastolic blood pressure ,Inter-dialytic weight gain and thirst
score . The reduction in both predialysis plasma sodium and predialysis DBP was not
significant. Also there was no change of any measurements of all body water
compartments.
Conclusions: Optimization of the dialysate sodium prescription is necessary to assure
favorable sodium balance and cardiovascular stability in HD patients. Empirical
reduction of dialysate sodium in stable HD patients is well tolerated, safe and
beneficial. Empirical reduction of dialysate sodium to below predialysis plasma sodium
level was tolerated in some patients. Further studies are required to find out the effect of
empirical reduction of dialysate sodium in hypotension prone HD patients.
i | Abstracts
Nephrology Dialysis Transplantation
SP431
UREA, CREATININE AND PHOSPHATE REMOVAL:
HEMODIALYSIS ADEQUACY ASSESSED BY WEEKLY
MONITORING
Andrzej Ksiazek3, Wojciech Zaluska3, Jacek Waniewski1, Malgorzata Debowska1
and Alicja Wojcik-Zaluska2
1
Department of Mathematical Modlling of Physiological Processes Institute of
Biocybernetics and Biomedical Engineering Warsaw Poland, 2Department of
Physical Therapy and Rehabilitation Medical University of Lublin Lublin Poland,
3
Department of Nephrology Medical University of Lublin Lublin Poland
Introduction and Aims: The assessment of small solute removal during hemodialysis
may be performed and compared using equivalent continuous clearance (ECC) also for
solutes without well defined volume of distribution (as phosphate), in contrast to KT/
V. ECC is defined as the removed mass per dialysis cycle time (one week) per a
reference solute concentration in serum, Cref, where ref may denote peak ( p), peak
average ( pa) (as for standard K, stdK), time average (ta) (as for equivalent renal
clearance, EKR), or treatment time average (as for KT normalized to dialysis cycle
time). We propose to apply these indices for the assessment of phosphate removal and
compare them between phosphate, urea and creatinine.
Methods: Eighteen patients on hemodialysis were examined during three consecutive
HD sessions of one week dialysis treatment cycle (with the interdialytic breaks of 2-2-3
days) and before the fourth session. Serum urea, creatinine and phosphate (measured
as inorganic phosphorus) concentrations were measured before, at 1, 2 and 3 h, at the
end and 45 min after each session, before the fourth dialysis session, and every 0.5 h in
dialysate. The removed mass was calculated from the measurements in outlet dialysis
fluid and dialysis fluid flow rate. The reference values of solute concentrations were
calculated from the weakly solute profiles in serum. The concentration of phosphate in
plasma was decreased by 15% to correct for phosphate binding to plasma protein and
estimate the concentration of diffusible phosphate..
Results: Mean (+/-SD) urea spKT/V was 1.31 ± 0.07; concentration reduction ratio was
0.73 ± 0.02 for urea, 0.65 ± 0.02 for creatinine, and 0.48 ± 0.17 for phosphate. The
calculated values of ECCare shown in Table 1. Note that the parameters calculated for
total plasma phosphate are about 15% lower than those for diffusible phosphate that is
unbound to protein.
SP431 Table 1. ECC values for different reference methods and effective dialyzer
clearance, Keff, for urea, phosphate and creatinine.
mL/min
ECCp
ECCpa
ECCta
ECCtrta
Keff
Urea
6.2±1.5
7.1±1.4
10.8±1.9
14.1±2.3
197±33
Diffusible phosphate
6.2±1.5
6.8±1.8
8.3±2.1
11.4±3.3
160±46
Phosphate
5.3±1.3
5.7±1.6
7.0±1.8
9.7±2.8
136±39
Creatinine
4.4±1.4
4.9±1.6
6.9±2.3
8.9±2.9
124±41
Conclusions: We conclude that the values of phosphate ECC and Keff are between the
respective parameters calculated for urea and creatinine, in agreement with the
molecular mass of phosphate, in spite of the unusually low phosphate concentration
reduction ratio.
SP432
THE IMPACT OF THE TECHNIQUE OF ARTERIO-VENOUS
FISTULA CANNULATION ON THE QUALITY OF DIALYSIS
Michelle Elias1, Helene Francois1, Erika Obada1, Hans Kristian Lorenzo1,
Bernard Charpentier1, Antoine Durrbach1 and Severine Beaudreuil1
1
Nephrology IFRNT, Hospital University, Le Kremlin Bicêtre, France
Introduction and Aims: Adequate hemodialysis is directly related to a better health
condition. The technique of the AVF puncture and the amount of blood recirculation
are important factors on which depends the quality of dialysis. The way the fistula is
cannulated and its influence has been investigated in very few studies.
Methods: Fifteen patients with end-stage renal Failure on regular intermittent
hemodialysis were studied for three consecutive treatments with both needles directed
upstream then for three treatments with the venous needle directed upstream and the
arterial needle directed downstream keeping the same distance between the needles
with the two techniques. Access recirculation rate and KT/V were measured each time.
Results: The mean recirculation rate with the first technique of cannulation was 10.1 %
compared to 9.1% with the 2nd technique (not significant: t student) and a mean Δ
recirculation for the same person of 1.2 (-0.5, +4). The difference between the KT/V
was also not significant with a mean KT/V of 1.33 with the 1st technique and 1.26 with
the 2nd one.
Conclusions: No difference was noted between the two techniques. The direction of
insertion of the needles should be decided on case by case depending on the anatomy
of the FAV and the feasibility of the puncture.
Volume 28 | Supplement 1 | May 2013
Abstracts
Nephrology Dialysis Transplantation
SP433
ON-LINE HEMODIAFILTRATION IMPROVES SURVIVAL OF
PATIENTS ON MAINTENANCE HAEMODIALYSIS: A
MULTICENTER COHORT EVALUATION
Goran Imamovic1, Daniele Marcelli2, Inga Bayh2, Rajko Hrvacevic3, Sonja Kapun4,
Aileen Grassmann2, Laura Scatizzi2 and Jelena Maslovaric3
1
Fresenius Medical Care, Zvornik, Bosnia and Herzegovina, 2Fresenius Medical
Care, Bad Homburg, Germany, 3Fresenius Medical Care, Beograd Serbia and
Montenegro, 4Fresenius Medical Care, Krško, Slovenia
Introduction and Aims: Hemodiafiltration (HDF) is the treatment modality that
employs convection and diffusion in order to facilitate removal of small and larger
molecular weight solutes. The clearance of large solutes is dictated by the ultrafiltration
volume and the sieving coefficient. HDF with a substitution fluid volume ≥ 15 L was
classified as high-efficiency HDF in the Dialysis Outcome and Practice Patterns Study
(otherwise low-efficiency). Aim of this study is to evaluate if post-dilution on-line HDF
improved patient survival compared to high-flux hemodialysis (HD).
Methods: The study was conducted in 13 dialysis centers; 4 in Bosnia and
Herzegovina, 4 in Slovenia and 5 in Serbia. Patients were included if they were
admitted to the dialysis center for maintenance renal replacement therapy (RRT) as
newly recruited patients or were ≤ 3 months on RRT. Study period was from January 1,
2007 to December 31, 2011. HDF high volume (HV) was defined as a substitution fluid
higher than the median substitution volume applied (20.4 L), otherwise low volume
(LV). Main statistical analysis was performed by using Cox regression, having all-cause
mortality as outcome. Patients were censored by the date of kidney transplantation,
treatment cessation, loss to follow-up or at December 31, 2011.
Results: 442 patients were included in the study. Baseline characteristics are reported in
the figure 1.During the follow-up, 59 patients died, 17 were transplanted and 2 were
lost to follow-up. After the adjustment for covariates only patients on HDF HV showed
significant lower Hazard Ratio in respect to patients on high-flux dialysis (HR 0.329;
95% CI 0.144-0.752; p=0.0084).
Conclusions: In conclusion, our data showed clear evidence of better patient survival
on high volume post-dilution on-line HDF compared to high-flux HD.
SP434
REMOVAL OF GADOTERIC ACID (DOTAREM®) BY
HEMODIALYSIS AND SAFETY IN DIALYSED PATIENTS
Ronald Daelemans1 and Sofie Mesens2
Nephrology, ZNA Stuivenberg, Antwerp, Belgium, 2Clinical Pharmacology Unit,
SGS Belgium NV, Antwerpen, Belgium
1
Introduction and Aims: To evaluate the dialysability of gadoteric acid in patients with
end-stage renal disease (ESRD) and requiring hemodialysis.
Methods: Phase I, monocentric, non-comparative, non-randomized, open-label
clinical trial, including 10 evaluable patients (male or female, aged ≥18 years),
presenting with ESRD who required hemodialysis for 4 hours, 3 times per week.
Gadoteric acid (Dotarem®) was injected intravenously at a dose of 0.1 mmol/kg. The
primary evaluation criterion was the decrease in serum gadoteric acid concentration
after each hemodialysis session. To calculate the dialysability, blood samples were
drawn simultaneously from the inflow and outflow lines of the circuit during the first
hemodialysis session, and from the vascular access just before and after each of the
three hemodialysis sessions. The 3 hemodialysis sessions started 1 to 2 hours, 2 days (i.
e., 48 ±2h) and 4 days (i.e., 96 ±4h), respectively, following the gadoteric acid injection.
The total gadolinium concentration was measured in the serum by inductively coupled
plasma mass spectrometry (ICP-MS). The secondary evaluation criteria were the
clinical safety (vital signs, injection-site tolerance) and laboratory assessments which
were evaluated during a 4-day follow-up after gadoteric acid injection. Adverse events
(AEs) and serious AEs were evaluated through a 3-week and 3-month post-injection
period, respectively.
Results: All 10 subjects were Caucasian, of which 5 (50.0%) were female. Median
(range) age was 64.0 (31-79) years. Median (range) weight was 70.6 (61-116) kg.
During the first hemodialysis, the mean gadolinium clearance (mL/min) was 224.6 at
0.5h and 225.9 at 1.5h and the gadolinium serum concentration decreased over time by
88% to 93% and 97% at 0.5h, 1.5h, and 4h after start of dialysis, respectively. A second
and third hemodialysis session allowed to further accelerate the removal of gadoteric
acid from the body, with a decrease of at least 99.7% of gadolinium serum
concentration (compared to the pre-dialysis value of the first session) after the third
dialysis. No AEs at least possibly related to gadoteric acid were reported. No AEs
occurred at the injection site during the observation period. There were no clinically
relevant changes in mean laboratory values and vital signs. No cases of NSF have been
reported so far.
Conclusions: The results of the study indicate that gadoteric acid was effectively
removed by 3 hemodialysis sessions in patients with ESRD. The good general safety
profile of gadoteric acid was also confirmed.
SP435
MONITORING ADVERSE EFFECTS OF ANTITUBERCULOSIS
CHEMOTHERAPY IN CHRONIC HEMODIALYSIS PATIENT:
PHARMACOVIGILANCE AND ROLE OF POISON CONTROL
CENTER
El Amrani Mohamed1, Arrache Wafae1, Hassani Kawtar1, Hamzi Mohamed
Amine1, Kabbaj Driss1 and Benyahia Mohammed1
1
Nephrology, Dialysis and Renal Transplantation Military Teaching Hospital
Mohammed V Rabat Morocco
SP433
SP433
Volume 28 | Supplement 1 | May 2013
Introduction and Aims: Tuberculosis (TB) remains a public health problem in
Morocco. It is more frequent, more severe and atypical in immunocompromised
patients, including chronic hemodialysis patients in whom treatment is, moreover, a
real challenge.
Methods: Prospective study from January 2010 to August 2012, including all chronic
hemodialysis patients with TB. We analyzed the clinical data and therapeutic and side
effects of antituberculosis treatment.
Results: Tuberculosis represents 22.9% of the cases of hospitalization for infection in
hemodialysis patients in our department: These 14 patients: 8 men and 6 women,
mean aged 48 years with mean duration in hemodialysis of 57 months, with 50%
during the first 2 years. Extrapulmonary localization represented 71.4% of cases. A
quadruple antituberculosis chemotherapy was prescribed in 57.1% of cases and a triple
association in 42.8% of cases. We recorded 4 cases of acute hepatic cytolysis and a
reversible confusional syndrome. Monitoring of isoniazide was systematically carried
out in the laboratory of poison control center (PCC) and had found an overdose in
35.7% of cases.
Conclusions: Tuberculosis occurs mostly during the first 2 years of hemodialysis. The
telltale signs are nonspecific. The location is especially extrapulmonary. The treatment
is a real challenge in this population particularly exposed to a high risk of
antituberculosis chemotherapy overdose, or, conversely, to therapeutic ineffectiveness
by the influence of hemodialysis on the pharmacokinetics of these drugs. Thus,
prescribing antibacillary in hemodialysis requires dosage precautions and close clinical
and laboratory monitoring. The recourse to the PCC is often necessary for optimal
therapeutic safety.
doi:10.1093/ndt/gft116 | i