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Journal Clubs

Journal Clubs. 2012-3-14 報告醫師： F1 侯羿州 指導醫師： MA 黃文宏. Clin J Am Soc Nephrol 4: S30–S40, 2009. LIFE magazine, April 28, 1947.

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Journal Clubs

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  1. Journal Clubs 2012-3-14 報告醫師：F1侯羿州 指導醫師：MA黃文宏

  2. Clin J Am Soc Nephrol 4: S30–S40, 2009.

  3. LIFE magazine, April 28, 1947

  4. In October 1989, the Dallas Dialysis Conference discussed the reasons that hemodialysis (HD) patients in the United States fared worse than those in other developed countries. • Relative mortality risk for patients with ESRD in the United States was still 15% higher than in Europe and 33% higher than in Japan.

  5. USA: 150, 862; EDTA: 124,796; Japan: 66244 • 5 year survival rate in USA: 40%. • Only the youngest patients in the US (less than 15 years) have longer survival than their counterparts in Europe and Japan. • In non-diabetics: US vs EDTA: RR1.22 US vs Japan: 1.40 Am J Kidney Dis. 1990 May;15(5):451-7

  6. Clin J Am Soc Nephrol4: S2–S4, 2009. doi: 10.2215/CJN.04730709

  7. In the past few years, many technological innovations in dialysis equipment have been developed, and new modalities and strategies have been introduced. • Mortality and morbidity of dialysis patients are determined by many medical, social factors(non-technical) and the impact of technical advances in dialysis.

  8. Quantification of dosage of dialysis • The choice of membranes (high flux versus low flux), • The choice between convection and diffusion, • The chemical composition and biologic purity of dialysate, sodium and volume profiling, and intradialytic volume monitoring aiming at improving hemodynamic stability.

  9. Dosage of dialysis • Kt/Vurea and Online Quantification of Dialysis Dosage • Duration and/or Frequency of Dialysis Is More Important than Kt/V

  10. Kt/Vurea and Online Quantification of Dialysis Dosage • single- pool Kt/Vurea (spKt/Vurea) index as a surrogate for removal of low molecular weight uremic retention solutes became widely applied after the report of the National Cooperative Dialysis Study (NCDS). >1.0 was adequate(1983) • Kt/V represents adequacy of dialysis, expressed as the product of clearance per time multiplied by the duration and adjusted for body size by dividing this clearance by the distribution volume.

  11. spKt/V overestimates equilibrated Kt/V with 0.15 to 0.20 because it fails to account for blood urea rebound after dialysis  1.2 • Kt/V represents only the behavior of urea, a rough estimate of small-solute removal  Long term outcome? • The Kt/V concept presumes that changing Kt/V by varying K or by varying t results in equal solute removals and outcomes

  12. Industry developed devices that could estimate Kt/V online, mostly based on the principle of ionic dialysance(NaCl). • Adjustmentsto correct intermethod differences may be necessary to ensure generalizability among ionic dialysance monitors in different dialysis machines.

  13. HEMOstudy • 1846 prevalent HD patients who were randomly assigned to a standard or high dosage of dialysis • Standard-dosage goal was spKt/V of 1.25, and the high-dosage goal was spKt/V of 1.65 • RR of 0.96 for high versus standard dosage; 95% confidence interval 0.84 to 1.10 • 19% lower risk for death than women in the standard-dosage group

  14. N Engl J Med 2002;347:2010-9.

  15. Women:RR0.81(p0.02) Men:nodifference. Kidney International Vol. 65(2004) pp 1386-1394

  16. DOPPS(Dialysis Outcomes and Practice Patterns Study) • Estimated by urea reduction ratio • This might suggest that current dialysis dosages are suboptimal for all but small women • Neither Kt/V nor urea reduction ratio seem to have an effect on outcome.

  17. American Journal of Kidney Diseases, Vol 43, No 6 (June), 2004: pp 1014-1023

  18. American Journal of Kidney Diseases, Vol 43, No 6 (June), 2004: pp 1014-1023

  19. Duration and /or Frequency of Dialysis Is More Important than Kt/V • The factor time plays an even more important role in the removal of middle molecules or other solutes that are difficult to remove by standard HD, such as beta-2 microglobulin and phosphorus • Mortality rate fell by 7% for each 30-min increase in session duration , independent of Kt/V (DOPPS)

  20. Kidney International (2006) 69, 1222–1228

  21. Kidney International (2006) 69, 1222–1228

  22. Kidney International (2006) 69, 1222–1228

  23. Nephrol Dial Transplant (2006) 21: 273–280

  24. Only 10% of the patients on long-hour dialysis had high phosphate levels, whereas only 30% required phosphate binder prescriptions • Extending treatment time comes for an economical price and that these modalities are affordable only when costs per treatment can be reduced.

  25. One way to allow more flexibility in HD schemes, either by prolonging HD or by increasing its frequency, is to apply this strategy at home.

  26. Membrane Flux: High Flux versus Low Flux • Multilayer membranes, consisting of a very thin, semipermeable fleece and a much thicker supporting membrane. • The concentration of Beta 2-microglobulin(B2M) decreases progressively when patients are treated on high-flux membranes

  27. J Am SocNephrol 20: 645–654,2009(MPO)

  28. J Am SocNephrol 20: 645–654,2009

  29. Membrane Permeability Outcome • High-flux dialysis showed a significant survival benefit of 37%, after adjustment, of patients with a low serum albumin. • Serum albumin>4g/dL=> no survival benefit.

  30. HEMO study • Low flux: B2Mclearance <10ml/min • High flux: B2M clearance >14ml/hr/mmHg, with mean B2M >20ml/min

  31. N Engl J Med, Vol. 347, No. 25 · December 19, 2002

  32. N Engl J Med, Vol. 347, No. 25 · December 19, 2002

  33. No significant survival difference • There were significant reductions in the risk for death from cardiac causes and the combined outcome of first hospitalizations or death from a cardiac cause in the high-flux group. • Patients who were enrolled in the study after >3.7 yrof maintenance dialysis: benefit on CVA and overall mortality.

  34. Technical Innovations in Hardware and Software of Dialysis Monitors • Online Monitoring Systems and Biofeedback • Sodium Modeling • Potassium Modeling • Temperature Control • Assessment of Fluid status and Body Composition

  35. Sodium Modeling • Sodium profiling with a high dialysate sodium concentration is an effective method to prevent intradialytic hypotension • Expense of a positive sodium balance during the dialysis session • Ultrafiltration rates can be reduced with better hemodynamic stability and without jeopardizing salt and water balances.

  36. Potassium Modeling • Patients presenting without sinus rhythm were 89% more likely to die and the risk for cardiovascular events and stroke increased by 75 and 16.4% • Sudden shifts in plasma potassium induced during and after an HD session may be among the causes of death in arrhythmia-prone patient

  37. Patients with frequent intradialytic premature ventricular complexes underwent dialysis using a dialysate with a fixed (2.5 mmol/L) potassium or one with an exponentially declining potassium (from 3.9 to 2.5 mmol/ L), the latter maintaining a constant blood-to-dialysate potassium gradient of 1.5 mmol/L throughout the procedure.

  38. Kidney International, Vol. 50 (1996), Pp. 609—617

  39. Temperature Control • A positive thermal balance, as a result of either a warm dialysate or a hyperthermic response to volume depletion, may interfere with the adjustments in venous and arterial tone and cardiac response. • Many studies have confirmed that when the dialysate temperature is adjusted to the range of 34 to 35.5°C

  40. Adjusting Thermal Balance and Intradialytic Hypotension Nephrol Dial Transplant (2006) 21: 1883–1898

  41. Adjusting Thermal Balance and dialysis Adequacy.

  42. Assessment of Fluid Status and Body Composition • The optimal postdialysis dry weight is in general clinically determined as the lowest body weight a patient can tolerate without intradialytic symptoms or hypotension. • The clinical method is very simple and cheap, objective, noninvasive, and universally available and suffices in a large majority of cases

  43. Inferior vena cava diameter, biochemical markers (e.g., atrial natriuretic peptide, brain natriuretic peptide [BNP], and its precursor NT-proBNP), BV monitoring (BVM), and bioimpedancecan be applied for assessing various aspects of volume status. • Inferior vena cava diameter and BNP: Correlates well with right atrial pressure but lacks sensitivity to assess dry weight, because it also largely depends on diastolic distensibility of the heart ProBNPis cleared by dialysis

  44. BV : the most applied monitoring relies on the evolution of the hematocrit in the dialyzer inlet blood line • Logics: If the parameter is within the desired values, the treatment continues unchanged.

  45. Hypotension during dialysis (top) and symptoms during the inter-dialysis period (bottom). The frequency of dialysis hypotension is reported as a whole (left; *) and within each sequence. The latter also reports the frequency during the run-in period, here indicated as the first A period before each sequence. The analysis neglecting the sequence showed a statistically significant reduction in the hypotension event rate (P = 0.004). The average number of symptoms occurring during inter-dialysis is reported as early (**) when it occurred in the first 6 hours after the end of dialysis, or as late (‡) when occurring between this time and the start of the following dialysis session. All the values are statistically significant at 1 level (P < 0.001) KidneyInt62: 1034– 1045, 2002

  46. Patients in whom BVM remained stable, more fluid could be removed during a dialysis session than in patients with steep decrease of BV • This study reflects only the clinical reality that some patients do and others do not tolerate ultrafiltration and that the latter tend to end up fluid overloaded. • No study has evaluated whether these systems perform better than close observation of the patient by skilled nurses.

  47. Bioimpedance analysis (BIA)

  48. BIA • Used for the assessment of fluid status for >30 yr. • The multifrequencytechnique has allowed a more refined measurement of the extracellular and intracellular water

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