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Activated charcoal tablets (mean dose, 3.19 g/day) reduced mean serum phosphate from 7.66 to 5.06 mg/dl in a 24-week study of 114 chronic HD patients (1). Levels increased to 7.50 mg/dl 2 weeks after stopping the charcoal.

Pulmonary hypertension, present in 110 of 288 chronic HD patients, was strongly associated with increased left atrial size (mean 2.4 vs. 2.0 cm/m2), but not with evidence of systolic or diastolic cardiac dysfunction (2). This, and the greater inferior vena cava diameter in the patients with pulmonary hypertension (8.8 vs. 7.5 mm/m2), suggested chronic volume overload as its etiology. Adjusted mortality was 2.17 fold higher in affected patients.

The adjusted likelihood of hospital admission for pulmonary embolus is 8 fold higher in dialysis patients than in those with normal kidney function according to an analysis of over 30,000,000 US hospital admissions (3).

Values for high sensitivity troponin T (hsTnT) were above the 99th percentile for the general population in 102 of 103 chronic HD patients (4). Values were generally stable with retesting after 2 weeks. Patients in the highest quartile were more likely to have coronary disease (59% vs. 22%), peripheral vascular disease (38% vs. 4%), and diabetes (18% vs. 7%) than those in the lowest quartile. Troponin I was elevated in only 13 of 103 patients.

Hemodialysis caused left ventricular systolic dysfunction in 29 of 105 patients; it most often occurred (17 patients) early in treatment (60 minutes) before any notable fall in blood volume (−0.9%) was seen (5). Cardiac function was assessed using echocardiograms before, and at 60 and 180 minutes intradialysis as well as 30 minutes after treatment. During a median follow-up of 16.4 months unadjusted mortality was far higher in those with dysfunction (31%) than in those without (8%), a finding that remained significant after correction for covariates including cardiac history, ultrafiltration volume, and ventricular mass.

The adjusted risk of cardiovascular mortality in 210 chronic HD patients was increased by 3.15 fold in those with substantial differences in left and right ankle pressures (≥15 mmHg systolic or ≥10 mmHg diastolic BP); the statistical adjustment included the ankle-brachial index (6).

Unexplained chronic hypotension in seven chronic HD patients rapidly resolved after successful renal transplantation (7). Initial postoperative pressor support was required; the eighth patient did not receive it, and died of bowel ischemia.

In a study of 282 chronic HD patients (162 with an AV fistula and 120 with a tunneled catheter or AV graft), prior use of a peripheral central vein catheter (PICC) increased the adjusted likelihood of not having an AV fistula by 2.8 fold (8). Use of a small bore tunneled internal jugular catheter is suggested as a PICC alternative.

In a randomized 8-week study of standard versus buttonhole needling of AV fistulae in 140 patients, hematoma formation was more common with standard needling (436 vs. 295 per 1000 HD sessions), but localized infection developed more often with buttonhole cannulation (50 vs. 22.4 per 1000 session) (9). Pain scores at 8 weeks did not differ in the groups.

DOPPS data on 37,414 chronic HD patients found that, after adjustment, each additional 30 minutes of treatment time was associated with a 6% lower mortality as well as lower serum phosphate and BP and higher hemoglobin and albumin (10).

A program of intradialytic oral nutritional supplements (thrice weekly use of various supplements with 14–20 g of protein) in patients with serum albumin values <3.5 g/dl reduced subsequent adjusted mortality—by 34% in the as treated analysis and 9% in the intention-to-treat analysis (11). The study was a retrospective Cox analysis of 5227 propensity score-matched pairs of patients.

Oral supplements of heme iron have been reported to be more effective than ionic iron because of a different absorptive mechanism. However, a randomized 6-month study comparing heme iron peptide and ferrous sulfate in 62 chronic PD patients showed no benefit for the peptide; serum ferritin levels were actually lower (124 vs. 292 mg/l) in the heme iron peptide group (12).

A randomized, blinded study of 92 new chronic HD patients found that 1 year of l-carnitine (1g IV after each dialysis) had no effect on erythropoietin response (13). Carnitine deficiency was seen in 30% of the placebo group.

Levels of serum dehydroepiandrosterone sulfate (DHEA-S), an anabolic adrenal androgen, were 40–53% lower in 494 HD patients (313 men) than in 122 matched healthy controls (14). Patients in the lowest quartile of DHEA-S level had a 2.5 fold higher adjusted mortality than patients in the third quartile.

A study of 10 HD patients found that 14 potentially toxic hydrocarbons and halocarbons rapidly increased in exhaled breath during HD (15). The source of these gaseous compounds was found to be the dialyzers and tubing sets used during treatment.

Cox analysis of 1842 patients in the HEMO study found that current smokers (17% of patients) had a 1.44 fold higher mortality than those who had never smoked (16).

Blood cultures collected from 293,094 chronic HD patients over a five-year period (2006–2010) found similar rates of bacteremia with methicillin-susceptible and -resistant staph aureus (2.1 and 1.9 per 100 outpatient years, respectively), but that vancomycin was most often used to treat both (56% and 75%, respectively) (17). Use of cefazolin rather vancomycin for methicillin susceptible infection was associated with a 38% lower adjusted risk of hospitalization or death.

A study of creatinine kinetics in 103 acute kidney injury patients on CVVHD found quite variable rates of creatinine generation (1.7–22.4 mg/kg/day) with a mean value far lower than that reported in stable outpatients (10.5 vs. 17.8 mg/kg/day) (18). Furthermore, patients in the lowest tertile of creatinine generation had an adjusted mortality rate 12 fold higher than patients in the highest tertile.

A randomized study of PD catheter insertion by radiologists (local anesthesia, fluoroscopic guidance, N = 57) and surgeons (general anesthesia, laparoscopy N = 56) found a much higher complication-free catheter survival at 1 year in the radiology group (42.5% vs. 18.1) (19). Dialysate leaks (17.9% vs. 7%) and peritonitis (6.5 vs. 3.6 per 100 catheter-months) were also significantly more common with the laparoscopic method.

References

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  2. References
  • 1
    Wang Z, Cui M, Tang L, Li W, Wei Y, Zhu Z, Jia X, Kong X, Xu D: Oral activated charcoal suppresses hyperphosphataemia in haemodialysis patients. Nephrol17:616620, 2012
  • 2
    Agarwal R: Prevalence, determinants and prognosis of pulmonary hypertension among hemodialysis patients. Nephrol Dial Transplant27:39083914, 2012
  • 3
    Kumar G, Sakhuja A, Taneja A, Majumdar T, Patel J, Whittle J, Nanchal R: Pulmonary embolism in patients with CKD and ESRD. Clin J Am Soc Nephrol7:15841590, 2012
  • 4
    Pianta T, Horvath A, Ellis V, Leonetti R, Moffat C, Josland E, Brown M: Cardiac high-sensitivity troponin T measurement: a layer of complexity in managing haemodialysis patients. Nephrology17:636641, 2012
  • 5
    Assa S, Hummel Y, Voors A, Kuipers J, Westerhuis R, DeJong P, Franssen C: Hemodialysis-induced regional left ventricular systolic dysfunction: prevalence, patient and dialysis treatment-related factors, and prognostic significance. Clin J Am Soc Nephrol7:16151623, 2012
  • 6
    Chen S, Chang J, Tsai Y, Tsai J, Su H, Hwang S, Chen H: Association of interleg bp difference with overall and cardiovascular mortality in hemodialysis. Clin J Am Soc Nephrol7:16461653, 2012
  • 7
    Muscroft L, Zehnder D, Fletcher S, Krishnan N, Watson D, Murthy B, Higgins R: Rapid resolution of severe sustained low blood pressure in haemodialysis patients after successful renal transplantation. Nephrol Dial Transplant27:42234227, 2012
  • 8
    Ters M, Schears G, Taler S, Williams A, Albright R, Jenson B, Mahon A, Stockland A, Misra S, Nyberg S, Rule A, Hogan M: Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients. Am J Kidney Dis60:601608, 2012
  • 9
    Macrae J, Ahmed S, Atkar R, Hemmelgarn B: A randomized trial comparing buttonhole with rope ladder needling in conventional hemodialysis patients. Clin J Am Soc Nephrol7:16321638, 2012
  • 10
    Tentori F, Zhang J, Li Y, Karaboyas A, Kerr P, Saran R, Bommer J, Port F, Akiba T, Pisoni R, Robinson B: Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the dialysis outcomes and practice patterns study (DOPPS). Nephrol Dial Transplant27:41804188, 2012
  • 11
    Lacson E, Wang W, Zebrowski B, Wingard R, Hakin R: Outcomes associated with intradialytic oral nutritional supplements in patients undergoing maintenance hemodialysis: a quality improvement report. Am J Kidney Dis60:591600, 2012
  • 12
    Barraclough K, Brown F, Hawley C, Leary D, Noble E, Campbell S, Isbel N, Mudge D, Eps C, Johnson D: A randomized controlled trial of oral heme iron polypeptide versus oral iron supplementation for the treatment of anaemia in peritoneal dialysis patients: hematocrit trial. Nephrol Dial Transplant27:41464153, 2012
  • 13
    Mercadal L, Coudert M, Vassault A, Pieroni L, Debure A, Ouziala M, Depreneuf H, Fumeron C, Servais A, Bassilios N, Becart J, Assogba U, Allouache M, Bouali B, Luong N, Dousseaux M, Montcel S, Deray G: Carnitine treatment in incident hemodialysis patients: the multicenter, randomized, double-blinded, placebo-controlled carnidial trial. Clin J Am Soc Nephrol7:18361842, 2012
  • 14
    Kakiya R, Shoji T, Hayashi T, Shimomura N, Tsujimoto Y, Tabata T, Shima H, Mori K, Fukumoto S, Tahara H, Koyama H, Emoto M, Ishimura E, Nishizawa Y, Inaba M: Decreased serum adrenal androgen dehydroepiandrosterome sulfate and mortality in hemodialysis patients. Nephrol Dial Transplant27:39153922, 2012
  • 15
    Li H, Meinardi S, Pahl M, Vaziri N, Blake D: Exposure to potentially toxic hydrocarbons and halocarbons released from the dialyzer and tubing set during hemodialysis. Am J Kidney Dis60:609616, 2012
  • 16
    Causland F, Brunelli S, Waikar S: Association of smoking with cardiovascular and infection-related morbidity and mortality in chronic hemodialysis. Clin J Am Soc Nephrol7:18271835, 2012
  • 17
    Chan K, Warren S, Thadhani R, Steele D, Hymes J, Maddux F, Hakim R: Prevalence and outcomes of antimicrobial treatment for staphylococcus aureus bacteremia in outpatients with ESRD. J Am Soc Nephrol23:15511559, 2012
  • 18
    Wilson F, Sheehan J, Mariani L, Berns J: Creatinine generation is reduced in patients requiring continuous venovenous hemodialysis and independently predicts mortality. Nephrol Dial Transplant27:40884094, 2012
  • 19
    Voss D, Hawkins S, Poole G, Marshall M: Radiology versus surgical implantation of first catheter for peritoneal dialysis: a randomized non-inferiority trial. Nephrol Dial Transplant27:41964204, 2012