Comparison of urea reduction ratio and dialysis efficacy in evaluating haemodialysis adequacy in chronic kidney disease patients in Wangaya Hospital

Background:An increasing number of patients with chronic kidney disease (CKD) impact an increased need for hemodialysis. Inadequate hemodialysis affects morbidity in patients with CKD. Determination of the urea removal index can be accomplished by several invasive and non-invasive methods. The purpose of this study was to compare the urea reduction ratio (URR) and dialysis efficiency (Kt/V)calculated automatically by hemodialysis machines to assess the adequacy of hemodialysis in patients with CKD.Methods:A cross-sectional analysis study was conducted on 58 CKD patients with age ?18 years, conventional 5-hour hemodialysis sessions twice weekly, using single use-hollow fiber dialyzers, and who had been receiving hemodialysis for ?6 months in the hemodialysis unit atWangaya Hospital from April 2022 to May 2022. Study data were obtained from medical records then described and analyzed using the statistical package for the social sciences (SPSS)program.Results:The mean of URR was 70.74�.04, while the mean of Kt/Vdelivered by machine was 1.27�19. More hemodialysis patients received adequate hemodialysis based on URR parameters compared to Kt/V parameters (84.5% versus 1.7%). There was no significant difference between age, sex, body mass index (BMI), comorbidities, vascular access and duration of dialysis with adequacy hemodialysis. There was a significant difference between URR and Kt/V in the evaluation adequacy of hemodialysis (p=0.000). In addition, there was a positive correlation between URR and Kt/V in theevaluation adequacy of hemodialysis (r=0.592, p=0.000).Conclusions:The URR is a more accurate parameter, but the Kt/V delivered by machine can help the URR demonstrate the adequacy of haemodialysis patients with CKD.

Relationship between dialysis quality and brain compliance in patients with end-stage renal disease (ESRD): a cross-sectional study

ABSTRACT BACKGROUND: The high number of patients with end-stage kidney disease (ESRD) on hemodialysis makes it necessary to conduct studies aimed at improving their quality of life. OBJECTIVES: To evaluate brain compliance, using the Brain4care method for intracranial pressure (ICP) monitoring, among patients with ESRD before and at the end of the hemodialysis session, and to correlate ICP with the dialysis quality index (Kt/V). DESIGN AND SETTING: Cross-sectional study conducted at a renal replacement therapy center in Brazil. METHODS: Sixty volunteers who were undergoing hemodialysis three times a week were included in this study. Brain compliance was assessed before and after hemodialysis using the noninvasive Brain4care method and intracranial pressure wave morphology was analyzed. RESULTS: Among these 60 ESRD volunteers, 17 (28%) presented altered brain compliance before hemodialysis. After hemodialysis, 12 (20%) exhibited normalization of brain compliance. Moreover, 10 (83%) of the 12 patients whose post-dialysis brain compliance became normalized were seen to present good-quality dialysis, as confirmed by Kt/V > 1.2. CONCLUSIONS: It can be suggested that changes to cerebral compliance in individuals with ESRD occur frequently and that a good-quality hemodialysis session (Kt/V > 1.2) may be effective for normalizing the patient's cerebral compliance.

Calidad de hemodiálisis en pacientes con enfermedad renal crónica en el Hospital Nacional de Itauguá

RESUMEN Introducción: la enfermedad renal crónica es un problema de salud pública, de gran impacto y costo para el Estado y el enfermo, por ello la importancia de conocer la calidad en hemodiálisis, tratamiento en su estadio final. Objetivos: determinar la calidad de hemodiálisis en pacientes con enfermedad renal crónica en el Hospital Nacional de Itauguá, Paraguay. Métodos: se realizó un estudio observacional, descriptivo, de corte transversal, donde se incluyó 101 pacientes con enfermedad renal crónica hemodializados con esquema trisemanal en el Departamento de Nefrología del Hospital Nacional, Itauguá, Paraguay. Se midieron variables demográficas, clínicas, laboratoriales y calidad de diálisis. El estudio fue aprobado por el comité de ética de la Universidad Nacional de Itapúa, Paraguay. Resultados: la edad media 47,46 años, el 55,45% fue de sexo masculino, el 41,58% se encontraba en normopeso, la comorbilidad más frecuente fue la hipertensión arterial (65%), las etiologías más frecuentes fueron la hipertensiva (30,69%) y la diabética (22,77%). La infección viral más frecuente fue la hepatitis B. Los accesos vasculares fueron la fístula arteriovenosa (56,44%), el catéter tunelizado (24,75%) y el catéter simple (15,84%). La media de los resultados laboratoriales fue: hemoglobina 8,9 g/L, ferritina 500 ng/dL, calcio 8,9 mg/dL, fósforo 5,5 mg/dL y albúmina 3,98 g/dL. El valor promedio del porcentaje de reducción de urea fue 64% y del índice Kt/v fue 1,15. Conclusión: la calidad de hemodiálisis en este centro es baja, objetivado por el porcentaje de reducción de urea promedio y el índice kt/v inferior a lo recomendado por las guías.

ABSTRACT Introduction: Chronic kidney disease is a public health problem, with a great impact and cost for the State and the patient, hence the importance of knowing the quality of hemodialysis, treatment in its final stage. Objectives: To determine the quality of hemodialysis in patients with chronic kidney disease at the Hospital Nacional of Itauguá, Paraguay. Methods: An observational, descriptive, cross-sectional study was carried out, including 101 patients with chronic kidney disease hemodialyzed with a three-week schedule in the Department of Nephrology of the Hospital Nacional of Itauguá, Paraguay. Demographic, clinical, laboratory and dialysis quality variables were measured. The study was approved by the ethics committee of the National University of Itapúa, Paraguay. Results: The mean age was 47.46 years, 55.45% were male, 41.58% had normal weight, the most frequent comorbidity was arterial hypertension (65%), the most frequent etiologies were hypertensive (30.69%) and diabetic (22.77%). The most frequent viral infection was hepatitis B. The vascular accesses were the arteriovenous fistula (56.44%), the tunneled catheter (24.75%) and the simple catheter (15.84%). The mean values of the laboratory results were: hemoglobin 8.9 g/L, ferritin 500 ng/dL, calcium 8.9 mg/dL, phosphorus 5.5 mg/dL and albumin 3.98 g/dL. The mean value of the urea reduction percentage was 64% and the Kt/v index was 1.15. Conclusion: The quality of hemodialysis in this center is low, objectified by the percentage of the mean urea reduction and the kt/v index lower than the value recommended by the guidelines.

Factors Related to Exercise Habits of Maintenance Hemodialysis Patients / The Japanese Journal of Rehabilitation Medicine

Hemodialysis patients need to acquire exercise habits because physical inactivity in hemodialysis patients is associated with increased mortality. However, factors associated with exercise habits in hemodialysis patients are unknown. The purpose of this study was to investigate the factors related to exercise habits in hemodialysis patients. We measured 104 hemodialysis patients' exercise habits (transtheoretical model：TTM), laboratory data, self-efficacy (SE), short physical performance battery and grip strength, nutritional index, dialysis vintage, fluid removal, and Kt/V. Multiple linear regression analysis was carried out to assess the association of the aforementioned factors with TTM. As a result, in multiple linear regression analysis, SE, age, and Kt/V were associated with TTM (R2＝0.34, p＜0.05). hemodialysis patients may require mental support, such as SE and adequate dialysis dose, to acquire exercise habits.

Study of correlation between adequacy of dialysis and glycemic control in patients of type 2 diabetes mellitus with chronic kidney disease stage 5

Background: The adequacy of haemodialysis in patients of type 2 diabetes mellitus with chronic kidney disease stage 5 depends on several clinical as well as laboratory parameters. Previous studies from Western literature have identified several clinical and laboratory markers for predicting adequacy of dialysis. There is a dearth of literature regarding the same in Indian patient populace. Authors aimed to find correlation, if any, between glycemic control and adequacy of dialysis in this cohort of patients.Methods: A set of 200 patients of type 2 diabetes mellitus who have undergone hemodialysis at a tertiary care hospital were included in the study. Random blood sugar (RBS), Glycated hemoglobin (HbA1c) were measured at admission. After 4 hours of dialysis, the urea reduction ratio (URR) and Kt/V was measured for each patient. The correlation coefficient as well as linear equation of the association between these variables were calculated. Standard statistical method and software were used in the process.Results: The study revealed a linear negative correlation between the variables RBS, HbA1c and URR as well as Kt/V. This suggests the importance of pre dialysis glycemic control in patients undergoing hemodialysis.Conclusions: Authors formulate the hypothesis that glycated hemoglobin and random blood sugar at admission correlate well with the outcome and adequacy of dialysis in patients of stage 5 chronic kidney disease undergoing haemodialysis.  Good glycemic control (HbA1c <6.5 % and RBS <120 mg/dL) have shown to be important predictive markers of adequate dialysis. The hypothesis needs to be tested with a larger study.

ABC de la diálisis peritoneal en pediatría / ABC of the peritoneal dialysis in pediatrics

Resumen: La enfermedad renal crónica terminal (ERCT) tiene una incidencia de 5,5 a 9 ppm, y una prevalencia de 23 a 65 ppm en menores de 15 años. La diálisis peritoneal (DP) crónica representa en pediatría la terapia de reemplazo renal más usada, previo al trasplante renal. Existen 2 tipos de DP crónicas, manual (DPCA) y automatizada (DPA), cuya elección se basa en las características del peritoneo eva luado mediante el test de equilibrio peritoneal (PET), que divide a los pacientes en transportadores altos (intercambio rápido), promedio alto, promedio bajo, y bajos (intercambio lento). Este test eva lúa básicamente el transporte de solutos, al cual se ha sumado el MiniPET, que evalúa el transporte peritoneal de agua libre. Se debe igualmente determinar la cuantía de diálisis (Kt/V), que representa la dosis de diálisis aplicada, con un valor mínimo sugerido de 1,7, relacionado a la morbimortalidad. Estos parámetros deben ser evaluados periódicamente para ajustar la DP, y cada vez que se sospeche una depuración o ultrafiltración inadecuadas. El objetivo de esta revisión es entregar conceptos bási cos sobre fisiología del transporte peritoneal, modalidades de DP, evaluación del transporte de agua y solutos peritoneal, y el cálculo de la dosis de diálisis para una diálisis ajustada a las necesidades de cada paciente, como también revisar los mecanismos de corrección y ajuste del procedimiento cada vez que se requiera.

Abstract: End-stage renal disease (ESRD) has an incidence of 5.5 to 9 pmp, and a prevalence of 23 to 65 pmp in children under 15 years of age. Chronic peritoneal dialysis (PD) represents the most widely used renal replacement therapy in children before kidney transplantation. There are two PD modalities, the manual one (CAPD) and the automated one (APD). The choice is based on the peritoneum characteristics, evaluated through the peritoneal equilibrium test (PET), which divides patients into high transporters (rapid exchange membrane), high average, low average, and low transporters (slow exchange membrane). This test basically evaluates the solutes transport rate, and the MiniPET has been added which evaluates peritoneal free water transport. The amount of dialysis (Kt/V), which represents the dose of dialysis administered also must be evaluated to assure a minimal value of 1.7 related to morbidity and mortality. These parameters should be evaluated periodically to ad just the PD and whenever suspected an inadequate clearance or ultrafiltration. The objective of this review is to provide basic concepts on peritoneal transport physiology, PD modalities, free water transport and peritoneal solute transport evaluation, and the dialysis dose to be applied according to the patient's needs, as well as reviewing the correction mechanisms and procedure adjustment whenever required.

Factors Related to Exercise Habits of Maintenance Hemodialysis Patients / The Japanese Journal of Rehabilitation Medicine

Hemodialysis patients need to acquire exercise habits because physical inactivity in hemodialysis patients is associated with increased mortality. However, factors associated with exercise habits in hemodialysis patients are unknown. The purpose of this study was to investigate the factors related to exercise habits in hemodialysis patients. We measured 104 hemodialysis patients' exercise habits (transtheoretical model：TTM), laboratory data, self-efficacy (SE), short physical performance battery and grip strength, nutritional index, dialysis vintage, fluid removal, and Kt/V. Multiple linear regression analysis was carried out to assess the association of the aforementioned factors with TTM. As a result, in multiple linear regression analysis, SE, age, and Kt/V were associated with TTM (R2＝0.34, p＜0.05). hemodialysis patients may require mental support, such as SE and adequate dialysis dose, to acquire exercise habits.

Efecto de ajuste del flujo dializante (Qd) sobre la eficacia en hemodiálisis a pacientes de bajo peso / Effect of flow adjustment dialysate (Qd) hemodialysis on effectiveness of underweight patients / Efeito do ajuste do fluxo dialisante (Qd) sobre a eficácia em hemodiálise realizada em pacientes com baixo peso

Las guías KDOQI del año 2006 utilizan como estándar de adecuación para la diálisis el parámetro Kt/V, donde V es el volumen de distribución de urea. Los pacientes con bajo peso tienen menor cantidad total de agua corporal total (menor V), de modo que es posible reducir la cantidad de Qd sin alterar la eficacia de la diálisis. Objetivo: evaluar el efecto de la reducción del Qd sobre la adecuación de la diálisis en pacientes con pesos menores o iguales a 60 kg sometidos a hemodiálisis. Metodología: estudio observacional con alcance comparativo realizado en la unidad de diálisis de una clínica especializada de Bogotá. Se evaluaron dos valores de Qd (400 ml/min y 500 ml/min) dentro del proceso de diálisis de individuos con peso menor o igual a 60 kg. Se hizo un seguimiento de tres meses para cada forma de diálisis y al final de cada mes se midieron los niveles de Kt/V, hemoglobina y fósforo. Resultados: fueron incluidos 61 pacientes, 60,7% de sexo femenino. La edad media fue de 55,9 años (DE 14,8) para las mujeres y 60,1 años (DE 13,9) para los hombres. No se observaron diferencias estadísticamente significativas entre los niveles medios de las variables evaluadas, en los momentos de seguimiento ni al final del estudio. Conclusiones: es posible tener una adecuada terapia de diálisis utilizando un valor menor al establecido por los estándares tradicionales cuando se tienen pacientes con bajo peso, siempre y cuando se mantengan los demás parámetros de suplencia renal.

KDOQI guidelines in 2006 using standard dialysis adequacy Kt/V, where V is volume of distribution of urea, underweight patients have lower total body water, lower V, which could reduce the requirement without affecting Qd the efficiency of dialysis. Objective: to evaluate the effect on the adequacy of dialysis Qd reduction occurs in patients weighing less than or equal to 60 kg who are on hemodialysis. Methodology: patients with chronic kidney disease on hemodialysis regularly with weight less than or equal to 60 kg of a renal clinic to evaluate two periods I and II, were continued therapy parameters with decrease of Qd for the second period. The variables were collected directly by the researchers of the history. The values thus obtained would be compared using t test or paired variables, and statistical significance of the test below 0,05. Results: we included 61 patients, 60.7% female, mean age 57,3 years (SD 14,8). Average age of men 60.1 (SD 13,9) and women was 55,9 (SD 15,4). There were no statistically significant differences for the variables Kt/V, Hemoglobin and there was a significant reduction in the phosphorus levels. Conclusions: this study demonstrates that adequate therapy is achieved with less than Qd traditional standards, with 400 ml/min in patients with low weight as long as you keep the other parameters of renal substitution.

As guias KDOQI do ano 2006 utilizam como padrão de adequação da diálise o Kt/V, onde V é o volume de distribuição da ureia. Pacientes com baixo peso têm menor quantidade total de água no corpo total, (menor V), de modo que seria possível reduzir a quantidade de Qd sem afetar a eficiência da diálise. Objetivo: avaliar o efeito que tem a redução do Qd sobre a adequação da diálise em pacientes com hemodiálise que têm peso menor ou igual a 60 kg. Metodologia: estudo descritivo realizado na unidade de diálise de uma clínica especializada de Bogotá. Foram avaliados dois valores de Qd (400 ml/min e 500 ml/min) dentro do processo de diálise realizado em indivíduos com peso menor ou igual a 60 Kg. Realizou-se um seguimento de três meses para cada uma das formas de diálise aplicada e ao final de cada mês realizaram-se medições dos níveis de Kt/V, hemoglobina e fósforo. Resultados: o estudo observacional incluiu 61 pacientes, 60,7% do gênero feminino. A idade média foi de 55,9 anos (DE 14,8) para as mulheres e 60,1 anos (DE 13,9) para os homens. Não foram observadas diferenças estatisticamente significantes entre os níveis médios das variáveis nas medições de seguimento nem ao final do estudo. Conclusões: conclui-se que é possível obter uma terapia adequada de diálise com um valor de Qd inferior ao estabelecido sob os padrões tradicionais em pacientes como baixo peso, sempre e quando sejam mantidos os demais parâmetros de suplência renal.

Antibody response following Hepatitis B vaccination in peritoneal dialysis patients: does normalized urea clearance matter?

OBJECTIVES: Data on the factors that contribute to the antibody response to hepatitis B virus vaccination in peritoneal dialysis patients are scarce. The current study was conducted on a group of peritoneal dialysis patients to learn how the response to hepatitis B virus vaccination varies according to the patient's clearance of urea normalized to total body water (Kt/V). METHODS: A convenience sample of 33 peritoneal dialysis patients (13 women and 20 men, with a mean age of 49¡12 years) was administered double doses (20 μg IM in each deltoid muscle) of recombinant hepatitis B vaccine at 0, 1, 2, and 6 months. Response to immunization was measured at one to three months after the final dose of vaccine. The subjects were divided into groups according to the level of antibodies to hepatitis B surface antigen (anti-HBs), including non-responders ( < 10 IU/L), weak responders (10-100 IU/L), and good responders ( > 100 IU/L). RESULTS: Among non-responders, weak responders, and good responders, significant differences were found in age (54 ± 12 vs. 56 ± 9 vs. 45¡12 years, respectively; p = 0.049) and recombinant human erythropoietin use (20 vs. 29 vs. 76 percent, respectively; p = 0.016). No significant differences in weekly total Kt/V (p = 0.704), weekly peritoneal Kt/V (p = 0.064) and residual glomerular filtration rate (p = 0.355) were found across the three groups. CONCLUSIONS: Delivered clearance measured by weekly peritoneal Kt/V and total clearance measured by weekly total Kt/V did not predict the response to hepatitis B virus vaccination in patients on peritoneal dialysis.

Clinical Characteristics of Uremic Pruritus in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Pruritus is a common, unpleasant symptom in patients on maintenance hemodialysis (HD), however its pathogenesis remains unclear. The aim of this study was to evaluate the prevalence of pruritus in chronic renal failure patients on hemodialysis and to correlate its presence with several clinical and laboratory parameters. METHODS: One hundred seventy patients on maintenance HD were enrolled, Some relevant clinical and laboratory parameters (age, sex, duration of dialysis, type of membrane, underlying renal disease, medications, erythropoietin (EPO) and laboratory findings including hematocrit, creatinine, urea, calcium, phosphorus, parathyroid hormone (PTH), erythrocyte sediment rate (ESR), albumin, beta2-microglobulin (beta2MG) and lipid profile as well as parameters of adequate dialysis (Kt/Vurea, URR) were evaluated. RESULTS: Total 170 patients (80 males) were enrolled and pruritus was found in 60 patients (Group I, M:F=29:31). One hundred ten patients did not complain pruritus (Group II, M:F=51:59). Mean age was significantly higher in Group I (59.6+/-14.8 vs. 54.3+/-13.6 years, p<0.05). There was no difference in sex, type of membrane, primary renal disease, serum beta2MG, ESR, EPO dose, duration of dialysis and serum albumin level. The mean value of Kt/V was higher in Group II (1.39+/- 0.36 vs. 1.51+/-0.27, p<0.035). CONCLUSION: Pruritus was more common in older patients and low Kt/V, but other clinical characteristics and laboratory findings were not correlated with uremic pruritus.

Clinical Characteristics of Uremic Pruritus in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Pruritus is a common, unpleasant symptom in patients on maintenance hemodialysis (HD), however its pathogenesis remains unclear. The aim of this study was to evaluate the prevalence of pruritus in chronic renal failure patients on hemodialysis and to correlate its presence with several clinical and laboratory parameters. METHODS: One hundred seventy patients on maintenance HD were enrolled, Some relevant clinical and laboratory parameters (age, sex, duration of dialysis, type of membrane, underlying renal disease, medications, erythropoietin (EPO) and laboratory findings including hematocrit, creatinine, urea, calcium, phosphorus, parathyroid hormone (PTH), erythrocyte sediment rate (ESR), albumin, beta2-microglobulin (beta2MG) and lipid profile as well as parameters of adequate dialysis (Kt/Vurea, URR) were evaluated. RESULTS: Total 170 patients (80 males) were enrolled and pruritus was found in 60 patients (Group I, M:F=29:31). One hundred ten patients did not complain pruritus (Group II, M:F=51:59). Mean age was significantly higher in Group I (59.6+/-14.8 vs. 54.3+/-13.6 years, p<0.05). There was no difference in sex, type of membrane, primary renal disease, serum beta2MG, ESR, EPO dose, duration of dialysis and serum albumin level. The mean value of Kt/V was higher in Group II (1.39+/- 0.36 vs. 1.51+/-0.27, p<0.035). CONCLUSION: Pruritus was more common in older patients and low Kt/V, but other clinical characteristics and laboratory findings were not correlated with uremic pruritus.

Comportamiento de parámetros dialíticos y nutricionales en peritoneo diálisis pediátrica / Behaviour of dialysis and nutritional parameters in paediatric peritoneal dialysis (PD)

El manejo de pacientes pediátricos en diálisis peritoneal requiere la vigilancia continua de la dosis de diálisis y el apoyo nutricional, para lograr el mejor crecimiento y desarrollo posibles en el niño urémico. Para esto se requiere medir una serie de variables dialíticas y nutricionales que permitirán un ajuste continuo de nuestra terapia. Objetivos: 1) conocer el valor de diferentes parámetros dialíticos y nutricionales en niños en diálisis peritoneal crónica, 2) calcular la dosis de diálisis (Kt/V), la velocidad de catabolismo proteico (VCP), el Equivalente de la Aparición de Nitrógeno Ureico (PNA), el Balance nitrogenado, el test de Equilibrio Peritoneal (PET) y 3) calcular la correlación entre ellas. Pacientes y Método: Se evaluó en forma prospectiva 15 niños en diálisis peritoneal crónica, realizando 59 mediciones en 6 meses de seguimiento. Se controló mensualmente las variables clínicas: peso, talla, superficie corporal, volumen urinario y volumen de dializado de 24 hrs; se midió en plasma, orina y dializado en forma simultánea: creatinina, proteína, albúmina y nitrógeno ureico; y estudio ácido base y electrolitos en plasma. Se mantuvo un aporte proteico calórico según recomendaciones RDA (Recommended Dietary Allowances), y se calculó el Kt/Vurea peritoneal y residual mensual, el PET cada 6 meses, y la VCP, Balance Nitrogenado y PNA mensuales. Resultados: El Kt/V urea promedio residual y total fue de 1,49 ± 1 y 3,41 ± 0,86 respectivamente. Se demostró una correlación positiva entre el Kt/V y la depuración de creatinina residual (p < 0,05). El PET al inicio y fin del estudio para D/ Pcreatinina hora 4 fue 0,78 ± 0,01 y 0,74 ± 0,13 respectivamente (p = n.s.), y para el D4/D0 glucosa los valores fueron 0,35 ± 0,11 y 0,34 ± 0,08 (p = n.s.). La ingesta diaria proteica fue de 3,32 ± 1,05 y el catabolismo proteico 1,32 ± 0,47 gr/kg/día, con un Balance Nitrogenado de + 2,0 gr/kg/día, y un PNAn de 0,94 ± 0,33. El Kt/ V residual y total se correlacionaron significativamente con el PNAn, y se encontró una correlación significativa pero negativa entre ingesta proteica y bicarbonato plasmático (p < 0,05). Conclusión: Las variables estudiadas muestran un balance proteico positivo y un Kt/V superior a las recomendaciones para adultos, sugiriendo que mayor dosis de diálisis se asocia a mejores indicadores nutricionales. La correlación negativa entre bicarbonato en plasma e ingesta proteica sugiere una relación entre el aporte proteico y acidosis, lo cual requiere una cuidadosa supervisión.

The management of children on PD requires constant monitoring of the dose of dialysis and nutritional support in order to maximise growth and development in the uraemic child. The measurement of a series of dialytic and nutritional variables allow the adjustment of treatment to the childs needs. Objectives: 1) to measure the different variables in child undergoing PD, 2) calculate the dialysis dose (Kt/V), the protein catabolic rate (PCR), the urea equivalent of nitrogen appearence (PNA), the nitrogen balance, the peritoneal equilibrium test (PET) and, 3) to determine the correlation between them. Patients and Methods: A prospective study of 15 children undergoing chronic PD, with 59 serial measurements in a 6 month period. Monthly measurements of weight/height, body surface area, urine volume, dialysis volume in 24 hrs, and the values of creatine, protein, albumin and urea in plasma, urine and dialysate, and in plasma the acid-base and electrolytes. A diet containing proteins according to RDA was given. Kt/V urea peritoneal and residual, PCR, PNA and nitrogen balance were measured monthly, PET every 6 months. Results: The mean Kt/V residual and total was 1.49 ± 1 and 3.41 ± 0.86 respectively. A positive correlation between Kt/v and residual creatine clearence was found (p < 0.05). There were no significant differences between the PET for creatinin (4th hour) or glucose D4/D0 at the beginning and end of the study, 0.78 ± 0.01 and 0.74 ± 0.13 for creatinine and 0.35 ± 0.11 and 0.34 ± 0.08 respectively. Dietary protein intake was 3.32 ± 1.05, protein catabolism 1.32 ± 0.47 gm/kg/day, with a nitrogen balance of 2 gm/kg/day and a PNAn of 0.94 ± 0.33. Total and residual Kt/V was correlated with the PNAn, and a negative correlation between protein intake and plama bicarbonate was found. Conclusions: The variables studied show a positive protein balance and a Kt/V greater than the recommended for adults, suggesting that bigger dialysis doses results in a better nutritional status. The negative correlation between plasma bicarbonate and protein intake suggests a relation between protein intake and acidosis, of which needs to be carefully monitored.

Usefulness of Assessing Hemodialysis Adequacy Using the Stop Dialysate Flow (SDF) Method / 대한신장학회잡지

BACKGROUND: K/DOQI guidelines recommend the slow flow method as a standardized method of postdialysis blood sampling for measuring hemodialysis adequacy. However, it is not easy to adopt this method when working in busy renal units where it is often difficult to obtain repeated samples exactly at the specified time. The stop dialysis flow (SDF) method recommended by the Scottish Renal Association since 1998 has the advantage of involving 2 steps only: (1) switch off dialysate flow at the end of hemodialysis without altering the blood pump speed and (2) take a blood sample after 5 minutes from the arterial or venous port. However, there are some limitations to SDF mthod in that it does not allow for tissue rebound after the first 5 minutes postdialysis and cannot be used directly to calculate equilibrated Kt/V (Kt/Veq) using either a 30-minute postdialysis sample. We derived a formula that uses a 5-minute postdialysis BUN sample using the SDF method to estimate the BUN concentration at 30 minutes and investigated if it is useful to assess hemodialysis adequacy using this method. METHODS: A total of 51 patients who had been undergoing hemodialysis in Chonnam National University Hospital and had agreed in joining this study were involved. Patients were randomly selected to 2 groups. Blood samples were obtained immediately before dialysis and at 0, 5, and 30 minutes postdialysis. We calculated the linear relationship between the 5-minute and 30-minute postdialysis samples in group A patients (n=25) and validated this equation using the data from the other group B patients (n= 26). We predicted what the 30-minute BUN concentration would be using the measured value of BUN at 5 minutes and compared directly the value of our estimated 30-minute BUN with the measured 30- minute BUN. RESULTS: There was a tight linear correlation (R2=0.993, p<0.05), between measured 5-minute postdialysis BUN concentrations and measured 30-minute postdialysis BUN concentrations in group A patients. This relationship is described by the linear regression equation: 30-minute BUN concentration=1.05x(5-minute BUN concentraion)+1.04. We used this equation to estimate the 30-minute BUN concentration in group B patients based on the 5-minute postdialysis BUN sample from these patients. And there was a close correlation between estimated and measured 30-minute postdialysis BUN concentration (R2= 0.989, p<0.05). The sensitivity, specificity, positive, and negative predictive values of this equation were high when used to estimate 30-minute urea reduction ratio (URR) greater than 65% (88.9%, 100%, 100 %, and 94.4%, respectively) and 30-minute Kt/Vsp greater than 1.2 (100%, 100%, 100%, 100%, respectively). CONCLUSION: We could estimate 30-minute postdialysis BUN concentration, 30-minute Kt/V, and 30-minute URR exactly using SDF method and linear regression equation derived in this study. The advantage of involving 2 steps only makes SDF method a useful tool in assessing hemodialysis adequacy.

The Changes of Body Compositions and Associated Factors in CAPD Patients During First One Year / 대한신장학회잡지

PURPOSE: CAPD is an important treatment modality along with hemodialysis and kidney transplantation in end stage renal disease. Malnutrition is very common and associated with increased morbidity and mortality in CAPD patients. The cause of malnutrion in CAPD patients might be multifactorial. This prospective study was carried out to investigate nutritional changes for 1 year after initiation of peritoneal dialysis by measurement body composition, especially lean body mass (LBM) using bioelectrical impedance analysis (BIA) and dual energy X-ray absorptiometry (DEXA) and to evaluate the factors associated with malnutrition in CAPD patients. METHODS: Among new CAPD patients from May, 2001 to Dec, 2002 in our hospital, 25 patients were enrolled. Body weight, LBM, LBM percen t (%LBM), fat mass, fat mass percent (%fat mass), ECF volume and ECF/TBW were compared between 1st month and 12th month after initiation of PD. The biochemical parameters, Urea kinetic modeling, Peritoneal equilibration test, the amounts of glucose absorption through the dialysate, the amounts of protein and albumin loss through the dialysate were measured at the same time point with measurement of the body composition. RESULTS: There were significantly decreased LBM (46.3+/-9.1 kg to 44.7+/-9.0 kg in BIA, 45.7+/-9.3 kg to 42.1+/-7.9 kg in DEXA, p< 0.05, respectively) but significantly increased fat mass (16.3+/-6.2 kg to 20.2+/-7.9 kg in BIA, 15.7+/-6.6 kg to 20.1+/-7.4 kg in DEXA, p<0.01, respectively) during first one year. Mean weekly Kt/V were significantly correlated with the changes of LBM (r=-0.64 in BIA, r=-0.81 in DEXA, p<0.01, respectively). With the multiple regression test, 1st month weekly Kt/V in BIA and DEXA were significant predictors of the changes of LBM for 1 year (beta-coefficients: -0.573 in BIA, -0.773 in DEXA, p<0.01, respectively). CONCLUSION: Adequate dialysis, especially 1st month adequacy, is very important for maintaining good nutritional status for one year after initiation of peritoneal dialysis.

The Method to Predict Postdialysis Equilibrated Kt/V with Only Intradialytic Urea Samples / 대한신장학회잡지

PURPOSE: Postdialysis urea rebound(PDUR) causes the overestimation of actual amount of delivered dialysis in Kt/V from single pool urea kinetic. To correct PDUR and predict equilibrated Kt/V(eKt/V) some methods have suggested by Daugirdas, et al., Smye, et al. and Tattersall, et al. The purposes of this study were to determine the optimum intradialytic urea sample time that fits best with PDUR and to compare calculated Kt/V by this sample with the different other methods. METHODS: The subjects were 21 patients who were dialyzed at three times 4 hours weekly, using bicarbonate and cellulosynthetic membranes. Blood samples to measure BUN were obtained at initiation of dialysis session and then at 80, 120, 180, 200, 210, 220 minutes, and the end of dialysis session times and then at 45 minutes of postdialysis. We compared four different methods of eKt/V with the equilibrated 45-minute PDUR Kt/V(eKt/V PDUR) as the reference method. RESULTS: The mean PDUR was 17.2+/-%. spKt/V and eKt/V PDUR was 1.300+/-.24 and 1.120+/-.20 respectively, leading to overestimation of actual delivered Kt/V by 13.5+/-%. The best time for intradialytic sampling to fit with PDUR BUN was 40 minute before the end of session. eKt/V by Daugirdas formulae(eKt/V Dau=1.315+/-.21, r=0.972, p<0.001), Tattersal formulae(eKt/V Tat=1.134+/-.22, r= 0.972, p<0.972, p<0.001) and Smye formulae(eKt/V Smye=1.156+/-.24, r=0.900, p<0.001) showed good correlation with eKt/V PDUR. eKt/V calculated by the sample of 40 minute before end of session(eKt/V T-40=1.120+/-.20, r=0.984) had tendency of the best correlation with eKt/V PDUR. Among these different methods, eKt/V T-40 had the best degree of agreement with eKt/V PDUR by Bland-Altman analysis. CONCLUSION: Our results suggest that the use of spKt/V is not adequate to estimate the amount of delivered hemodialysis dose because of the existence of significant postdialysis urea rebound even conventional 4 hour dialysis. Intradialytic sampling method is a simple and accurate method to predict eKt/V for use in clinical practice.

Is it True that the Shorter Distance between Needles, the More Recirculation in Hemodialysis? / 대한신장학회잡지

BACKGROUND: To assess the adequacy of dialysis, serial urea kinetic modeling (single-pool Kt/V) is used. The main problems that lead to impaired delivery of dialysis prescriptions are inadequate blood flow, reduced treatment time and recirculation. If it is true that the shorter distance between two needles induces the more recirculation, short needle distance would reduce Kt/V. But, usually there is no access recirculation, because upstream access supply exceeds the demand of the blood pump. So we have a question about the relationship between recirculation and needle distance. METHODS: Thirty five chronic dialysis patients were enrolled. We measured access recirculation (a two-needle, slow/stop flow method) and Kt/V with needle distance of 2 cm, 5 cm, and 11 cm in each patient. Three dialysis session were done with each needle distance. Treatment time, dialyzer and blood flow rate were fixed during the study period. RESULTS: Access recirculation with needle distance of 2 cm was 5.37+/-7.53%, with needle distance of 5 cm, 4.26+/-5.69%, and with needle distance of 11 cm, 4.30+/-5.69%. There was no difference of recirculation between three distance. Kt/V with needle distance of 2 cm was 1.27+/-0.19, with needle distance of 5 cm was 1.26+/-0.19, and with needle distance of 11 cm was 1.23+/-0.18. There was no difference of Kt/V between three distance. CONCLUSION: There is no relationship between access recirculation and needle distance. We suggest that short distance between two needles does not increase recirculation and may not a cause of impaired delivery of dialysis prescription.

Factors Influencing Malnutrition in Maintenance Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Malnutrition in maintenance hemodialysis(HD) patients has been referred to underdialysis with low protein intake and to metabolic acidosis. However, the respective effects of underdialysis, protein intake and metabolic acidosis have not been clearly demonstrated. To evaluate the role of the dialysis dose, protein intake and metabolic acidosis on nutrition, we measured the predialysis serum HCO3, pH, serum albumin, PCRn, Kt/V, and BMI in 41 uremic patients on maintenance bicarbonate HD for 66.93+/-51.86 months. Patients with chronic liver diseases, malignancies, diabetes and cachexia were excluded. RESULTS: Mean age was 46+/-13 years; Kt/V, 1.22+/-0.27; PCRn, 0.90+/-0.16g/kg/day; serum albumin, 4.2+/-0.21g/dL; BMI, 20.47+/-2.09kg/m2; HCO3, 18.4+/-2.9mEq/L; Serum albumin showed a significant direct correlation with PCRn(p=0.001), and a significant inverse correlation with serum HCO3(r=0.43, por=20mEq/L. PCRn in the former was 0.94+/-0.6g/kg/day and in the latter 0.80+/-0.14g/kg/day(p<0.05). The role of PCRn appeared to be more important than metabolic acidodsis in determining the serum albumin levels. CONCLUSIONS: In patients hemodialyzed with relatively adequate Kt/V and whose serum bicarbonate levels maintained within mild acidosis range, PCRn may exert a detrimental effect on serum albumin concentration.