Blood volume monitoring.

BACKGROUND: In CKD stage 5 diabetic patients (DM), only approximately half of the interdialytic weight gain was accounted for by sodium intake. The other half was due to pure water gain, probably caused by hyperglycemia. Dialysis treatment faces two major troubles: the removal of the extra amount of water and the therapy of the compromised compensatory mechanisms. The described situation is the reason why new technologies in hemodialysis were developed. Blood volume monitoring (BVM) with regulation of ultrafiltration and sodium (Hemocontrol, Hospal, Belgium; Hameomaster, Nikkiso Co. Ltd, Japan) was evaluated to describe the advantages for efficacy and compatibility in hemodialysis therapy. METHODS: 18 cardiovascular instable patients (DM) were included into the study (age 56.4 +/- 12.5, 7 female, 11 male). Begin of dialysis 39 +/- 9.3 months before the study, dialysis time/session 258.3 +/- 15.4 min, 3 sessions/week, blood flow 250 ml/min, dialysate flow 500 ml/min, prephase: standard bicarbonate dialysis (HD; HCO3 - 35 mmol/l) 2 weeks, BVM: 48 weeks. Clinical parameters evaluated before BVM and 48 weeks after BVM: number of muscle cramps (MC) and hypotensive episodes (HypoEp) during dialysis, optimal weight (OptW), single pool Kt/V (sp Kt/V), equilibrated Kt/V (db Kt/V), systolic blood pressure (BP), antihypertensive drugs (AntiDr), cardiac ejection fraction (EF) and left ventricular mass index (LVMI). RESULTS: In comparison with HD after 48 weeks with BVM, we can demonstrate a reduction of MC by 83.7%, HypoEp by 88.9%, OptW by 1.7%. The improved refilling and reduction of OptW led to an increase of sp Kt/V by 34.8% and db Kt/V by 33.3%. AntiDr were reduced to 56.6% compared to HD, BP lowered by 4.4%. Due to BVM, EF increases to 123.8% and LVMI decreases by 25.2%. CONCLUSION: BVM can improve clinical parameters for adequacy of hemodialysis. It offers a unique possibility to treat diabetic patients according to their special needs.

Changes in lymphocytic cluster distribution during extracorporeal immunoadsorption.

The success of apheresis treatment is often measured as a decrease in the detected antibodies and an improvement in different disease-related scores. Sometimes, however, the seriousness of the disease does not correlate with the antibody level. During a period of 8 years, 15 patients (3 myasthenia gravis, 1 multiple sclerosis, 2 systemic lupus erythematosus, 3 alloimmunized kidney transplant, 6 rheumatoid arthritis) were treated by protein A immunoadsorption. Lymphocyte subpopulations (activated T cells, cytolytic T cells, B cells, natural killer cells) and inflammatory proteins (ferritin, C-reactive protein, alpha1-antitrypsin, alpha2-macroglobulin) were analyzed. After observing clinical outcomes, the patients could be divided into 2 groups, respectively: Group 1, responding patients with remission of disease; and Group 2, delayed-responding patients, who required chronic treatment. Group 1 patients characteristically showed a greater increase in activated T and cytolytic T cells which correlated with a greater decrease of B cells. It might be possible that protein A immunoadsorption induced immunomodulation. Further immunological investigation is required to verify these findings.

Online hemodiafiltration versus acetate-free biofiltration: a prospective crossover study.

Online hemodiafiltration (online HDF) and acetate-free biofiltration (AFB) are 2 innovative renal replacement therapies. Convincing evidence has shown that both techniques are superior to conventional hemodialysis in many aspects. The aim of the present investigation was to compare online HDF and AFB in 12 stable maintenance hemodialysis patients in a prospective, randomized crossover trial. Twelve stable dialysis patients, age 49.7 +/- 11.3 years and on dialysis for 83.5 +/- 76.7 months, were treated prospectively and randomly by either AFB, predilution HDF (pre-HDF), or postdilution HDF (post-HDF) for a total of 36 weeks using exclusively F60S high-flux dialyzers. Routine blood biochemical tests, bone metabolism parameters, and clearance for both small and larger molecular weight substances were measured at defined intervals. During the trial period inter- and intradialysis symptoms, e.g., hypotensive episodes and intradialysis arterial blood gas analyses, were recorded. Both online HDF and AFB were well accepted by the overwhelming majority of patients and also by the dialysis staff. Pretreatment sodium, total and ionized calcium, chloride, bicarbonate, and urea did not differ within or between the 3 treatment groups. Potassium increased slightly in HDF patients while phosphate and beta2-microglobulin (beta2-M) decreased in all groups. After dialysis, AFB patients exhibited a significantly higher bicarbonate concentration and lower potassium level when identical potassium concentrations in dialysate were used. Patients receiving AFB manifested less intradialysis partial pressure of oxygen drop and partial pressure of carbon dioxide rise than those on HDF treatments. HDF treatments could afford higher single-pool and double-pool Kt/V, higher effective urea and beta2M clearance, and lower total interdialysis symptom scores than the AFB treatment method. While bone metabolism parameters did not differ between the 3 dialysis modalities, some parameters such as deoxypyridinoline in HDF and osteocalcin, pyridinoline, and deoxypyridinoline in AFB deteriorated at the end of the crossover study. Aluminum concentration decreased progressively to about one-third of prestudy values at the end of the study with all 3 treatments. AFB was associated with a lower predialysis mean arterial pressure (MAP), a smaller drop in MAP during treatment, and similar hypotension episodes compared with the 2 HDF treatments. Albumin concentration showed a trend to decrease during the first 2 months of the trial period followed by a slight increase thereafter but still significantly lower than initial value at the end of crossover. Both online HDF and AFB share most of the features of optimal renal replacement therapy. Online HDF is superior to AFB in such aspects as increased delivered dialysis dose both for small and larger molecular weight toxins and less interdialysis symptoms. On the other hand, AFB is associated with a smaller effect on arterial blood gas values and improved intradialysis hemodynamic tolerance. Some dialysis-related symptoms and complications in the case of our AFB practice could be attributable, at least in part, to low dialysate calcium level.