Dialysis adequacy and Kt/V

Formica M, Bosticardo G.

S.C. Nefrologia e Dialisi, Dipartimento Area Medica Mondovi'-Ceva, ASL CN1, Cuneo. marco.formica@aslcnl.it

Abstract

Fractional clearance of urea to quantify the adequacy of dialysis was introduced in the late 1980s to allow nephrologists to personalize hemodialysis treatment, assess its effectiveness (dose), and create an index that would represent the concept of adequate dialysis. Since then, the number of nephrologists really involved in this novelty has been rather small, while the majority have been using the new instrument more or less uncritically. A

t the same time, the dialysis technology has evolved: the extracorporeal techniques have become more diversified, dialyzers have been transformed in terms of materials, hydraulic permeability and purification efficiency, and treatment schedules have been modified in terms of duration and frequency. The purpose of this paper is to evaluate, at a distance of about 30 years, the validity of the control parameter of dialysis - Kt/V - in 2010. In essence, the authors claim that Kt/V is of marginal utility in the quantification of traditional dialysis, while it is wholly inappropriate for frequent or long-term treatment schemes. 

We maintain that the calculation of Kt/V is still a tool to be used - also recommended by international guidelines - at least until the validation of new and more efficacious solutions, in order to avoid ineffective dialysis sessions (in terms of dose for small molecules), although it does not provide any certainty of a fully adequate performance in terms of reduced morbidity and mortality.

G Ital Nefrol. 2011 Mar-Apr;28(2):152-6.

PMID 

2148802

[PubMed - indexed for MEDLINE],  

http://www.ncbi.nlm.nih.gov/pubmed/21488029

Healthcare providers need to engage patients

Assoc. Prof. Dr Mohamed Azmi Ahmad Hassali, School of Parmaceutical Sciences, Universiti Sains Malaysia,, Penang

The Star Online  - http://thestar.com.my/news/story.asp?file=/2011/7/27/focus/9178711&sec=focus

I READ with interest “Medicines not prescribed properly” (The Star, July 17). I think both doctors and pharmacists need to be more responsible to head off such problems in our hospitals.

This can be resolved by good communication between the two parties. It is known that in our public hospital system, the patient might be seen by different doctors during their visits. And things are more complicated in Malaysia as the patient never questions what medicines are given on each visit.

Besides that, lack of communication between healthcare providers and the patient also contributes to problems related to medication adherence.

To be a good healthcare provider, one must have empathy, the ability to translate complexities into simple matters and the ability to act on the obvious.

I urge healthcare providers in hospitals to be more rational in prescribing, and to inform their patients well in terms of their medication or any procedure that is needed.

In some cases, based on his clinical judgment, the doctor might need to change the patient’s pharmacotherapy management by either adding new drugs or omitting previously prescribed ones. When this happens, appropriate explanations need to be given to the patient.

I hope healthcare providers in this country will engage patients in any decision making process, and they also need to improve their communication at every level of the rational medicines use process in order to overcome medication errors, patient confusion and medication wastage.

Reader's comment

"What beautiful stories, I wish both couples a long and happy life together, especially my friends, Gel & Bianca!" on topic "Sharing Love and Kidneys too published on 17/7/2011 Simon Green 25-July-2011

By Simon Green 

Dialysis centre reaching full capacity with new patients

By DIANA ROSE
sarawakstar@thestar.com.my 

http://thestar.com.my/metro/story.asp?file=/2011/7/21/southneast/9139367&sec=southneast

MIRI: End-stage renal failure patients are on the rise here and the Malaysian Red Crescent (MRC) kidney dialysis centre is alarmed that it may not be able to accommodate the needs of the ever-increasing number of patients.

The centre’s founder and president Datuk Lee Kim Shin, who is also the Infrastructure Development and Communications Assistant Minister, said it had 78 dialysis machines and 217 patients.

“Our maximum capacity is 400 patients, but with an average of three new patients monthly, we will soon be overloaded,” said Lee, adding that the centre had spent RM30.8mil to acquire 30 new machines recently.

“There is an urgent need to create awareness on healthy living and taking care of kidneys,” said Lee at the launch of a public health talk here yesterday.

The talk themed “Understanding Your Health Better” was organised jointly by the centre, Parkway Health’s patient assistance centre andUnited Daily News.

Read full article here

Not enough kidney donors

By LOH FOON FONG
foonfong@thestar.com.my

http://thestar.com.my/news/story.asp?file=/2011/7/18/nation/9121100&sec=nation 

PETALING JAYA: Only a mere 2% of Malaysians have donated their kidneys in the last 20 years, says National Kidney Foundation (NKF)founder Dr S.S. Gill.

He said the donation campaign programmes had not been effective in raising the kidney donor rates.

“If we continue with our present approach to obtain more kidney donors, we will be in the same boat in the next 20 years,” he said yesterday.

On Saturday, two men became Malaysia's first patients to successfully undergo kidney transplants by receiving kidneys from their spouses who were of incompatible blood groups.

While he welcomed such gestures, Dr Gill said more needs to be done to encourage cadaveric donors as this would be the first and best choice.

He said most kidney transplants were done in India or China and with laws passed in these countries controlling the transplants, the cost of transplanting a kidney had escalated from between RM30,000 and RM50,000 to RM150,000 and RM250,000 or more.

“In the past, only a few could afford it and now only the super-rich are able to undergo these transplants,” he said, adding that the number of dialysis patients have increased with over 4,000 new patients recorded last year.

Dr Gill said many countries have encouraged organ transplants.

“Some, like Iran and Australia, offer compensation for donors in several forms. Spain has one of the highest transplant rates resulting from trained and persuasive transplant co-ordinators in most hospitals,” he added.

The National Transplant Resource Centre chief coordinator Datin Dr Lela Yasmin Mansor said the centre was looking into the Australian method of asking its learner drivers to volunteer to donate their kidneys if they die in a road accident.

She said they had been getting more referrals from hospitals and calls from family members of the deceased who wanted to donate their organs.

Sharing love and kidneys, too

By YUEN MEIKENG
meikeng@thestar.com.my

KUALA LUMPUR: For love of their husbands, two women donated one kidney each to their ailing spouses.

Their husbands not only received a new lease of life, but also became Malaysia's first patients to successfully undergo kidney transplants despite having incompatible blood groups with their donors.

Filipina Bianca Abdundo said she gave a kidney to 32-year-old Geland Delous Reyes Gonzalodo without hesitation.

“We just got married on April 29. I want to spend many more years with him,” said the 27-year-old when met at the Prince Court Medical Centre (PCMC) here yesterday.

Geland was the first to undergo the transplant at PCMC on July 1, followed by tour guide Lee Leong Kim the next day.

Anything for love: Kidney patients Geland (second from left) and Lee (second from right) at the Prince Court Medical Centre, Kuala Lumpur, yesterday. With them are their respective wives, Bianca (left) and Hernawati.

“I am a Filipino but I consider myself a Malaysian as I have a second chance at life here,” said Geland, a senior contract engineer.

Lee's wife Hernawati Subli said her husband was definitely worth the sacrifice.

Read full article here

The Significance of Extreme Elevation of the Erythrocyte Sedimentation Rate in Hemodialysis Patients


Mohammed Al-Homrany
Department of Medicine (Nephrology Division), College of Medicine, King Khalid University, Abha, Saudi Arabia 
Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2011 Jul 13];13:141-5


Abstract:


We conducted this study to determine the prevalence of elevated erythrocyte sedimentation rate (ESR) in chronic hemodialysis patients and to evaluate the dialytic and serum factors that might explain this elevation. ESR was measured using the Westergren method immediately before and immediately after dialysis sessions in 200 stable (i.e. with no other obvious systemic illnesses) hemodialysis patients and in 50 hemodialysis patients during concurrent acute illnesses. 


ESR was found to be > 25 mm/h in 180 (90%) patients, >50 mm/h in 76 (38%) and > 100 mm/h in 64(32%) patients. The mean pre dialysis ESR was not significantly different from the mean post dialysis ESR (77 ± 38 Vs 78 ± 35 mm/h, respectively). The mean ESR in the 50 patients during acute illnesses was not significantly different from the mean ESR measured during the stable state. Among all dialytic, biochemical and serum factors that were studied in this population, fibrinogen was the only factor that independently correlated significantly with ESR (P=0.015). 


In conclusion, this study showed that our dialysis patients had a tendency for elevated ESR and almost one third of them (32%) had ESR >100 in the absence of malignancy or other clinical factors known to cause such levels. There was a significant correlation between elevated ESR and fibrinogen level. Thus, an ESR of > 100 does not necessarily warrant extensive investigations for causes other than the renal failure/hemodialysis state unless other indicators exist to justify the search.


Read full article here

Digi Services back online after we get bailed!!!

Low Calcium Dialysate During Hemodialysis and Sudden Cardiac Arrest

Rod Franklin - Medscape Medical News  

November 24, 2010 (Denver, Colorado) — Sudden cardiac arrest (SCA) is the most common cause of death among patients with end-stage renal disease (ESRD) on hemodialysis; it occurs at a rate 30 times greater than in the general population. But research presented here at Renal Week 2010: American Society of Nephrology 43rd Annual Meeting suggests that modifications of dialysate prescriptions, particularly with regard to calcium levels, can help mitigate SCA risk.

The results of the study were also published online September 1 in Kidney International.

In an abstract presented as a follow-up to their 2009 study on alterations of dialysate prescriptions for ESRD patients, researchers from the Duke University Medical Center Division of Nephrology in Durham, North Carolina, reported that reduced calcium dialysate levels are associated with increased risk for SCA, despite published guidelines suggesting that calcium dialysate concentrations be lowered as a means of controlling vascular complications and soft tissue calcification.

Recommendations promulgated by the National Kidney Foundation Kidney Disease Outcome Quality Initiative in 2000 suggested a reduction of calcium dialysate levels to 2.5 mEq/L. The recent Duke University study, led by Patrick H. Pun, MD, showed, however, that such adjustments are likely to worsen the prolongation of QT intervals, which has been acknowledged as a source of increased risk for ventricular tachyarrhythmias and sudden death.

Read full article here

Comparison of effect of cellulose triacetate and polysulfone membrane onGPIIb/IIIa and platelet activation.

Kurangano T. Kuno T. Takahashi Y. Yamamt C Nagura T. Takahashi S. Kanmause K

Second Dept of Internal Medcine, Nihon Uiversity School of Medicine, Tokyo Japan. kurangano@med.nihon-u.ac.jp

Abstract

BACKGROUND:

During hemodialysis session, several adverse reactions can occur on platelets, which are attributable to bioincompatibility of the dialysis membrane. Glycoprotein IIb/IIIa (GPIIb/IIIa) is the receptor for fibrinogen, which mediates platelet aggregation and adhesion. Accordingly, we compared the influence of a cellulose triacetate (CTA) and polysulfone (PS) membrane on GPIIb/IIIa and platelet activation.

METHODS:

Blood samples from 5 patients on hemodialysis were taken at 0 time, 15 min, 30 min, 60 min and 240 min, during a single hemodialysis session, by a crossover design using CTA or PS. Platelet count and plasma concentration of GPIIb/IIIa, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF-4) were measured. GPIIb/IIIa was measured by flow cytometry. beta-TG and PF-4 were measured by ELISA.

RESULTS:

There was no significant change in the total amount of GPIIb/IIIa during dialysis session between the CTA and PS. However, the level of bound GPIIb/IIIa was significantly (p < 0.0002) increased from 1,426 +/- 435 to 40,446 +/- 2,777 mol/PLT with PS. In contrast, there was no significant change with CTA (3,258 +/- 1,469 to 4,301 +/- 1,422 mol/PLT). The platelet counts and beta-TG and PF-4 behavior during the dialysis session did not show significant change between the PS and CTA.

CONCLUSION:

The characterization of changes in platelet membrane receptor (GPIIb/IIIa) may be a useful marker for studying the biocompatibility of dialysis membranes. On platelet aggregation, CTA might be more biocompatible membrane than PS.

Copyright 2003 S. Karger AG, Basel