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Comment on the article: "Cost comparison of online haemodiafiltration with high-flux haemodialysis" by Oates et al
No full textResults from the RISCAVID study: is haemodiafiltration associated with improved survival? Reply
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The biological response to online Hemodiafiltration
No full textThe biologic response to uremia and to the associated chronic inflammation is an active area of research. Among the different modalities developed in the technology field of chronic renal replacement, hemodialfiltration has evolved consistently. On-line production of substitution fluid by 'cold sterilization' of dialysis fluid by ultrafiltration gives access to virtually an unlimited amount of sterile and non-pyrogenic intravenous grade solution. Today, on line HDF is already a widespread, accepted treatment. Here, we will review the main mechanisms through which on line hemodialfiltration acts and the biological response observed in relation to the immune system dysfunction and the anemia associated to chronic kidney disease. Copyright (c) 2007 S. Karger AG, Basel
On-Line Hemodiafiltration in the Large RISCAVID Study
No full textDespite significant advances in hemodialysis (HD) and medical therapy, mortality rates in patients with chronic kidney disease stages (CKD-5D) remain unacceptably high, with cardiovascular (CV) mortality risk in dialysis patients being several times higher than that of a general population. The CV mortality risk of a 25- to 34-year-old dialysis patient is approximately the same as the one of an otherwise healthy person aged over 85 in the general population. HD patients are not only exposed to the various traditional risk factors valid for the general population but in addition also to the non-traditional risk factors resulting either from uremia per se or from the dialysis treatment. Our understanding of chronic inflammation in CKD-5D and of its influence in the accelerated atherosclerotic process has greatly evolved. Dialysis therapy, performed efficiently, has the potential to provide CKD-5D patients with benefits beyond the life-saving function of removal accumulated waste products and excess fluid. There is sufficient evidence to indicate that on-line hemodiafiltration has the potential to improve chronic inflammation, fluid overload, left ventricular hypertrophy, anemia and quality of life of CKD-5D patients. In the search for more effective, safer and less expensive approaches to the management of the above conditions, an innovative concept of biocompatibility should be broadened to the HD system/patient evaluation. Here, we intend to present new insights obtained from a prospective observational study (RISCAVID,'RISchio CArdiovascolare nei pazienti afferenti all'Area Vasta In Dialisi') performed on a large HD population in the northwestern region of Tuscany, Italy, on the assessment of the different parameters of chronic inflammation and gross/CV mortality and anemia management. Copyright (C) 2011 S. Karger AG, Base
Vascular calcifications as a footprint of increased calcium load and chronic inflammation in uremic patients: a need for a neutral calcium balance during hemodialysis?
No full textCardiovascular complications caused by an accelerated atherosclerotic disease represent the largest single cause of mortality in chronic renal failure patients. The rapidly developing atherosclerosis of the uremic syndrome appears to be caused by a synergism of different mechanisms, such as malnutrition, oxidative stress and genetic factors. Recent studies provide evidence that chronic inflammation plays an important role in the pathogenesis of cardiovascular diseases. Hyperphosphatemia and an increased calcium-phosphate ion product have also been associated with an increased risk of death. Cardiovascular calcifications secondary to increases in phosphate and calcium load in dialysis patients might exert an important contribution to the excess cardiovascular mortality and morbidity in dialysis patients. Elevated serum levels of plasma C-reactive protein (CRP) are associated with the extent and severity of the atherosclerotic processes as well as with an increased risk of experiencing myocardial infarction and sudden cardiac death in apparently healthy subjects. In patients affected by pre-dialytic renal failure increased levels of CRP and IL-6 were recorded in 25% of our population; CRP and IL-6 were inversely related with renal function. These data suggest the activation - even in the predialytic phase of renal failure - of mechanisms known to contribute to the enhanced cardiovascular morbidity and mortality of the uremic syndrome. In recent years we have investigated the hypothesis that the chronic inflammatory state of the uremic patient could be at least in part due to the dialytic technique. We have shown that the increase of CRP in stable dialysis patients may be due to the stimulation of monocyte/macrophage by backfiltration of dialysate contaminants. During conventional dialysis, a positive calcium balance and a concomitant inflammatory state may act as cofactors in the development of cardiovascular calcifications. We suggest that this hypothesis should be verified by clinical studies. A reevaluation of the ideal calcium levels in the dialysate is warranted: a neutral intradialytic calcium balance is probably more appropriate, although not easily attainable
Severe hypotension during hemofiltration in an uremic patient with metabolic alkalosis
No full textWe describe a case of medication induced metabolic alkalosis in a maintenance dialysis patient who developed severe hypotension while undergoing a lactate hemofiltration procedure. A 73-year-old man with ESRD due to renovascular disease was used to ingesting up to 30 grams per day of a non-prescription medication (Effervescent granulate 250 grams, CRASTAN(TM), Pisa Italy) consisting of sodium bicarbonate, citric acid, glucose and lemon flavor. For technical problem lactate hemofiltration was performed and thirty minutes after dialysis was started a severe symptomatic hypotension occurred (blood pressure 65/35 mmHg). Lactate hemofiltration was suspended and one-hour later standard bicarbonate dialysis was performed without any clinical problem. The different mechanisms in acidosis buffering occurring in lactate and bicarbonate hemofiltration were discussed
Impact of Dialysis Technique on Renal Anemia
No full textCardiovascular disease is a significant complication in chronic kidney disease (CKD) and a major cause of death in dialysis patients. Clinical studies have shown that anemia is associated with reduced survival in patients undergoing chronic hemodialysis. Furthermore, an association between anemia and adverse cardiovascular outcomes has also been observed in patients with earlier stages of CKD not yet requiring dialysis. Although this fact still remains controversial, high-efficiency on-line hemodiafiltration (HDF) has been shown to improve anemia and to reduce the need for erythropoietin-stimulating agents in hemodialysis (HD) patients. This positive effect has been attributed to the fact that the convective methods might remove some protein-bound erythropoietic inhibitor substances. Moreover, in HD patients, renal anemia is linked to the inflammatory state of uremic syndrome. It is also worth nothing that the improvement in anemia is associated with a reduced inflammatory state in patients undergoing on-line HDF. Here, we have reviewed the current knowledge of the effect of dialysis technique on renal anemia. Copyright (C) 2011 S. Karger AG, Base
Antiplatelet agents in hemodialysis
No full textPatients affected by cardiovascular disease (CVD) are treated with antiplatelet agents (AA) and/or anticoagulant drugs, which are fundamental in the management of stroke, coronary atherosclerotic disease, peripheral vascular disease and atrial fibrillation. CVD is the most important cause of death in chronic renal failure (CRF). Death rates from myocardial infarction (MI) and from all other cardiac causes exceed those for the general population. Incidence of MI in CRF is triple that in the general population. Moreover, mortality is seven- to eight-fold higher in patients requiring chronic hemodialysis compared to the general population, and approximately 40% of deaths in this population are attributable to coronary artery disease (CAD). For these reasons, AA are widely used in patients affected by CRF. Current data do not support a protective effect of antiplatelet administration in hemodialytic patients as primary prevention of cardiovascular mortality. Different results have been obtained concerning secondary prevention of CVD. The Cooperative Cardiovascular Project demonstrated that dialysis patients treated with aspirin following MI had a 43% lower mortality. Another study reported that the use of aspirin and beta-blockers following MI was associated with lower mortality in CRF patients. However, aspirin plus clopidogrel seems to increase the hemorrhagic risk without a significant reduction in cardiovascular mortality and there are insufficient data to support the use of new AA drugs in hemodialytic patients. In conclusion, since CRF patients are one of the groups at highest risk for atherosclerotic events, it could be reasonable to use aspirin in HD patients. However, the bleeding risk in HD patients needs to be strongly evaluated, especially before starting dual AA treatment
ABCs of hemodiafiltration prescription: The Pisa style
No full textIn end-stage kidney disease patients, hemodiafiltration, a mixed diffusive-convective technique, has shown beneficial effects in terms of improvement of anemia, inflammation, mineral bone disorders, malnutrition and cardiovascular stability. Greater convective volume exchange was also associated with improved overall and cardiovascular survival. However, absolute target threshold volume would be difficult to define and achieve in daily clinical practice, mainly because of differences in patient size. Convective volumes standardized for body surface area would appear to be the simplest approach in clinical practice. Several factors can affect achievement of optimal convective volume, with vascular access being the main limiting factor. Based on our own clinical experience, hemodiafiltration is a more effective and preferable dialysis technique but only when a target convective volume greater than 20 L can be achieved. Conversely, standard high flux hemodialysis or expanded hemodialysis may be helpful and valuable alternative dialysis techniques
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