The effects of nocturnal compared with conventional hemodialysis on mineral metabolism: A randomized‐controlled trial

Hyperphosphatemia is common among patients receiving dialysis and is associated with increased mortality. Nocturnal hemodialysis (NHD) is a long, slow dialytic modality that may improve hyperphosphatemia and disorders of mineral metabolism. We performed a randomized‐controlled trial of NHD compared with conventional hemodialysis (CvHD); in this paper, we report detailed results of mineral metabolism outcomes. Prevalent patients were randomized to receive NHD 5 to 6 nights per week for 6to 10 hours per night or to continue CvHD thrice weekly for 6 months. Oral phosphate binders and vitamin D analogs were adjusted to maintain phosphate, calcium and parathyroid hormone (PTH) levels within recommended targets. Compared with CvHD patients, patients in the NHD group had a significant decrease in serum phosphate over the course of the study (0.49 mmol/L, 95% confidence interval 0.24–0.74; P=0.002) despite a significant reduction in the use of phosphate binders. Sixty‐one percent of patients in the NHD group compared with 20% in the CvHD group had a decline in intact PTH (P=0.003). Nocturnal hemodialysis lowers serum phosphate, calcium‐phosphate product and requirement for phosphate binders. The effects of NHD on PTH are variable. The impact of these changes on long‐term cardiovascular and bone‐related outcomes requires further investigation.     

Modifications to bicarbonate conductivity: A way to increase phosphate removal during hemodialysis? Proof of concept

Introduction Hyperphosphatemia and cardiovascular mortality are associated particularly with end‐stage renal disease. Available therapeutic strategies (i.e., diet restriction, calcium [or not]‐based phosphate binders, calcimimetics) are associated with extrarenal blood purification. Compartmentalization of phosphate limits its depuration during hemodialysis. Several studies suggest that plasmatic pH is involved in the mobilization of phosphate from intracellular to extracellular compartments. Consequently, the efficiency of modified bicarbonate conductivity to purify blood phosphate was tested. Methods Ten hemodialysis patients with chronic hyperphosphatemia (>2.1 mmol/L) were included in the two three–sessions‐per week periods. Bicarbonate concentration was fixed at 40 mmol/L and 30 mmol/L in the first and second periods, respectively. Phosphate depuration was evaluated by phosphate mobilization clearance (K_M). Findings Although bicarbonatemia was lower during the second period (21.0 ± 2.7 vs. 24.4 ± 3.1 mmol/L, P < 0.01), no difference was observed in phosphatemia (2.4 ± 0.5 vs. 2.3 ± 0.4 mmol/L, P = NS). The in‐session variation of phosphate was lower (?1.45 ± 0.42 vs. ?1.58 ± 0.44 mmol/L, P < 0.05) and K_M was higher during the second period (82.94 ± 38.00 vs. 69.74 ± 24.48 mL/min, P < 0.05). Discussion The decrease of in‐session phosphate and the increase in K_M reflect phosphate refilling during hemodialysis. Thus, modulation of serum bicarbonate may play a role in controlling the phosphate pool. Even though correcting metabolic acidosis during hemodialysis remains important, alkaline excess can impair phosphate mobilization clearance. Clinical trials are needed to test the efficiency and relevance of a strategy where bicarbonatemia is corrected less at the beginning of sessions.     

Nutritional education for management of osteodystrophy: Impact on serum phosphorus,quality of life,and malnutrition

Introduction Osteodystrophy management includes dietary phosphorus restriction, which may limit protein intake, exacerbate malnutrition‐inflammation syndrome and mortality among hemodialysis patients. Methods A multicenter randomized controlled trial was conducted in Lebanon, to test the hypothesis that intensive nutrition education focused on phosphorus‐to‐protein balance will improve patient outcomes. Six hemodialysis units were randomly assigned to the trained hospital dietitian (THD) protocol (210 patients). Six others (184 patients) were divided equally according to the patients’ dialysis shifts and assigned to Dedicated Dietitian (DD) and Control protocols. Patients in the THD group received nutrition education from hospital dietitians who were trained by the study team on renal dietetics, but had limited time for hemodialysis patients. Patients in the DD group received individualized nutritional education on dietary phosphorus and protein management for 6 months (2‐hour/patient/month) from study renal dietitians. Patients in the control group continued receiving routine care from hospital dietitians who had limited time for these patients and were blinded to the study. Serum phosphorus (mmol/L), malnutrition‐inflammation score (MIS), health‐related quality of life (HRQOL) index and length of hospital stay (LOS) were assessed at T0 (baseline), T1 (postintervention) and T2 (post6 month follow up). Findings Only the DD protocol significantly improved serum phosphorus (T0:1.78 ± 0.5, T1:1.63 ± 0.46, T2:1.69 ± 0.53), 3 domains of the HRQOL and maintained MIS at T1, but this protective effect resolved at T2. The LOS significantly dropped for all groups. Discussion The presence of competent renal dietitians fully dedicated to hemodialysis units was superior over the other protocols in temporarily improving patient outcomes.     

The effect of frequent hemodialysis on matrix metalloproteinases,their tissue inhibitors,and FGF23: Implications for blood pressure and left ventricular mass modification in the Frequent Hemodialysis Network trials

Background: Frequent hemodialysis modifies serum phosphorus, blood pressure, and left ventricular mass (LVM). We ascertained whether frequent hemodialysis is associated with specific changes in biomarker profile among patients enrolled in the frequent hemodialysis network (FHN) trials. Methods: This was a post hoc analysis of biomarkers among patients enrolled to the FHN trials. In particular, we hypothesized that frequent hemodialysis is associated with changes in a specific set of biomarkers which are linked with changes in blood pressure or LVM. Results: Among 332 randomized patients, 243 had biomarker data available. Of these, 124 patients were assigned to 3‐times‐a‐week hemodialysis (94 [Daily Trial] and 30 [Nocturnal Trial]) and 119 patients were assigned to 6‐times‐a‐week hemodialysis (87 [Daily Trial] and 32 [Nocturnal Trial]). Frequent hemodialysis lowered phosphate, blood pressures, LVM, log fibroblast growth factor (FGF)23, and tissue inhibitors of metalloproteinase (TIMP)—2 levels. The fall in phosphate was associated with changes in FGF23 (r = 0.48, P < 0.001) [Daily Trial] and (r = 0.55, P < 0.001) [Nocturnal Trial]) and tended to be associated with changes in systolic blood pressure (r = 0.18, P = 0.057) [Daily Trial] and (r = 0.31, P = 0.04) [Nocturnal Trial]. Within the Daily Trial, changes in MMP2 (r = 0.20, P = 0.034) were associated with changes in LVM. In the Nocturnal Trial, changes in TIMP‐1 (r = 0.37, P = 0.029) and MMP 9 (r = ?0.38, P = 0.01) were associated with LVM changes. MMP2 changes were associated with changes in systolic blood pressure. Conclusions: Reduction of serum phosphate by frequent hemodialysis may modulate FGF23 levels and systolic blood pressure. Markers of matrix turnover are associated with LVM changes. Frequent hemodialysis may affect pathological mediators of chronic kidney disease‐mineral bone‐metabolism disorder.     

Phosphate‐binding efficacy of crushed vs. chewed lanthanum carbonate in hemodialysis patients

Lanthanum carbonate, a chewable noncalcium‐containing phosphorus (P) binder, is useful for treating secondary hyperparathyroidism in patients who have hypercalcemia and cannot swallow whole tablets. However, some patients cannot chew tablets or prefer to crush and mix them with food. This study was conducted to determine the P‐binding efficacy of crushed lanthanum and compare it with chewed lanthanum in hemodialysis (HD) patients. After a 1‐week washout period, 11 hemodialysis patients (7 men, 4 women) were randomized to receive, in a crossover fashion, lanthanum 1000 mg 3 times daily chewed with meals and lanthanum 1000 mg 3 times daily crushed into a fine powder, mixed with applesauce and taken with meals, for 4 weeks each. Serum P was measured at the end of each washout (baseline) and weekly during treatment. Changes in serum P from baseline for crushed lanthanum were compared with chewed lanthanum using paired sample t test. Administration of crushed lanthanum resulted in a significant reduction in serum P from baseline (P reduction [mg/dL] for crushed lanthanum in week 1: 2.1 ± 0.4, week 2: 1.7 ± 0.5, week 3: 1.7 ± 0.5, week 4: 1.7 ± 0.4, P<0.05). No statistically significant differences were observed in serum P reduction from baseline and serum P attained during treatment with crushed when compared with chewed lanthanum. Crushed lanthanum is effective in reducing serum P and have similar P‐binding efficacy to chewed lanthanum. Crushing lanthanum and mixing it with food can thus be an option for patients who are unable to chew or swallow whole tablets.     

Comparison of calcium phosphate product values using measurement of plasma total calcium and serum ionized calcium

Calcium phosphate product (Ca x Pi) is a clinically relevant tool to estimate the cardiovascular risk of patients with renal failure. In reports, mostly total serum calcium has been used. As measurement of serum ionized calcium has some benefits and is being used increasingly, we estimated the respective levels of calcium phosphate product using both total (t-Ca x Pi) and ionized calcium (ion-Ca x Pi). Fifty-eight healthy individuals and 180 hemodialysis (HD) patients from 2 centers were studied. Diagnostic accuracies for corresponding values of the t-Ca x Pi and ion-Ca x Pi were calculated using a GraphROC program. Of HD patients, 64% had t-Ca x Pi <4.4 mmol(2)/L(2) regarded as a desirable goal, and 10% had values over 5.6 mmol(2)/L(2) associated with a high cardiovascular risk. Based on GraphROC analysis, t-Ca x Pi of 4.4 mmol(2)/L(2) corresponded to a value of 2.2 mmol(2)/L(2) of ion-Ca x Pi and, respectively, t-Ca x Pi of 5.6 mmol(2)/L(2) corresponded 2.8 mmol(2)/L(2) of ion-Ca x Pi. Owing to the good agreement between the results in the 2 centers, these values for risk levels can be used in both centers. When measurement of ionized calcium is used, Ca x Pi values of 2.2 and 2.8 mmol(2)/L(2) can be used instead of generally used values of 4.4 and 5.6 mmol(2)/L(2) with total calcium.     

Calcium‐phosphate and parathyroid intradialytic profiles: A potential aid for tailoring the dialysate calcium content of patients on different hemodialysis schedules

Severe hyperparathyroidism is a challenge on hemodialysis. The definition of dialysate calcium (Ca) is a pending issue with renewed importance in cases of individualized dialysis schedules and of portable home dialysis machines with low‐flow dialysate. Direct measurement of calcium mass transfer is complex and is imprecisely reflected by differences in start‐to‐end of dialysis Ca levels. The study was performed in a dialysis unit dedicated to home hemodialysis and to critical patients with wide use of daily and tailored schedules. The Ca‐phosphate (P)‐parathyroid hormone (PTH) profile includes creatinine, urea, total and ionized Ca, albumin, sodium, potassium, P, PTH levels at start, mid, and end of dialysis. “Severe” secondary hyperparathyroidism was defined as PTH > 300 pg/mL for ≥3 months. Four schedules were tested: conventional dialysis (polysulfone dialyzer 1.8–2.1 m²), with dialysate Ca 1.5 or 1.75 mmol/L, NxStage (Ca 1.5 mmol/L), and NxStage plus intradialytic Ca infusion. Dosages of vitamin D, calcium, phosphate binders, and Ca mimetic agents were adjusted monthly. Eighty Ca‐P‐PTH profiles were collected in 12 patients. Serum phosphate was efficiently reduced by all techniques. No differences in start‐to‐end PTH and Ca levels on dialysis were observed in patients with PTH levels < 300 pg/mL. Conversely, Ca levels in “severe” secondary hyperparathyroid patients significantly increased and PTH decreased during dialysis on all schedules except on Nxstage (P < 0.05). Our data support the need for tailored dialysate Ca content, even on “low‐flow” daily home dialysis, in “severe” secondary hyperparathyroid patients in order to increase the therapeutic potentials of the new dialysis techniques.     

Effects of l‐carnitine supplement on serum inflammatory cytokines,C‐reactive protein,lipoprotein (a), and oxidative stress in hemodialysis patients with Lp (a) hyperlipoproteinemia

Inflammation, oxidative stress, and high concentration of serum lipoprotein (a) [Lp (a)] are common complications in hemodialysis patients. The present study was designed to investigate the effects of l ‐carnitine supplement on serum inflammatory cytokines, C‐reactive protein (CRP), Lp (a), and oxidative stress in hemodialysis patients with Lp (a) hyperlipoproteinemia [hyper Lp (a)]. This was an unblinded, randomized clinical trial. Thirty‐six hyper Lp (a) hemodialysis patients (23 men and 13 women) were randomly assigned to either a carnitine or control group. Patients in the carnitine group received 1000 mg/d oral l ‐carnitine for 12 weeks, whereas patients in the control group did not receive any l ‐carnitine supplement. At baseline and the end of week 12, 5 mL of blood were collected after a 12‐ to 14‐hours fast and serum free carnitine, CRP, interleukin‐1β, interleukin‐6 (IL‐6), tumor necrosis factor‐α, Lp (a), and oxidized low‐density lipoprotein were measured. Serum free carnitine concentration increased significantly by 86% in the carnitine group at the end of week 12 compared with baseline (P<0.001), while serum CRP and IL‐6 showed a significant decrease of 29% (P<0.05) and 61% (P<0.001), respectively. No significant changes were observed in serum free carnitine, CRP, and IL‐6 in the control group. There were no significant differences between the two groups in mean changes of serum interleukin‐1β, tumor necrosis factor‐α, Lp (a), and oxidized low‐density lipoprotein concentrations. l ‐carnitine supplement reduces inflammation in hemodialysis patients, but has no effect on hyper Lp (a) and oxidative stress.     

Hemodialysis‐induced changes in the blood composition affect function of the endothelium

Hemodialysis induces oxidative stress causing intravascular inflammation, which may cause endothelial dysfunction. We evaluated how hemodialysis‐induced changes in blood affect the function of endothelial cells in in vitro culture. Serum samples were collected from 42 uremic patients treated with hemodialysis, one before the start of dialysis and the other one at the end of session. All patients were dialysed with polysulfone dialyzer. Concentrations of the inflammatory molecules carbonyl protein and metabolites of NO synthesis were measured in blood. Additionally, the effect of the serum obtained before and after dialysis on the function of endothelial cells in in vitro culture was studied. Hemodialysis caused increase of monocyte chemoattractant protein (MCP)‐1 (+17%), hepatocyte growth factor (+91%), and pentraxin‐3 (+30%) concentration in serum. Concentration of carbonyl protein was decreased by 30%. Decrease of blood level of asymmetric dimethylarginine (?25%) and nitrate/nitrites (?62%) was observed. Serum obtained after hemodialysis stimulated proliferation of endothelial cells (+10%) and synthesis of MCP‐1(+11%) in these cells. Hemodialysis‐induced intravascular inflammation changes the function of endothelial cells, which may lead to acceleration of atherosclerosis.     

Inadvertently high dialysate magnesium causing weakness and nausea in hemodialysis patients

As maintenance hemodialysis patients are exposed to large quantities of dialysis water, any contamination of it might be reflected in plasma levels. We present a series of cases due to such a contamination. Six maintenance hemodialysis patients dialyzing at the same peripheral hemodialysis facility presented to us over a short period of time with symptoms mimicking inadequate dialysis. Their blood urea and creatinine levels were not very high, but all the patients had hypermagnesemia [serum Mg levels = 1.8 (±0.3) mmol/L]. Except for one patient who had cardiac arrest at presentation, all patients improved after undergoing hemodialysis at our center [serum Mg at discharge = 0.86 (±0.01) mmol/L]. The origin of hypermagnesemia was traced to dialysis water contamination with magnesium due to inadequate maintenance of the water treatment system. Corrective measures improved the quality of water, and no further cases were reported from that center. Proper maintenance and periodic checks of the quality of water are central to the outcomes of maintenance hemodialysis patients.     

Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate,clinical, and laboratory outcomes: A 1‐year retrospective observation study

Introduction: While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed. Methods: A 1‐year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin). Findings: NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age‐adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77–20.99, P = 0.04). They consumed less aluminum‐based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol²/L², P < 0.01), with similar hemoglobin levels. Discussion: NHHD appeared to offer higher employment rate, lower dosage of aluminum‐based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong.     

Dialysate bicarbonate variation in maintenance hemodiafiltration patients: Impact on serum bicarbonate,intradialytic hypotension and interdialytic weight gain

Introduction: The dialysate bicarbonate (DB) influences the acid‐base balance in dialysis patients. Very low and high serum bicarbonate (SB) have been related with a higher mortality. Acid‐base balance also has been associated with hemodynamic effects in these patients. The trial aim was to compare the effect of DB concentration variation on SB levels in maintenance hemodiafiltration (HDF) patients and the effect on intradialytic hypotension and interdialytic weight gain. Methods: A prospective study, with 9 months of follow‐up, involving 93 patients, divided in two groups: group 1 and group 2 with a DB of 34 mmol/L and 30 mmol/L, respectively, with monitoring of pre and post HDF SB, intradialytic hypotension, and interdialytic weight gain. Findings: Pre dialysis SB was higher in group 1: median concentration of 22.7 mmol/L vs. 21.1 mmol/L (P < 0.001). Post dialysis SB levels were higher in group 1: median concentration of 28.0 mmol/L vs. 25.3 mmol/L (P < 0.001). Post dialysis SB in alkalotic range was only detected in group 1 (51.2% of the patients). No significant differences were detected in intradialytic hypotension rate [28.0 vs. 27.4 episodes per 1000 sessions in group 1 and 2, respectively, (P = 0.906)] or in average interdialytic weight gain [2.9% vs. 3.0% in group 1 and 2, respectively, (P = 0.710)]. Discussion: DB of 30 mmol/L appears to be associated with SB levels closer to physiological levels than 34 mmol/L. The bicarbonate dialysate, in the tested concentrations, did not appear to have a significant impact on intradialytic hypotension and interdialytic weight gain in maintenance HDF patients.     

Effect of serum FGF‐23, MGP and fetuin‐A on calcium‐phosphate metabolism in maintenance hemodialysis patients

This study was aimed to explore the role of serum fibroblast growth factor (FGF)‐23, matrix Gla protein (MGP) and fetuin‐A in the calcium‐phosphate metabolism and their predicting value in coronary artery calcification in maintenance hemodialysis (MHD) patients. This study included 64 patients who receive hemodialysis in our hospital. The serum FGF‐23, MGP and fetuin‐A were analyzed by enzyme‐linked immunosorbent assay (ELlSA). Coronary artery calcification score (CACS) was evaluated by coronary artery computed tomography scan. The 64 patients (30 males, 34 females, 60.6 ± 11.3 years of age) received an average dialysis vintage of 6.88 ± 2.94 years. We divided the CACS into three levels, and 13 (20.31%), 16 (25%), and 35 (54.69%) exhibited a CACS of 0–100, 100–400, and >400, respectively. Dialysis vintage, serum FGF‐23, fetuin‐A, phosphorus and high‐density lipoprotein‐C levels were identified as independent variables of CACS by stepwise multiple regression analysis. The area under receiver operating characteristic curve indicated that serum FGF‐23 and fetuin‐A were useful for identifying CAC in MHD patients. The cut‐off value corresponding to the highest Youden's index was serum FGF‐23 ≥ 256 pg/mL and fetuin‐A ≤ 85 μg/mL, which was defined as the optimal predictors of CAC. Different combinations of serum FGF‐23 and fetuin‐A in parallel or in series effectively boosted the identification of CAC. The incidence of CAC is high in MHD patients. Serum FGF‐23 and fetuin‐A levels are closely correlated with CAC.     

Phosphate removal model: an observational study of low-flux dialyzers in conventional hemodialysis therapy

Precise assessing phosphate removal by hemodialysis (HD) is important to improve phosphate control in patients on maintenance HD. We reported a simple noninvasive model to estimate phosphate removal within a 4‐hour HD. One hundred sixty‐five patients who underwent HD 4 hours per session using low‐flux dialyzers made of polysulfone (1.2 m²) or triacetate (1.3 m²) were enrolled. Blood flows varied from 180 to 300 mL/min. Effluent dialysate samples were collected during the 4‐hour HD treatment to measure the total phosphate removal. Predialysis levels of serum phosphate, potassium, hematocrit, intact parathyroid hormone, total carbon dioxide (TCO₂), alkaline phosphatase, clinical and dialysis characteristics were obtained. One hundred thirty‐five observations were randomly selected for model building and the remaining 30 for model validation. Total amount of phosphate removal within the 4‐hour HD was mostly 15–30 mmol. A primary model (model 1) predicting total phosphate removal was Tpo₄ = 79.6 × C₄₅ (mmol/L) ? 0.023 × age (years) + 0.065 × weight (kg) ? 0.12 × TCO₂ (mmol/L) + 0.05 × clearance (mL/min) ? 3.44, where C₄₅ was phosphate concentration in spent dialysate measured at the 45 minute of HD and clearance was phosphate clearance of dialyzer in vitro conditions offered by manufacturer's data sheet. Since the parameter TCO₂ needed serum sample for measurement, we further derived a noninvasive model (model 2):Tpo₄ = 80.3 × C₄₅ ? 0.024 × age + 0.07 × weight + 0.06 × clearance ? 8.14. Coefficient of determination, root mean square error, and residual plots showed the appropriateness of two models. Model validation further suggested good and similar predictive ability of them. This study derived a noninvasive model to predict phosphate removal. It applies to patients treated by 4‐hour HD under similar conditions.     

Effects of music on complications during hemodialysis for chronic renal failure patients

The study was planned as a case‐control study to examine the effects of music on some of the complications experienced by chronic renal failure (CRF) patients during hemodialysis. A total of 60 patients (30 intervention and 30 control) diagnosed with end‐stage renal failure undergoing hemodialysis treatment participated in this study. The study was conducted in Manisa Merkez Efendi State Hospital Hemodialysis Unit and Manisa Özel Anemon Hemodialysis between April 2012 and July 2012. The intervention group listened 30 minutes in each session (12 total sessions) Turkish art music at the beginning of the third hour of their hemodialysis sessions. Patient Information Form and visual analog scale to assess pain, nausea, vomiting, and cramps during hemodialysis session were used. For the analysis of data, the number, percentage, chi‐square test, and significance test of independent group differences between two averages were conducted. According to the findings of the study, the average of the intervention and control group ages, respectively, was 50.86 ± 11.3 and 55.13 ± 9.68. The primary duration of hemodialysis treatment for both intervention and control groups was “1 year and above” (70.0%). The intervention group's pain and nausea scores were lower than the control group for all 12 sessions. The difference between the intervention and the control group's pain scores was significant (P < 0.05). However, in pain scores from the first session to 12th session, continuous decreasing trend was not observed. According to the results, music can be used as an independent nursing practice for reduction of complications for CRF patients receiving hemodialysis treatment.     

Effect of high‐protein supplemental therapy on subjective global assessment of CKD‐5D patients

Adequate nutrition in patients on hemodialysis is an important step for improving the quality of life. This prospective study was undertaken to monitor the nutritional status of patients who were given high‐protein supplements on malnutrition inflammation score (MIS) and to correlate with biochemical parameters in maintenance hemodialysis (MHD) patients. This prospective study was conducted on 55 chronic kidney disease patients on MHD (37 women, 18 men), aged between 21 and 67 years. Of the 55 patients, 26 patients received high‐protein commercial nutritional supplements, whereas 29 patients received high‐protein kitchen feeding. Every patient had their MIS, 24‐hour dietary recall, hand grip, mid arm circumference, triceps skin‐fold thickness at 0, 3, and 6 months. Each of the above parameters was compared between the high‐protein commercial nutritional supplement cohort and high‐protein kitchen feeding cohort, and the data were analyzed. Of the 55 patients, 82.61% of patients on high‐protein kitchen feeding group and 66.67% in high‐protein commercial nutritional supplement group were nonvegetarian (P = 0.021). According to the MIS, improvement was observed in malnutrition status from 3‐ to 6‐month period in 38.1% of patients in high‐protein commercial supplement group, whereas only in 8.7% in high‐protein kitchen feeding group (P = 0.04). Assessment showed improvement in malnutrition status with high‐protein commercial nutritional supplement, which was marked in patients with age group >65 years (P = 0.03) and in those in whom serum albumin is <35 g/L (P = 0.02). Both high‐protein kitchen feeding and high‐protein commercial nutritional supplement cohorts were observed to have improvement in overall nutritional status. Older patients >65 years with lower serum albumin levels (<3.5 g/dL) were observed to have significant improvement in nutritional status with high‐protein commercial nutritional supplements.     

Treating mineral metabolism disorders in patients undergoing long hemodialysis: A search for an optimal strategy

In hemodialysis (HD) patients, mineral metabolism (MM) disorders have been associated with an increased mortality rate. We report the evolution of MM parameters in a stable HD population undergoing long hemodialysis by performing an annual cross-sectional analysis for every year from 1994 to 2008. The therapeutic strategy has changed: the dialysate calcium concentration has decreased from a mean of 1.7 ± 0.1 to 1.5 ± 0.07 mmol/L and has been adapted to parathyroid hormone serum levels (from 1 to 1.75 mmol/L). The use of calcium-based and aluminum-based phosphate binders has decreased and they have been replaced by sevelamer; alfacalcidol has partly been replaced by native vitamin D. The percentage of patients with a parathyroid hormone serum level between 150 and 300 pg/mL has increased from 9% to 67% (P<0.001); the percentage of patients with phosphataemia between 1.15 and 1.78 mmol/L has increased from 39% to 84% (P<0.001). The percentage of those with albumin-corrected calcemia between 2.1 and 2.37 mmol/L has increased from 29% to 61% (P<0.001), and that of patients with a calcium-phosphorous product (Ca × P) level >4.4 mmol/L decreased from 8.8% to 2% (P=0.02). Although patients undergo long and intensive HD treatment, MM disorders are common. However, an appropriate strategy, mostly consisting of native vitamin D supplementation, progressive replacement of calcium-based phosphate binders with non–calcium-based ones, and individualization of dialysis session duration and dialysate calcium concentration, would result in a drastic improvement.     

Effects of flaxseed consumption on systemic inflammation and serum lipid profile in hemodialysis patients with lipid abnormalities

Inflammation and lipid abnormalities are two important risk factors for cardiovascular disease in hemodialysis (HD) patients. The present study was designed to investigate the effects of flaxseed consumption on systemic inflammation and serum lipid profile in HD patients with lipid abnormalities. This was an unblinded, randomized clinical trial. Thirty HD patients with dyslipidemia (triglyceride >200 mg/dL and/or high‐density lipoprotein‐cholesterol (HDL‐C) <40 mg/dL) were randomly assigned to either a flaxseed or control group. Patients in the flaxseed group received 40 g/day ground flaxseed for 8 weeks, whereas patients in the control group received their usual diet, without any flaxseed. At baseline and at the end of week 8, 7 mL of blood was collected after a 12‐ to 14‐hour fast and serum concentrations of triglyceride, total cholesterol, low‐density lipoprotein‐cholesterol (LDL‐C), HDL‐C, and C‐reactive protein (CRP) were measured. Serum concentrations of triglyceride (P < 0.01), total cholesterol (P < 0.01), LDL‐C (P < 0.01), and CRP (P < 0.05) decreased significantly in the flaxseed group at the end of week 8 compared with baseline, whereas serum HDL‐C showed a significant increase (P < 0.01). These changes in the flaxseed group were significant in comparison with the control group. The study indicates that flaxseed consumption improves lipid abnormalities and reduces systemic inflammation in HD patients with lipid abnormalities.     

Reduction of carbamylated albumin by extended hemodialysis

Introduction Among conventional hemodialysis (CHD) patients, carbamylated serum albumin (C‐Alb) correlates with urea and amino acid deficiencies and is associated with mortality. We postulated that reduction of C‐Alb by intensive HD may correlate with improvements in protein metabolism and cardiac function. Methods One‐year observational study of in‐center nocturnal extended hemodialysis (EHD) patients and CHD control subjects. Thirty‐three patients receiving 4‐hour CHD who converted to 8‐hour EHD were enrolled, along with 20 controls on CHD. Serum C‐Alb, biochemistries, and cardiac MRI parameters were measured before and after 12 months of EHD. Findings EHD was associated with reduction of C‐Alb (average EHD change ?3.20 mmol/mol [95% CI ?4.23, ?2.17] compared to +0.21 [95% CI ?1.11, 1.54] change in CHD controls, P < 0.001). EHD was also associated with increases in average essential amino acids (in standardized units) compared to CHD (+0.38 [0.08, 0.68 95%CI]) vs. ?0.12 [?0.50, 0.27, 95% CI], P = 0.047). Subjects who reduced C‐Alb more than 25% were found to have reduced left ventricular mass, increased urea reduction ratio, and increased serum albumin compared to nonresponders, and % change in C‐Alb significantly correlated with % change in left ventricular mass. Discussion EHD was associated with reduction of C‐Alb as compared to CHD, and reduction of C‐Alb by EHD correlates with reduction of urea. Additional studies are needed to test whether reduction of C‐Alb by EHD also correlates with improved clinical outcomes.     

Is there an association between intradialytic hypotension and serum magnesium changes?

Intradialytic hypotension (IDH) is the most common complication of hemodialysis (HD). The aim of this study was to investigate the significance of intradialytic changes of serum magnesium (sMg) and its relation to IDH. We considered 58 patients undergoing HD. Serum magnesium was measured at start, after 2 hours, and at the end of the HD sessions. Total sMg concentration corrected for albumin was according to Krolles proposed formula. Blood pressure was measured every 30 min. Data were analyzed by SPSS.15. A P value of less than 0.05 was considered as significant. Occurrence of IDH among HD patients was 27.6% (16/58). Serum magnesium decreased significantly during HD session (P<0.05). Comparing corrected sMg in IDH group with non-IDH group showed that: corrected sMg was 0.66 ± 0.14 mmol/L vs. 0.84 ± 0.26 mmol/L at the start of dialysis (P=0.43), 0.62 ± 0.17 mmol/L vs. 0.74 ± 0.23 mmol/L (P=0.04) at 2 hours, and 0.61 ± 0.12 mmol/L vs. 0.72 ± 0.22 mmol/L (P=0.03) at the end of dialysis. Intradialytic hypotension episodes were significantly related to a decrease in sMg during dialysis (P=0.02). There was a significant decrease in sMg levels during dialysis. Intradialytic hypotension was significantly related to lowered sMg levels during dialysis.