Citrate anticoagulant hemodialysate in renal failure patients at high risk of bleeding

Objective: The aim of this study was to observe the anticoagulant effect of the new type of citrate anticoagulant hemodialysate in renal failure patients at high risk of bleeding. Methods: 57 patients at high risk of bleeding were given hemodialysis for 4 hours and were divided into 3 groups according to hemodialysis procedures: Group 1 was saline‐flush hemodialysed with bicarbonate hemodialysate. Group 2 was hemodialysed with citrate hemodialysate and with no anticoagulant. Group 3 was hemodialysed with bicarbonate hemodialysate and with nadroparin calcium (a low molecular weight heparin, LMWH) as anticoagulant. Bleeding complication, coagulation of extracorporeal circuit, venous blood pressure, heart rate, QT_C, activated coagulation time (ACT), ionized‐calcium (iCa⁺⁺), total calcium and pH, , Na⁺, K⁺, Cl^?, BUN, Cr, GPT, GST, TBIL, DBIL, as well as the blood cell counts were monitored during hemodialysis, and a scanning electron microscopic (SEM) analysis was used to investigate the morphology of thrombus formation and cellular aggregation on the interior surface of hemodialysis membranes. Results: During the hemodialysis in Group 1, venous blood pressure increased continuously, resulting in the failure of hemodialysis for 4 out of 19 patients. Hemodialysis for 4 hours in Group 2 were all successfully fulfilled. No bleeding episodes occurred. No severe clotting of dialyzers and blood accesses was observed. ACT was extended and iCa⁺⁺ decreased obviously in the venous line, but ACT and iCa⁺⁺ in vivo were normal. pH, tended to increase but not to metabolic alkalosis levels. Na⁺, K⁺, Cl^?, GPT, GST, TBIL, DBIL, as well as the counts of blood cells were all within the normal range. There was no severe thrombus observed by SEM in the hollow fibers. In Group 3, severe bleeding complication happened to 3 out of 19 patients, and one of them died. ACT was extended obviously at the arterial end. Conclusions: The citrate anticoagulant hemodialysate was proved to be practical, safe and effective. So it is indicated for patients with an active or recently active bleeding focus.     

Studies of phosphate dynamics during hemodialysis

Regulation of phosphate (PO₄) in hemodialysis patients is very difficult and ideal levels are rarely maintained. A high removal and a normal phosphate level is important, as high and low levels are both associated with morbidity and a very high mortality.
We studied phosphate dynamics and its relation to other small "uremic" molecules in 48 patients by measuring pre‐ and postdialysis levels and all removed phosphate, urea and creatinine (creat) in all dialysate during 455 dialyses done at different frequencies (freq): 3.7 ± 1.2, range 3–6 treatments per week and durations of dialysis (t): mean: 196 ± 95, range 80–560 min and with high (HF) and low flux membranes.
Kt/V‐PO₄, Kt/V‐urea and Kt/V‐creat, volumes (Vr) for all solutes and their relationships to frequency and duration of dialysis, urea clearance and predialysis phosphate were calculated.  

     

Antibiotic lock: In vitro stability of vancomycin and four percent sodium citrate stored in dialysis catheters at 37°C

Catheter-related bacteremia (CRB) is a major cause of morbidity and mortality especially among patients receiving hemodialysis (HD). Antibiotic lock therapy represents a promising technique in the treatment of CRB. Several studies have evaluated antibiotics in combination with heparin as an interdialytic locking solution as adjunctive therapy for CRB. The objective of this study was to evaluate the chemical stability of the vancomycin in 4% sodium citrate in HD catheters as an interdialytic lock. Vancomycin was prepared and diluted with sodium citrate 4% and stored in polyvinyl chloride syringes, 2 carbothane dialysis catheters (Hemostar^®) and 2 dual floating HD catheters (CardioMed^®). Syringes were stored at 4 °C or 23 °C and the catheters were stored in an incubator at 37 °C for 72 hours. Samples underwent daily chromatographic analysis and the luminal concentration of vancomycn was determined on study days 0, 1, and 3. When vancomycin is reconstituted with normal saline to achieve a concentration of 50 mg/mL, and then further diluted in 4% sodium citrate, to achieve concentrations of either 1 or 3 mg/mL, and then stored at 4 °C, room temperature, or 37 °C, solutions were observed to retain >92% of the initial concentration for the study period of 3 days. Based on the fastest degradation rate determined with 95% confidence interval, >90% is retained for 6.53 days. We conclude that vancomycin—4% citrate solutions stored in polyvinyl chloride syringes or HD catheters are not significantly affected by temperature or concentration within the 72 hours storage period. Therefore, these solutions can be anticipated to be suitable as a HD interdialytic antibiotic lock in standard HD catheters.     

Infections Recurrent empyema due to Salmonella enteritidis in a patient on hemodialysis

In end‐stage renal failure, impaired renal catabolism leads to retention of beta 2 microglobulin (ß2M), identified as the major constituent of hemodialysis (HD) related amyloidosis. It has been previously shown that, while using a high flux (HF) HD membrane, nocturnal hemodialysis (NHD) with its increased time and frequency provides a much higher clearance of ß2M compared to conventional HD. We compared serum ß2M levels between low flux (LF) and HF in a group of 9 NHD patients who dialyse 8 hours 6 nights/week. Fresenius polysulfone LF membrane size F6‐F8 HPS dialyser were used for the first 15 months (mth) of NHD (SA 1.3–1.8 m²). Subsequently, polysulfone HF FX80 dialyzer were used (SA 1.8 m²). Blood flow and dialysate flow rates were unchanged throughout the study. ß2M levels were measured at 6, 12, 15 mth on LF and at 6, 12 mth on HF. Albumin, homocysteine (Hcy), and phosphate (Phos) levels were also recorded at these times. ß2M levels trended upwards during the 15 mth on LF (36.6 ± 10.57 at 6 mth vs 47.1 ± 11.7 at 15 mth). On introduction of HF, there was a significant fall in ß2M at 6 mth to 12.4 ± 3.5 (p < 0.003), while ß2M levels were unchanged at 12 mth of HF. A downward trend in Hcy levels with the use of HF was noted (12.9 ± 2.9 at 0 mth Vs 11.1 ± 3.7 at 12 mth). Plasma albumin and Phos levels remained unchanged as did the use of Phos supplementation. Levels of ß2M continued to rise on NHD with LF, indicating inadequate clearance. With the introduction of HF there was a significant fall in ß2M levels consistent with improved clearance. The implications of this are that ß2M clearance may be time and frequency dependent only if dialyser membrane flux is adequate.     

Solute kinetics with short-daily home hemodialysis using slow dialysate flow rate

"NxStage System One^™" is increasingly used for daily home hemodialysis. The ultrapure dialysate volumes are typically between 15 L and 30 L per dialysis, substantially smaller than the volumes used in conventional dialysis. In this study, the impact of the use of low dialysate volumes on the removal rates of solutes of different molecular weights and volumes of distribution was evaluated. Serum measurements before and after dialysis and total dialysate collection were performed over 30 times in 5 functionally anephric patients undergoing short-daily home hemodialysis (6 d/wk) over the course of 8 to 16 months. Measured solutes included β₂ microglobulin (β₂M), phosphorus, urea nitrogen, and potassium. The average spent dialysate volume (dialysate plus ultrafiltrate) was 25.4±4.7 L and the dialysis duration was 175±15 min. β₂ microglobulin clearance of the polyethersulfone dialyzer averaged 53±14 mL/min. Total β₂M recovered in the dialysate was 106±42 mg per treatment (n=38). Predialysis serum β₂M levels remained stable over the observation period. Phosphorus removal averaged 694±343 mg per treatment with a mean predialysis serum phosphorus of 5.2±1.8 mg/dL (n=34). Standard Kt/V averaged 2.5±0.3 per week and correlated with the dialysate-based weekly Kt/V. Weekly β₂M, phosphorus, and urea nitrogen removal in patients dialyzing 6 d/wk with these relatively low dialysate volumes compared favorably with values published for thrice weekly conventional and with short-daily hemodialysis performed with machines using much higher dialysate flow rates. Results of the present study were achieved, however, with an average of 17.5 hours of dialysis per week.     

The effect of hemodialysis duration on 703 hemodialysis patients in our center

There are limited data on demographics, long‐term follow‐up, and iron/rHuEPO requirements of hemodialysis (HD) patients in Turkey. The aim of the study was to analyze the effects of the HD duration, primary illness, blood pressure, and age on serum albumin, CRP, blood pressure, iron/rHuEPO requirements, PTH, and HCV positivity of HD patients. 703 patients (280 women, 423 men, aged 47.8 ± 15.5 years) from 4 HD units were included and grouped according to the duration on HD. The demographic, clinical, and biochemical data of the last 3 months for each patient were recorded retrospectively. When the groups were compared, patients with a longer HD duration were younger and percentage of diabetic patients decreased as the duration increased. Serum albumin and CRP levels were similar between the groups. When the groups were compared according to the blood pressure profiles, after the 5^th year, a decline in the systolic blood pressures was observed. Diastolic blood pressures were similar across the years. There was no significant difference in need of antihypertensive medicines. Iron requirements showed a fall after the 5^th year, and an increase in after the 10^th year. There was a decline in the hematocrit levels by the duration on HD but there was no change in rHuEPO requirements over the years. Parathyroid hormone levels and HCV positivity tended to increase across the years. Our results revealed that during the first 10 years, age, etiology (diabetes, hypertension), and blood pressure control seemed to be important factors affecting survival. Whereas, after the 10^th year, patients seemed to be more prone to the long‐term complications of HD, such as HCV infection, anemia, secondary hyperparathyroidism.     

Short Daily Hemodialysis vs. Short Daily Hemofiltration (Search for Optimal Prescription)

It has been shown that daily hemodialysis as well as convective transfer by hemofilitration improve the quality of extra renal treatment. Two following phases of treatment of three weeks each were tested in 2 patients: daily hemodialysis 2.5 h 6 times/week (HD*6) and daily hemofiltration 2.75 h 6 times/week (HF*6) performed according to the following modalities. Phase I, blood flow rates (QB): 300 mL/min, hemofilter 1.4 m²AN 69 dialysate flow 500 mL/min. Phase II, QB: 150 mL/min, hemofilter 1m²AN 69, exchange volume of 10 L/session; 5 L predilution and 5 L postdilution (conditions were limited by the device). We measured, during the third week of treatment of each phase, the weekly mass transfers and the predialysis plasma levels of urea (U), creatinine (C), phosphate (P), and B2 microglobulin (B2M). In the 2 phases, HD*6 and HF*6, respectively, the weekly urea Kt was: 120 vs. 60 L; std Kt/V: 3.30 vs. 2.0; npcr: 1.26 vs. 1.42 g kg^–1 day^–1.  

     

Severe hypercalcemia caused by Milk‐Alkali syndrome requiring urgent hemodialysis – Tums by the ton

An increased frequency of the Milk‐Alkali syndrome in the last several years has been noticed related to increasing use of calcium carbonate as a phosphate binder in CKD patients, as an antacid or as calcium supplementation. We present a case of severe hypercalcemia secondary to Milk‐Alkali syndrome that precipitated acute renal failure requiring urgent hemodialysis. A 59-year‐old male with history of hypertension, diabetes mellitus, and acid reflux presented to the ER with confusion, lethargy, nausea, vomiting, and diarrhea. His family relayed a history of recent indigestion and relief with Tums. He was taking several tablets at short intervals to self‐treat the indigestion. At the time of presentation, patient was confused and noted to be dehydrated. Lab findings were significant for elevated BUN/Cr‐ 121 mg/dl/11.1 mg/dl (baseline Cr 1.1 mg/dl few months ago), bicarbonate 38 mg/dl, calcium 16.7 mg/dl, ionized Ca of 1.76 mmol/L, iPTH 10 pg/ml, PTHrP 0.7 pg/ml. Medical management with intravenous fluids and furosemide showed no improvement in renal failure, or calcium level. Patient was then started on hemodialysis with 2.0 mmol/L calcium in the dialysate the next day. There was gradual improvement in patient's mental status, calcium values, and renal failure over the ensuing 2 weeks.
Discussion and Conclusions:  The diagnosis of Milk‐Alkali syndrome is made on the basis of history. Metabolic abnormalities involved in this syndrome are hypercalcemia with low to normal PTH and Vit. D levels, renal failure, and metabolic alkalosis. Failed medical management required acute dialysis in this patient. Acute hemodialysis in such a case could be life saving. Due to increasing use of calcium carbonate for dyspepsia and osteoporosis, patients should be made aware of these severe, potentially life-threatening adverse effects.     

A case of plasma component exchange using membrane plasma separator EVACURE™

Purpose:  Performed free coagulant hemodialysis to patients having hemorrhage with the hope to avoid aggravation of bleeding caused by anticoagulant agent from dialysis. Method:  Examined 19 cases of patients with bleeding tendency, whether it is possible to perform free coagulant hemodialysis by using PAES membrane, EVAL membrane, PS membrane, Cellulose triacetate membrane and Vitamin‐E modified‐dialysis membrane. Result:  With PAES membrane, the result showed a non‐ blockade rate of 91% after four hours and 100% after two hours. Therefore, blockade was prevented with a fairly high rate. In cases of blockade, most of them were possibly avoidable with a little contrivance as the reason were lack of establish blood flow rate, faulty position of a needle, etc. Conclusions:  By using PAES membrane, it was possible to perform free coagulant hemodialysis. In order to completely have no blockade of blood lines in the future, we must strive further on.     

Intensive In-Center Hemodialysis for Children: A Case for Longer Dialysis Duration

Background:  Children with renal failure need their dialysis time optimized. Although traditional surrogate markers of outcome in pediatric patients have been growth and development, increasing attention is being focused on cardiovascular risk factors, such as hypertension, volume overload, malnutrition, and elevated calcium (Ca) and phosphorus (P) levels. We have previously shown catch-up growth without growth hormone, in children undergoing long intermittent hemodialysis. Recently we analyzed retrospectively cardiovascular risk factors in patients treated with this regimen.
Methods:  Patients starting dialysis between 1997 and 2001 and on dialysis at least 6 months were evaluated. Charts were reviewed for Ca, P, parathyroid hormone (PTH), albumin, hemoglobin and blood pressure levels, Ca intake, blood pressure medications, dialysis time, and clearance and ultrafiltration rates. Means were calculated for 6- month intervals, up to 36 months.
Results:  Mean equilibrated dialyzer Kt/V _urea ranged from 1.9 to 2.1, and mean weekly dialysis time for oliguric patients varied from 14.8 to 16.3 hr, with average hourly ultrafiltration rates from 0.3 to 0.4 L. Mean values for P and Ca × P were below 1.8 mM and 4.4 mmol   ² /L ² , respectively. Mean hemoglobin levels were 115 to 126 g/L, albumin 39 to 41 g/L, and PTH 156 to 231 pg/mL. Most patients had normal predialysis blood pressures.
Conclusions:  In this pediatric cohort, intensive center hemodialysis was associated with excellent growth, nutrition, Ca, P, and anemia control and reasonable blood pressure values. Large multicenter studies are needed to better determine optimal dialysis therapy for children.     

Bioreactance: A new tool for cardiac output and thoracic fluid content monitoring during hemodialysis

Outpatient hemodialysis therapy (HD) can be associated with hemodynamic compromise. Bioreactance^® has recently been shown to provide accurate, noninvasive, continuous, measurements of cardiac output (CO) and thoracic impedance (Zo) from which thoracic fluid content (TFC) can be derived assuming TFC=1000/Zo. This study was designed to evaluate the changes in TFC in comparison with the traditional indices of fluid removal (FR) and to understand the trends in CO changes in HD patients. Minute-by-minute changes in TFC and CO were prospectively collected using the bioreactance system (NICOM^®) in HD patients of a single unit. Changes in body weight (ΔW), hematocrit (ΔHct), and amount of FR were also measured. Twenty-five patients (age 77 ± 11 years) were included. The TFC decreased in all patients by an average of 5.4 ± 7.9 kΩ⁻¹, weight decreased by 1.48 ± 0.98 kg, and FR averaged 2.07 ± 1.93 L over a 3- to 4-hour HD session. There were good correlations between ΔTFC and ΔW (R=0.80, P<0.0001) and FR (R=0.85, P<0.0001). ΔHct (4.13 ± 3.42%) was poorly correlated with ΔTFC (R=0.35, P=0.12) and FR (R=0.40, P=0.07). The regression line between FR and TFC yielded FR=1.0024−0.1985TFC; thus, a 1 kΩ⁻¹ change of Zo correlates with an ∼200 mL change in total body water. The change in CO (−0.52 ± 0.49 L/min m²) during HD did not correlate with FR (R=0.15, P=NS). Changes in TFC represented the monitored variable most closely related to FR. CO remained fairly constant in this stable patient cohort. Further studies in high-risk patients are warranted to understand whether TFC and CO monitoring can improve HD session management.     

Gigacycle fatigue of ferrous alloys

The objective of this paper is to determine the very long fatigue life of ferrous alloys up to 1 × 10¹⁰ cycles at an ultrasonic frequency of 20 kHz. A good agreement is found with the results from conventional tests at a frequency of 25 Hz by Renault between 10⁵ and 10⁷ cycles for a spheroidal graphite cast iron. The experimental results show that fatigue failure can occur over 10⁷ cycles, and the fatigue endurance stress S _max continues to decrease with increasing number of cycles to failure between 10⁶ and 10⁹ cycles. The evolution of the temperature of the specimen caused by the absorption of ultrasonic energy is studied. The temperature increases rapidly with increasing stress amplitudes. There is a maximum temperature between 10⁶ and 10⁷ cycles which may be related to the crack nucleation phase. Observations of fracture surfaces were also made by scanning electron microscopy (SEM). Subsurface cracking has been established as the initiation mechanism in ultra-high-cycle fatigue (>10⁷ cycles). A surface–subsurface transition in crack initiation location is described for the four low-alloy high-strength steels and a SG cast iron.     

A study of 8 hour long night dialysis with the Aksys PHD dialysis system

The Aksys PHD system is designed for short quotidian dialysis employing a 52‐liter batch of ultrapure dialysate and up to 30 in situ hot water reuses of the entire extracorporeal circuit including a 40‐liter physical cleaning before each dialysis. Methods:  We studied the effect of the 52‐liter tank during 108 long 5–8 hour dialysis 3.5–6 times/week in 5 patients and one 50‐liter patient simulator for 4 weeks. Phosphate (PO₄), beta‐2 microglobulin (b‐2), urea (BUN), and creatinine (creat) were measured pre‐, during, and post‐dialysis 86 times and in total dialysate 74 times during long dialysis. Tank saturation, Kt/V, and monthly chemistries were also measured. Results:  Patient weight 76 ± 2 kg, QB 234 ± 23 ml/min, QD 498 ± 13 ml/min. Dialysate was recirculated 4.8 times during 8 hours.  

     

Controlling exit site infections: Does it decrease the incidence of catheter‐related bacteremia in children on chronic hemodialysis?

The aim of this retrospective study was to investigate whether the application of a chlorhexidine-impregnated dressing (Biopatch^®) at the exit site of tunneled-cuffed hemodialysis catheters has any effect on the incidence and etiology of catheter-related bacteremia (CRB). This study was carried out over a 5-year period in a single center, where, in the first 2½ years, the exit sites were cleansed with betadine at every hemodialysis session and then covered with a transparent dressing (pre-Biopatch^® Era). During the next 2½ years, Biopatch^® was applied to the exit site once a week after cleansing with betadine, and then covered with a transparent dressing (Biopatch^® Era). The application of Biopatch^® significantly decreased the incidence of exit site infections (ESI) (P<0.05). However, there was no difference in the incidence of CRBs or their microbiological distribution. The improved ESI rate had no effect on the overall catheter survival time. The antimicrobial sensitivities of the Gram-positive microorganisms were statistically different for the 2 different types of infections (P<0.05). In conclusion, even though Biopatch^® is effective in decreasing the incidence of ESI, it has no effect on the incidence of CRB, the etiology of CRB, or the overall catheter survival time. The distinct difference between the antimicrobial sensitivities of the ESI and CRB suggests that they are not a spectrum of the same pathogenesis. These preliminary data support the intraluminal pathogenesis of CRB, rather than the exit site as a possible entry point for the extraluminal route.     

Clinical Experiences High‐flux hemodialysis in the treatment of severe valproic acid overdose: A case report

Introduction:  Hemoperfusion, with or without hemodialysis, has been used to treat patients suffering from severe valproic acid poisoning. We report a patient suffering from severe valproic acid intoxication who was treated effectively with high‐flux hemodialysis alone. Case:  A 20‐year‐old man with a history of bipolar disorder was admitted after having ingested unknown amounts of valproic acid (Depakote®), prednisone, and erythromycin. He was agitated and obtunded but hemodynamically stable initially. Serum valproic acid level was 1,028 μg/mL. Urine toxicology screen as well as serum levels of ethanol, acetaminophen, and acetylsalicylic acid levels were negative. A gastric lavage was followed by activated charcoal instillation. Subsequent myoclonic twitchings that progressed to continuous seizure activity were managed with intravenous lorazepam therapy and endotracheal intubation. Serum valproic acid value measured two hours after admission remained elevated at 1,046 μg/mL. Hemodialysis was performed continuously for 10.5 hours using a high‐flux, polysulfone dialyzer (Polyflux 21S, Fresenius Medical Care, Lexington, MA), a dialyzer blood flow of 200–300 mL/min, and a dialysate flow of 500 mL/min. The therapy brought about a fall in serum valproic acid level to 110 μg/mL and a complete recovery of the patient. Discussion:  Valproic acid (144 Dalton) is 90–95% protein‐bound at therapeutic serum values. However, in the face of an overdose, the unbound fraction rises because of saturation of protein‐binding sites. This unbound fraction is readily dialyzable. We suggest that high‐flux hemodialysis is effective in the treatment of severe valproic acid poisoning.     

Procyanidins Gels : Influence of Ions on the Celification of Carraghenan Solutions

The formulation of procyanidin gels based on carraghenans is described. Gelling vehicles were selected to obtain stable, limpid gels of satisfactory viscosity and pH compatible with antiulcer therapy. Effort was focused on the study of the influence of cations (Na⁺, K⁺, Ca⁺⁺) and associated anions (chloride, citrate, gluconate), on the gelification : the best results were obtained with trisodium-citrate.     

Citrate anticoagulation for pediatric continuous venovenous hemodiafiltration

Objective: To describe the use of argatroban in a post‐cardiac operation patient with heparin‐induced thrombocytopenia requiring hemodialysis and continuous veno‐veno hemodialysis (CVVH). Case Summary: A 23‐year-old Caucasian female with heparin‐induced thrombocytopenia developed acute renal failure after cardiovascular surgery. Argatroban was used as a substitute for heparin during hemodialysis and CVVH. Both activated partial thromboplastin time (aPTT) and activated clotting time (ACT) were used to guide the dosage of argatroban. The patient was successfully dialyzed without clotting of the circuit. The dosage required in our patient was much lower than the manufacturer's recommendation. Discussion: Argatroban is a thrombin inhibitor that does not cross react with heparin. It is metabolized by the liver, and dosage adjustment is recommended in patients with severe hepatic impairment. The correct dosage for patient with unstable hemodynamics is not known. Our patient had apparently normal hepatic function at the initiation of dialysis, but the dosage of argatroban recommended by the manufacturer resulted in prolonged elevation of the aPTT and ACT with associated gastrointestinal bleeding. This may be related to hepatic congestion secondary to poor cardiac function and/or severe anasarca. And the dosage of argatroban required during dialysis was much lower than the recommendation. Conclusions: Argatroban is an effective alternative of heparin for CVVH. The correct initial dosage in patients with mild hepatic impairment and unstable hemodynamics is still unclear.     

Technical note High-cycle fatigue crack initiation and propagation behaviour of high-strength sprin steel wires

An attempt has been made to characterize high-cycle fatigue behaviour of high-strength spring steel wire by means of an ultrasonic fatigue test and analytical techniques. Two kinds of induction-tempered ultra-high-strength spring steel wire of 6.5 mm in diameter with a tensile strength of 1800 MPa were used in this investigation.
The fatigue strength of the steel wires between 10⁶ and 10⁹ cycles was determined at a load ratio R = −1. The experimental results show that fatigue rupture can occur beyond 10⁷ cycles. For Cr–V spring wire, the stress–life ( S – N ) curve becomes horizontal at a maximum stress of 800 MPa after 10⁶ cycles, but the S – N curve of the Cr–Si steel continues to drop at a high number of cycles (>10⁶ cycles) and does not exhibit a fatigue limit, which is more correctly described by a fatigue strength at a given number of cycles. By using scanning electron microscopy (SEM), the crack initiation and propagation behaviour have been examined. Experimental and analytical techniques were developed to better understand and predict high-cycle fatigue life in terms of crack initiation and propagation. The results show that the portion of fatigue life attributed to crack initiation is more than 90% in the high-cycle regime for the steels studied in this investigation.     

We Should Strive for Optimal Hemodialysis: A Criticism of the Hemodialysis Adequacy Concept

Adequacy of hemodialysis is frequently equated with Kt/V_urea , the amount of urea clearance (K) multiplied by time (t) and divided by urea distribution volume (V). Several formulas have been developed to calculate Kt/V_urea from the pre‐ and post‐dialysis urea concentrations. In three‐times‐weekly hemodialysis, a single pool (spKt/V_urea) value of 1.3 per treatment is commonly considered to indicate adequate therapy.
Despite providing the recommended spKt/V_urea of 1.3 per treatment, short dialysis with rapid ultrafiltration is associated with multiple intradialytic and interdialytic complications. Patients experience cramps, nausea, vomiting, headaches, fatigue, hypotensive episodes during dialysis, and hangover after dialysis; patients remain fluid overloaded with subsequent poor blood pressure control, left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality.
According to Webster's dictionary, "optimal" means most desirable or satisfactory; "adequate" means sufficient for a specific requirement or barely sufficient or satisfactory. Optimal dialysis is the method of dialysis yielding results that cannot be further improved. New approaches, including hemeral quotidian or long nocturnal dialysis, provide opportunities to abandon the notion that adequate dialysis is "good enough" for our patients. Optimal dialysis should be our goal. Dialysis sessions should be long and frequent enough to provide excellent intra‐ and interdialytic tolerance of hemodialysis, normalization of serum calcium and phosphorus, blood pressure control, normal myocardial morphology and function, and hormonal balance, and to eliminate all, even subtle, uremic symptoms.     

Quality of life, self‐care and sense of coherence in patients on hemodialysis: A comparative study

The number of patients treated for end-stage renal disease increases in Sweden like the rest of the world. During the last six years more than 1000 persons a year started renal replacement therapy. Today hemodialysis patients have the opportunity to choose different treatment modalities—home hemodialysis, self‐care dialysis, or conventional dialysis. Purpose:  The aim of the study was to investigate differences in patient on home hemodialysis, self‐care dialysis, and conventional dialysis regarding quality of life, self‐care, and sense of coherence. Methods:  Questionnaires were used: Short Form (SF‐36), Appraisal of Self‐Care Agency (ASA‐scale), and Sense of Coherence scale (SOC). 19 patients were included in the study (five patients on home hemodialysis, six self‐care patients, and eight patients on conventional dialysis). Results:  The results showed a tendency of higher scores in quality of life, self‐care, and sense of coherence for the home hemodialysis patients. Conclusion:  Since the number of participants in this study was low, it is necessary to include more patients in a future study in order to verify the results.