Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS.
TL;DR: Longer TT and higher Kt/V were independently as well as synergistically associated with lower mortality, and a randomized clinical trial of longer dialysis sessions in thrice-weekly HD is warranted.
About: This article is published in Kidney International.The article was published on 2006-04-01 and is currently open access. It has received 490 citations till now. The article focuses on the topics: Risk of mortality.
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TL;DR: The results of this study indicate that the hydration state is an important and independent predictor of mortality in chronic HD patients secondary only to the presence of diabetes.
Abstract: Background. While cardiovascular events remain the primary form of mortality in haemodialysis (HD) patients, few centres are aware of the impact of the hydration status (HS). The aim of this study was to investigate how the magnitude of the prevailing overhydration influences long-term survival. Methods. We measured the hydration status in 269 prevalent HD patients (28% diabetics, dialysis vintage = 41.2 ± 70 months) in three European centres with a body composition monitor (BCM) that enables quantitative assessment of hydration status and body composition. The survival of these patients was ascertained after a follow-up period of 3.5 years. The cut off threshold for the definition of hyperhydration was set to 15% relative to the extracellular water (ECW), which represents an excess of ECW of ∼2.5 l. Cox-proportional hazard models were used to compare survival according to the baseline hydration status for a set of demographic data, comorbid conditions and other predictors. Results. The median hydration state (HS) before the HD treatment (� HSpre) for all patients was 8.6 ± 8.9%. The unadjusted gross annual mortality of all patients was 8.5%.
580 citations
Additional excerpts
...Due to the inability to quantify the individual hydration state, previous studies assessing the outcome have used surrogate parameters such as IDWL [43], inter-dialysis weight gain and ultrafiltration rate [44]....
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TL;DR: Higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular death, and hospitalization for cardiovascular disease.
391 citations
Cites background or methods from "Longer treatment time and slower ul..."
...41).(15) Subsequent data suggest that the cut point of 10 ml/h/kg may have been too low to observe a true UFR–CV mortality association,(16) and the issue remains unsettled....
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...In the primary analysis, UFR was categorized as p10 ml/h/kg, 10–13 ml/h/kg, and 413 ml/h/kg based on precedent in the literature.(15,16) Secondary analysis considered a cubic spline representation of UFR....
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...UFR was expressed in terms of ml/h/kg by dividing the ultrafiltration volume by dialysis session length and target weight.(15,16) In the primary analysis, UFR was categorized as p10 ml/h/kg, 10–13 ml/h/kg, and 413 ml/h/kg based on precedent in the literature....
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...Only one previous study has examined the association between UFR and CV mortality, failing to show a significant difference in risk between participants with UFR p10 versus 410 ml/h/kg.(15) Subsequent work (which considered allcause but not CV mortality) suggested that a threshold of...
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TL;DR: The HRP provides an invaluable tool for classifying patients in terms of BPsys and DeltaHS and the proximity of these parameters to reference ranges and represents an important step towards more objective choice of strategies for the optimal treatment of hypertension and FO.
Abstract: BACKGROUND Hypertension and fluid overload (FO) are well-recognized problems in the chronic kidney disease (CKD) population. While the prevalence of hypertension is well documented, little is known about the severity of FO in this population. METHODS A new bioimpedance spectroscopy device (BCM-Body Composition Monitor) was selected that allows quantitative determination of the deviation in hydration status from normal ranges (DeltaHS). Pre-dialysis systolic blood pressure (BPsys) and DeltaHS was analysed in 500 haemodialysis patients from eight dialysis centres. A graphical tool (HRP-hydration reference plot) was devised allowing DeltaHS to be combined with measurements of BPsys enabling comparison with a matched healthy population (n = 1244). RESULTS Nineteen percent of patients (n = 95) were found to have normal BPsys and DeltaHS in the normal range. Approximately one-third of patients (n = 133) exhibited reasonable control of BPsys and fluids (BPsys 150 mmHg) with a concomitant DeltaHS >2.5 L (possible volume-dependent hypertension). In contrast, 13% of patients (n = 69) were hypertensive with DeltaHS <1.1 L (possible essential hypertension). In 10% of patients (n = 52), BPsys <140 mmHg was recorded despite DeltaHS exceeding 2.5 L. CONCLUSION Our study illustrated the wide variability in BPsys regardless of the degree of DeltaHS. The HRP provides an invaluable tool for classifying patients in terms of BPsys and DeltaHS and the proximity of these parameters to reference ranges. This represents an important step towards more objective choice of strategies for the optimal treatment of hypertension and FO. Further studies are required to assess the prognostic and therapeutic role of the HRP.
265 citations
Cites result from "Longer treatment time and slower ul..."
...This might be due to shorter treatment times in the USA compared to Europe [48] and may explain the observed higher mortality of dialysis patients in the USA [49]....
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TL;DR: The patient has a history of undiagnosed central giant cell granuloma, and the treatment of IDH and antihypertensive drugs and preventive medication was determined to be safe and effective.
Abstract: 1. Evaluation of the patient1.1 Assessment of dry weight1.2 Measurement of blood pressure and heart rateduring dialysis1.3 Cardiac evaluation2. Lifestyle interventions2.1 Sodium restriction2.2 Food and caffeine intake during dialysis3. Factors relation to the dialysis treatment3.1 Manipulation of ultrafiltration3.1.1 Ultrafiltration profiling3.1.2 Blood volume controlled ultrafiltration3.2 Dialysate composition.3.2.1 High sodium dialysis and sodium profiling3.2.2 Dialysate buffer3.2.3 Dialysate calcium3.2.4 Other components of dialysate3.3 Dialysis membranes/contamination ofdialysate.3.4 Dialysate temperature.3.5 Convective techniques and isolatedultrafiltration.3.5.1 Convective techniques3.5.2 Isolated ultrafiltration3.6 Dialysis duration and frequency.3.7 Switch to peritoneal dialysis.4. Antihypertensive drugs and preventive medication4.1 Antihypertensive drugs4.2 Preventive vasoactive agents4.3 Carnitine5. Stratified approach to prevent IDH6. Treatment of IDH6.1 Trendelenburg position6.2 Stopping ultrafiltration6.3 Infusion fluids6.4 Protocol
242 citations
TL;DR: High UFRs are independently associated with increased mortality risk in HD patients and longer or more frequent dialysis sessions should be considered in order to prevent the deleterious consequences of excessive UFR.
Abstract: Background. High ultrafiltration rate on haemodialysis (HD) stresses the cardiovascular system and could have a negative effect on survival. Methods. The effect of ultrafiltration rate (UFR; ml/h/ kg BW) on mortality was prospectively evaluated in a cohort of 287 prevalent uraemic patients in regular HD from 1 January 2000 to 31 December 2005. Patients: 165 men and 122 women, age 66 � 13 years, on regular HD for at least 6 months, median: 48 months (range 6–372 months). Mean UFR was 12.7 � 3.5 ml/h/kg BW, Kt/V: 1.27 � 0.13, body weight (BW): 62 � 13 kg, PCRn: 1.11 � 0.20 g/kg/day, duration of dialysis: median 240 min (range 180–300 min), mean arterial blood pressure (MAP) 99 � 9 mm/Hg. One hundred and forty nine patients (52%) died, mainly for cardiovascular reasons (69%). Multivariate Cox regression analysis was utilized to evaluate the effect on mortality of UFR, age, sex, dialytic vintage, cardiovascular disease (CVD), diabetes, dialysis modality, duration of HD, BW, interdialytic weight gain (IWG), body mass index (BMI), MAP, pulse pressure (PP), Kt/V, PCRn. Results. Age (HR 1.06; CI 1.04–1.08; P < 0.0001), PCRn (HR 0.17, CI 0.07–0.43; P < 0.0001), diabetes (HR 1.81, CI 1.24–2.47; P ¼ 0.007), CVD (HR 1.86; CI 1.32–2.62; P ¼ 0.007) and UFR (HR 1.22; CI 1.16–1.28; P < 0.0001) were identified as factors independently correlated to survival. We estimated the discrimination potential of UFR, evaluated at baseline, in predicting death at 5 years, calculating the relative receiver operating characteristic (ROC) curves and the cut-off that minimizes the absolute difference between sensitivity and specificity. Conclusions. High UFRs are independently associated with increased mortality risk in HD patients. Better survival was observed with UFR < 12.37 ml/h/kg BW. For patients with higher UFRs, longer or more frequent dialysis sessions should be considered in order to prevent the deleterious consequences of excessive UFR.
215 citations
Cites background from "Longer treatment time and slower ul..."
...While some studies have suggested that longer duration of HD sessions could be associated with better survival [7,8], other have failed to confirm this relationship [9,10], so no clear evidence for a direct association of UFR and patients outcome has emerged....
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References
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Book•
01 May 1997TL;DR: Survival analysis:techniques for censored and truncated data, Survival analysis: techniques for censored data analysis, survival analysis, and survival analysis techniques for truncated and uncoded data analysis.
Abstract: Survival analysis:techniques for censored and truncated data , Survival analysis:techniques for censored and truncated data , کتابخانه مرکزی دانشگاه علوم پزشکی ایران
3,423 citations
01 Jan 2012
TL;DR: Survival analysis:techniques for censored and truncated data, Survival analysis:Techniques for censorship and truncation data, کتابخانه مرکزی ایران.
Abstract: Survival analysis:techniques for censored and truncated data , Survival analysis:techniques for censored and truncated data , کتابخانه مرکزی دانشگاه علوم پزشکی ایران
2,727 citations
Baylor College of Medicine1, Cleveland Clinic2, University of Utah3, University of Illinois at Chicago4, National Institutes of Health5, University of Alabama6, Emory University7, Washington University in St. Louis8, University of California, Davis9, Tufts University10, Yeshiva University11, Harvard University12, University of Rochester13, Wake Forest University14, Vanderbilt University15, Duke University16
TL;DR: Patients undergoing hemodialysis thrice weekly appear to have no major benefit from a higher dialysis dose than that recommended by current U.S. guidelines or from the use of a high-flux membrane.
Abstract: Background The effects of the dose of dialysis and the level of flux of the dialyzer membrane on mortality and morbidity among patients undergoing maintenance hemodialysis are uncertain. Methods We undertook a randomized clinical trial in 1846 patients undergoing thrice-weekly dialysis, using a two-by-two factorial design to assign patients randomly to a standard or high dose of dialysis and to a low-flux or high-flux dialyzer. Results In the standard-dose group, the mean (±SD) urea-reduction ratio was 66.3±2.5 percent, the single-pool Kt/V was 1.32±0.09, and the equilibrated Kt/V was 1.16±0.08; in the high-dose group, the values were 75.2±2.5 percent, 1.71±0.11, and 1.53±0.09, respectively. Flux, estimated on the basis of beta2-microglobulin clearance, was 3±7 ml per minute in the low-flux group and 34±11 ml per minute in the high-flux group. The primary outcome, death from any cause, was not significantly influenced by the dose or flux assignment: the relative risk of death in the high-dose group as com...
1,670 citations
TL;DR: An analysis of error showed that this second-generation formula eliminated the overestimation of Kt/V in the high ranges found with the first-generation model, and total error was reduced.
Abstract: The original formula proposed to estimate variable-volume single-pool (VVSP) Kt/V was Kt/V = -In(R - 0.008 * t - f * UF/W), where in the Kt/V range of 0.7 to 1.3, f = 1.0 (* denotes multiplication). This formula tends to overestimate Kt/V as the Kt/V increases above 1.3. Because higher Kt/V values are now commonly delivered, the validity of both the urea generation term (0.008 * f) and correction for UF/W were explored by solving VVSP equations for simulated hemodialysis situations, with Kt/V ranging from 0.6 to 2.6. The analysis led to the development of a second-generation formula, namely: Kt/V = -In(R - 0.008 * t) + (4-3.5 * R) * UF/W. The first and second generation formulas were then used to estimate the modeled VVSP Kt/V in 500 modeling sessions in which the Kt/V ranged widely from 0.7 to 2.1. An analysis of error showed that this second-generation formula eliminated the overestimation of Kt/V in the high ranges found with the first-generation formula. Also, total error (absolute value percent error + 2 SD) was reduced with the second-generation formula. These results led to the proposal of a new formula that can be used for a very wide range of delivered Kt/V.
1,365 citations
TL;DR: Nonadherence was associated with increased mortality risk (skipping treatment, excessive IDWG, and high phosphate) and with hospitalization risk (kipping, high phosphate).
470 citations