Hemodialysis Vascular Access: A Historical Perspective on Access Promotion, Barriers, and Lessons for the Future.

This review describes the history of vascular access for hemodialysis (HD) over the past 8 decades. Reliable, repeatable vascular access for outpatient HD began in the 1960s with the Quinton-Scribner shunt. This was followed by the autologous Brecia-Cimino radial-cephalic arteriovenous fistula (AVF), which dominated HD vascular access for the next 20 years.

Detection of Hemodialysis Venous Needle Dislodgment Using Venous Access Pressure Measurements: A Simulation Study.

Key Points: Hemodialysis machine pressure alarms may not detect venous needle dislodgment when patients have changes in venous pressure. A cross-sectional analysis of hemodialysis treatment data identified the occurrences of venous pressure changes that would make it hard to trigger a machine alarm. A proof-of-concept use of a data analytic–derived algorithm for the detection of venous needle dislodgments was demonstrated.

Fundamentals of Arterial Blood Gas Interpretation.

Acid-base disturbances in patients with cardiopulmonary or other disorders are common and are often misinterpreted or interpreted incompletely. Treating acid-base disorders in greater detail facilitates pathophysiologic understanding and improved therapeutic planning. Understanding the ratiometric relationship between the lungs, which excrete volatile acid as carbon dioxide, and the kidneys, which contribute to maintenance of plasma bicarbonate, allows precise identification of the dominant acid-base disturbance when more than a simple disorder is present and aids in executing a measured treatment response.

Remote Monitoring of Sustained Low-Efficiency Dialysis (SLED) Machines in Intensive Care Unit.

The Henry Ford Health System provides patients with a safe, improved system of continuous kidney replacement therapy using a proprietary, 24-hour sustained low-efficiency dialysis (SLED). The SLED system utilizes regional citrate anticoagulation (RCA) in conventional hemodialysis machines that have been configured to provide slow dialytic therapy. Within our hospital complex, SLED-RCA systems are deployed in intensive care units distributed over 4 floors in 2 buildings.

Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF.

Development and validation of a risk score to prioritize patients for evaluation of access stenosis.

Background: Access flow dysfunction, often associated with stenosis, is a common problem in hemodialysis access and may result in progression to thrombosis. Timely identification of accesses in need of evaluation is critical to preserving a functioning access. We hypothesized that a risk score using measurements obtained from the Vasc-Alert surveillance device could be used to predict subsequent interventions.

Sodium-Based Osmotherapy in Continuous Renal Replacement Therapy: a Mathematical Approach.

Cerebral edema, in a variety of circumstances, may be accompanied by states of hyponatremia. The threat of brain injury from hypotonic stress-induced astrocyte demyelination is more common when vulnerable patients with hyponatremia who have end stage liver disease, traumatic brain injury, heart failure, or other conditions undergo overly rapid correction of hyponatremia. These scenarios, in the context of declining urinary output from CKD and/or AKI, may require controlled elevations of plasma tonicity increases of the plasma sodium concentration.

Continuous Renal Replacement Therapy for the Management of Acid-Base and Electrolyte Imbalances in Acute Kidney Injury.

Continuous renal replacement therapy (CRRT) is used to manage electrolyte and acid-base imbalances in critically ill patients with acute kidney injury. Although a standard solution and prescription is acceptable in most clinical circumstances, specific disorders may require a tailored approach such as adjusting fluid composition, regulating CRRT dose, and using separate intravenous infusions to mitigate and correct these disturbances. Errors in fluid prescription, compounding, or delivery can be rapidly fatal.

Treatment of Severe Metabolic Alkalosis with Continuous Renal Replacement Therapy: Bicarbonate Kinetic Equations of Clinical Value.

Concomitant severe metabolic alkalosis, hypernatremia, and kidney failure pose a therapeutic challenge. Hemodialysis to correct azotemia and abnormal electrolytes results in rapid correction of serum sodium, bicarbonate, and urea but presents a risk for dialysis disequilibrium and brain edema. We describe a patient with Zollinger-Ellison syndrome with persistent encephalopathy, severe metabolic alkalosis (highest bicarbonate 81 mEq/L), hypernatremia (sodium 157 mEq/L), and kidney failure despite 30 hours of intravenous crystalloids and proton pump inhibitor.

Iron repletion is associated with reduction in platelet counts in non-dialysis chronic kidney disease patients independent of erythropoiesis-stimulating agent use: a retrospective cohort study.

Background: Iron deficiency is common in non-dialysis chronic kidney disease (ND-CKD) patients and, on occasion, requires parenteral iron therapy. We investigated the effect of intravenous iron repletion on platelet counts in ND-CKD patients with and without concomitant darbepoetin administration.

Methods: We conducted a retrospective analysis of ND-CKD patients with iron deficiency anemia treated with low molecular weight iron dextran (LMWID) between 2005 and 2009 at our CKD clinic.

Treatment of severe hyponatremia in patients with kidney failure: role of continuous venovenous hemofiltration with low-sodium replacement fluid.

Patients with hypervolemic hyponatremia and kidney failure pose a special therapeutic challenge. Hemodialysis to correct volume overload, azotemia, and abnormal electrolyte levels will result in rapid correction of serum sodium concentration and place the patient at risk for osmotic demyelination syndrome. We present a patient with acute kidney injury and severe hypervolemic hypotonic hyponatremia (serum sodium<100 mEq/L) who was treated successfully with continuous venovenous hemofiltration.

Online Hemoglobin and Oxygen Saturation Sensing During Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation.

Optical hemoglobin and oxygen saturation sensor (OHOS) monitor when used in combination with other hemodynamic tools may be useful for continuous hemodynamic monitoring during ultrafiltration. The stand-alone OHOS monitor can easily be deployed predialyzer into the extracorporeal circuit of continuous renal replacement therapy (CRRT) systems. To maximize the accuracy of the OHOS in 24 hr CRRT systems, clotting in the optical blood chamber and the presensor dilution incurred by replacement fluid should be minimized.

Intravenous iron dextran as a component of anemia management in chronic kidney disease: a report of safety and efficacy.

Objective. We aimed to demonstrate safety and efficacy of intravenous (IV) low molecular weight iron dextran (LMWID) during treatment of anemic stage 3 and 4 chronic kidney disease (CKD) patients. Methods.

Sensors and hybrid therapies: a new approach with automated citrate anticoagulation.

Background: Hybrid therapies use intermittent hemodialysis (IHD) machines adapted to provide prolonged intermittent or continuous renal replacement therapy in the intensive care unit (ICU). Despite the low cost, hybrid therapy use is limited warranting a novel approach.

Methods: The literature was reviewed for limitations of hybrid protocols, use of regional citrate anticoagulation (RCA) on hybrid systems and sensors for IHD and hybrid therapy.

De novo once-monthly darbepoetin alpha treatment for the anemia of chronic kidney disease using a computerized algorithmic approach.

Background: Anemia of chronic kidney disease (CKD) has been traditionally treated by erythropoiesis-stimulating agents (ESAs) and/or iron following manual determination of dose. We hypothesized that once-monthly (QM) algorithmically dosed darbepoetin α (DA) and iron administration would successfully treat anemia of CKD in ESA-naïve CKD subjects.

Methods: QM DA and iron doses were determined via a computerized program targeting a hemoglobin (Hb) of 10.

Development of an online citrate/Ca2+ sensing system for dialysis.

An online citrate and Ca(2+) sensing system based on sequential injection analysis (SIA) is developed as a safety module for hemodialysis. Host 1 displays high affinity towards citrate, and was selected for this study owing to its unique structural features. The o-aminomethylphenylboronic moiety can effectively interact with the α-hydroxycarboxylate moiety of citrate and the remaining two guanidiniums may further stabilize the complex via hydrogen bonds.

Automated intravascular access pressure surveillance reduces thrombosis rates.

Although monitoring of vascular accesses by physical examination is nearly as sensitive as surveillance measurements by vascular access pressure when performed by examiners, the frequency of examinations is limited by time. We developed intravascular access pressure surveillance as a surrogate to physical examination. Using real-time data from hemodialysis machines, we derived intravascular access pressure ratios for each dialytic procedure.

Automated regional citrate anticoagulation: technological barriers and possible solutions.

Background: Large-scale adoption of regional citrate anticoagulation (RCA) is prevented by risks of the technique as practiced traditionally. Safe RCA protocols with automated delivery on customized dialysis systems are needed.

Methods: We applied kinetic analysis of solute fluxes during RCA to design a protocol for sustained low-efficiency dialysis (SLED) for critically ill patients.

What is so bad about a hemoglobin level of 12 to 13 g/dL for chronic kidney disease patients anyway?

Randomized controlled trials (RCTs) clearly indicate a possible cardiovascular morbidity and mortality risk when deliberately targeting a normal hemoglobin (Hb) concentration of 13 to 15 g/dL. By contrast, observational studies point to greater hospitalization and mortality at Hb levels <11 g/dL. There are no direct data to help us determine where, within this broad range, the optimal Hb lies.

Hemoglobin variability and hyporesponsiveness: much ado about something or nothing?

Hemoglobin (Hb) variability is considered a discrete clinical entity that when present may presage poor clinical outcomes. However, Hb variability is an intrinsic property of biological systems and is present in all patients, those with and without the anemia of chronic kidney disease. Taken together, variability actually represents the integration of multiple influences at multiple levels in the life of a red cell, namely the summation of positive and negative influences on erythropoiesis.

Effect of intravenous ascorbic acid in hemodialysis patients with EPO-hyporesponsive anemia and hyperferritinemia.

Background: Although erythropoietin (EPO)-hyporesponsive anemia in hemodialysis patients most commonly results from iron deficiency, the contributory role of chronic inflammation and oxidative stress in its pathogenesis is poorly understood. We conducted an open-label prospective study to assess the effect of vitamin C, an antioxidant, on EPO-hyporesponsive anemia in hemodialysis patients with unexplained hyperferritinemia.

Methods: Forty-six of 262 patients in an inner-city hemodialysis center met the inclusion criteria (administration of intravenous iron and EPO for > or = 6 months at a dose > or = 450 U/kg/wk, average 3-month hemoglobin [Hb] level < or = 11.

Effect of differing blood lines on delivered blood flow during hemodialysis.

Unlabelled: BACKGROUND The influence of differing blood tubing sets on delivered dialyzer blood flow (Q B ) was studied using ReadySet (RS; Medisystem Inc, Seattle, WA) and CombiSet (CS; Fresenius, Walnut Creek, CA).

Methods: In vitro, we measured Q B and pre-pump arterial pressures (P A; in millimeters of mercury) during 4 hours at a prescribed blood pump flow (Q P ) of 450 mL/min, using a glycerin-water mixture for RS and CS blood tubing sets (n = 10 each). We then performed 3 clinical studies to determine the difference between Q P and Q B as a function of P A for both tubing types and any effects of tubing type on delivered Kt/V in patients.

Prevention of hemodialysis-related muscle cramps by intradialytic use of sequential compression devices: a report of four cases.

Background: Hemodialysis (HD)-related lower extremity (LE) muscle cramps are a common cause of morbidity in end-stage renal disease patients on maintenance HD. Numerous pharmacologic and physical measures have been tried with variable success rates.

Methods: Sequential compression devices (SCD) improve venous return (VR) and are commonly used to prevent LE deep venous thrombosis in hospitals.

Dynamic venous access pressure ratio test for hemodialysis access monitoring.

Background: Early recognition of arteriovenous graft (AVG) dysfunction in hemodialysis (HD) patients followed by prompt corrective procedures reduces AVG thrombosis rates and lengthens access survival. We developed a method to prospectively monitor AVGs that uses an algorithm to calculate venous access pressure (VAP) during HD from the venous drip chamber pressure (VDP).

Methods: Sham HD with blood was performed using standard blood tubing and a 1-in.

Effects of systemic hemodynamics on flow within vascular accesses used for hemodialysis.

Absolute value of access flow (QA) and change in flow (deltaQA) over time are major determinants of access patency. However, QA may change in response to variation in systemic hemodynamics among dialysis sessions. We examined the effect of mean arterial pressure (MAP), cardiac output (CO), and segmental resistances (R) on QA.