A Comparison of Clinical Parameters and Outcomes over 1 Year in Home Hemodialysis Patients Using 2008K@home or NxStage System One.

The prevalence of home hemodialysis (HHD) in the United States is growing, driven in part by improvements in dialysis machines for home use. We assessed clinical parameters and outcomes in HHD patients using either Fresenius 2008K@home or NxStage System One over 1 year. Patients were 18 years or older and received HHD for ≥30 days between January 1, 2009, and June 30, 2010.

Home hemodialysis dose: balancing patient needs and preferences.

Background: The aim in defining the dose of HHD is to provide sufficient dialysis required to possibly 'normalize' all abnormalities associated with renal failure in order improve patient survival and quality of life. Much progress has been made in defining the dose required to accomplish this goal, but the evidence is still far from robust. The main limitations are incomplete understanding of uremic toxins, their relative importance in causing uremic symptoms, and our inability to comprehensively assess dry weight.

Intradialytic hypotension: frequency, sources of variation and correlation with clinical outcome.

Intradialytic hypotension (IH) is a frequent complication of hemodialysis (HD) and is associated with increased patient mortality and cardiovascular events. We studied IH to determine its variability, correlates, and clinical impact in 13 outpatient HD facilities. Blood pressure was captured by machine download.

The importance of residual renal function in peritoneal dialysis patients.

Increased peritoneal clearance can compensate for reductions in renal solute removal in patients receiving peritoneal dialysis (PD); however there is abundant evidence to suggest that renal rather than peritoneal clearance contributes to clinical outcomes. We review the evidence investigating the impact of residual renal function (RRF) and peritoneal solute clearances on survival and quality of life in PD patients. We also provide a comparison of the relative contribution of RRF and peritoneal clearance to patient survival.

Frequent hemodialysis: a critical review.

Conventional, thrice-weekly hemodialysis (CHD) is the most commonly prescribed dialysis regimen. Despite widespread acceptance of CHD, long-term analyses of registry data have revealed an increased risk for mortality during the long 2-day interdialytic interval of thrice-weekly therapies. High mortality rates during this period suggest that there may be a role for more frequent HD in improving patient outcomes and survival through elimination of the long interdialytic period.

The challenges of heat sterilization of peritoneal dialysis solutions: is there an alternative?

Peritoneal dialysis (PD) solutions are currently sterilized in an autoclave using high-temperature saturated steam. Although thermal methods are an effective means of sterilization, the heating of PD solutions results in the formation of toxic glucose degradation products (GDPs). Here, we review basic concepts in the sterilization of PD solutions and discuss possible alternatives to steam sterilization, including filtration, ohmic heat, ionizing radiation, and pulsed ultraviolet light.

Phosphate clearance in peritoneal dialysis: automated PD compared with continuous ambulatory PD.

Although dialytic removal of phosphate significantly contributes to the management of phosphate levels in end-stage renal disease, many patients on peritoneal dialysis (PD) still do not reach optimal phosphate control. The present review discusses the impact of PD modality--continuous ambulatory (CAPD) or automated (APD)--on phosphate removal. Relevant factors are the diffusive properties of the phosphate anion and the kinetics of phosphate distribution in various body compartments.

A new neutral-pH low-GDP peritoneal dialysis fluid.

Background: Conventional peritoneal dialysis fluids (PDFs) consist of ready-to-use solutions with an acidic pH. Sterilization of these fluids is known to generate high levels of glucose degradation products (GDPs). Although several neutral-pH, low-GDP PD solutions have been developed, none are commercially available in the United States.

Effects of citrate acid concentrate (citrasate®) on heparin N requirements and hemodialysis adequacy: a multicenter, prospective noninferiority trial.

Background: Citrasate®, citric acid dialysate (CD), contains 2.4 mEq of citric acid (citrate), instead of acetic acid (acetate) as in standard bicarbonate dialysate. Previous studies suggest CD may improve dialysis adequacy and decrease heparin requirements, presumably due to nonsystemic anticoagulant effects in the dialyzer.

GDPs and AGEs: impact on cardiovascular toxicity in dialysis patients.

Glucose degradation products (GDPs) are highly reactive precursors of advanced glycation end-products (AGEs). High glucose concentrations, GDPs, and AGEs can activate specific pathways, including inflammatory and oxidative stress response pathways, which may adversely affect the cardiovascular system. This review discusses the impact and possible mechanisms of action of GDPs and AGEs with regard to cardiovascular toxicity in chronic kidney disease patients.

Anemia management in patients receiving chronic hemodialysis.

Anemia treatment in hemodialysis-dependent (HDD) CKD patients involves adequate supply of iron and an erythropoiesis-stimulating agent (ESA). Despite widespread usage of these agents, there is no generally accepted "standard dosing algorithm" for treating anemia in HDD-CKD patients. The new anemia Quality Incentive Program (QIP) introduced by the Centers for Medicare & Medicaid Services represents a motivation to standardize and harmonize iron and ESA regimens with interactive electronic algorithms and novel modes of deliveries for IV iron and ESA doses.

Improving the delivery of coordinated and individualized care.

Pharmatech comprises systems for the automated use and coordination of clinical information, medical devices, care paths, and pharmacologic agents into specific prescription and care-delivery processes tailored to meet individual patient needs. In ESRD, future suites of applications to run on hemodialysis, peritoneal dialysis machines, external computers and devices both in-center and in the home setting offer the potential to further automate billing and inventory, improve documentation, reduce medical errors, and decrease costs. On a clinical basis, these systems will aid nurses, physician assistants, nurse practitioners, and physicians in performing and overseeing a wide range of clinical activities that constitute 21st-century medicine.

Introduction to Pharmatech.

The collection of papers published in this issue of Seminars in Dialysis describes our approach to Pharmatech, which is the integration of services, medical devices, and pharmacologic agents, into specific prescription processes. Pharmatech is developed to systematically facilitate an individual's prescription according to each patient's specific needs. This includes evidence-based algorithms for control, anemia management and isonatremic dialysis, devices to deliver precise doses of injectable drugs, and future developments to simplify loading new applications into the system.

Metabolic effects of dialyzate glucose in chronic hemodialysis: results from a prospective, randomized crossover trial.

Background: There is no agreement concerning dialyzate glucose concentration in hemodialysis (HD) and 100 and 200 mg/dL (G100 and G200) are frequently used. G200 may result in diffusive glucose flux into the patient, with consequent hyperglycemia and hyperinsulinism, and electrolyte alterations, in particular potassium (K) and phosphorus (P). This trial compared metabolic effects of G100 versus G200.

Effects of dialysate glucose concentration on heart rate variability in chronic hemodialysis patients: results of a prospective randomized trial.

Background: Chronic hemodialysis (HD) patients suffer from an appallingly high cardiovascular mortality. During HD, patients are exposed to dialysate glucose, which may alter blood glucose levels and thus exert effects on the autonomic nervous system. Heart rate variability (HRV) is an established indicator of autonomic nervous system activity and a predictor of cardiovascular outcomes.

Strategies to universally improve peritonitis rates, including use of dialysis solutions with low glucose degradation products.

Despite technology advances, prevention of peritonitis remains one of the major challenges in peritoneal dialysis (PD). Several innovative developments have shown an impact on peritonitis rates. Innovative antimicrobial-coated catheter modifications have been introduced, showing promising results in vitro.

A randomized, double-blind, placebo-controlled trial of calcium acetate on serum phosphorus concentrations in patients with advanced non-dialysis-dependent chronic kidney disease.

Background: Hyperphosphatemia in patients with chronic kidney disease (CKD) contributes to secondary hyperparathyroidism, soft tissue calcification, and increased mortality risk. This trial was conducted to examine the efficacy and safety of calcium acetate in controlling serum phosphorus in pre-dialysis patients with CKD.

Methods: In this randomized, double-blind, placebo-controlled trial, 110 nondialyzed patients from 34 sites with estimated GFR < 30 mL/min/1.

Home hemodialysis: a comparison of in-center and home hemodialysis therapy in a cohort of successful home hemodialysis patients.

We retrospectively evaluated 29 patients dialyzed for 6 months in-center on Fresenius 2008H or 2008K dialysis machines followed by 6 months at home using the Fresenius 2008K@home to determine the safety and efficacy of home hemodialysis (HHD) using the 2008K@home. Patients who initiated HHD were identified from order records and qualified for inclusion if they had available records and a minimum of three pre- and postdialysis blood urea nitrogen measurements during each period. Dialysis adequacy (mean standard weekly Kt/V) remained stable during the in-center (IC; 2.

A 1-year randomized trial of calcium acetate versus sevelamer on progression of coronary artery calcification in hemodialysis patients with comparable lipid control: the Calcium Acetate Renagel Evaluation-2 (CARE-2) study.

Background: Previous clinical trials showed that progression of coronary artery calcification (CAC) may be slower in hemodialysis patients treated with sevelamer than those treated with calcium-based phosphate binders. Because sevelamer decreases low-density lipoprotein cholesterol (LDL-C) levels, we hypothesized that intensive lowering of LDL-C levels with atorvastatin in hemodialysis patients treated with calcium acetate would result in CAC progression rates similar to those in sevelamer-treated patients.

Study Design: Randomized, controlled, open-label, noninferiority trial with an upper bound for the noninferiority margin of 1.

Case report of encapsulating peritoneal sclerosis: the interpretation of functional and structural peritoneal changes.

A case report describing the evolution of encapsulating peritoneal sclerosis is presented to illustrate some of the functional and structural peritoneal membrane changes characteristic of this complication of peritoneal dialysis. The appropriate monitoring of peritoneal transport rates and ultrafiltration, together with attention to clinical signs and symptoms, are essential to the early diagnosis of peritoneal membrane deterioration. Recent reports suggest that timely interventions such as a peritoneal membrane rest period may effectively halt the progression of these functional and structural changes.

Peritoneal dialysis solutions low in glucose degradation products: clinical experience and outcomes.

The latest literature describing clinical experiences with peritoneal dialysis solutions low in glucose degradation products (GDPs) is mostly consistent with previous reports suggesting less inflammation, better peritoneal mesothelial mass preservation, a lower rate of decline of residual renal function, and improved patient survival. The data suggest stable peritoneal transport rates, but no definite evidence has yet emerged of superior membrane preservation. Most studies have reported very low peritonitis rates, but without significant differences as compared with rates in patients exposed to conventional solutions.

Agents that modulate peritoneal membrane structure and function.

Extensive experience with chronic peritoneal dialysis has identified a series of functional and anatomical pathologic changes in the peritoneal membrane thought to be the result of repeated insults from bioincompatible solutions. Laboratory and clinical findings from recent investigations often conflict and are difficult to interpret due to variations in methodologies, animal models, study designs, and data analyses. The principal pathophysiologic mechanisms identified thus far are oxidative stress, inflammation, and their consequences.