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.

A year-long quality improvement project on fluid management using blood volume monitoring during hemodialysis.

Background: Inadequate removal of extracellular volume markedly increases blood pressure and contributes to high morbidity and mortality in hemodialysis patients. Advances in fluid management are needed to improve clinical outcomes. The aim of this quality improvement project was to examine the advantages of using a hematocrit-based, blood volume monitor (Crit-Line * ) for 12 months, as part of a clinic-wide, fluid management program in one dialysis facility.

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.

Effects of Crit-Line® monitor use on patient outcomes and epoetin alfa dosing following onset of hemodialysis: a propensity score-matched study.

Background: The Crit-Line® monitor (CLM) is a device for monitoring hematocrit, oxygen saturation and change in intravascular blood volume during hemodialysis. Prior studies have evaluated CLM use in dialysis patients, but not specifically in those new to dialysis.

Methods: In this retrospective analysis, 199 patients initiating dialysis at 8 facilities routinely using CLM were compared with 796 propensity score-matched non-CLM patients initiating dialysis at facilities not using CLM.

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.

In-center nocturnal hemodialysis performed thrice-weekly--a provider's perspective.

Favorable clinical outcomes related to morbidity, mortality, patient well-being, laboratory biomarkers, and medication use have been reported with in-center nocturnal hemodialysis (INHD); nevertheless, it is not entirely clear how much patient selection or physiologic mechanisms related to better fluid management and phosphorus (and calcium) metabolism may explain these outcomes. There are indications that INHD may be a preferred treatment option in specific cases, such as in patients with high interdialytic weight gain, poor tolerance to high ultrafiltration rate, hyperphosphatemia, or for those patients who work or go to school during the day. In the era of the new prospective payment system where quality standards become intertwined with reimbursement, an INHD program may be a useful method to help attain quality goals in facilities that have patients with unfavorable case-mix.

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.

New pH-neutral peritoneal dialysis solution, low in glucose degradation products, in a double-chamber bag.

Fresenius Medical Care-North America has developed a neutral-pH version of its Delflex peritoneal dialysis (PD) solution with low glucose degradation products (GDPs): Delflex Neutral pH. The Delflex Neutral pH system stores the PD solution in a dual-chamber bag. The product is admixed by the patient before use.

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.