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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 54-60
Can continuous venovenous hemofiltration prevent contrast-agent induced nephropathy in patients with advanced chronic kidney disease after coronary angiography?


Department of Nephrology, Mubarak Al Kabeer Hospital, Ministry of Health, Kuwait

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Date of Web Publication30-Dec-2010
 

   Abstract 

To determine whether contrast induced nephropathy (CIN) post coronary angio­graphy procedure can be prevented in chronic kidney disease (CKD) patients by continuous venovenous hemofiltration (CVVH), we evaluated 98 CKD patients [52 (53.1%) were males, the mean age was 60.7 ± 11.0 years] who underwent coronary angiography from January 2004 to December 2006. Serum creatinine (Cr) before the procedure was 411 ± 79.9 μmol/L and crea­tinine clearance (Cr Cl) was 18.04 ± 4.26 mL/min. All patients underwent post procedure CVVH for 21.34 ± 2.12 hours. The mean time interval between the procedure and the start of CVVH was 44.3 ± 18.8 min. The mean serum Cr at discharge was 403 ± 88.4 μmol/L (Cr Cl 18.5 ± 4.61 mL/min) and was 423 ± 88.9 μmol/L (Cr Cl17.6 ± 4.27 mL/min) 15 days after the procedure. One patient (1.02%) developed worsening of renal functions that required repeated CVVH during hospitalization and ended up on regular hemodialysis. There was no in-hospital mortality. We conclude that CVVH is effective in preventing CIN after coronary angiography in CKD patients.

How to cite this article:
Ghani AA, Hussain N, Al Helal B. Can continuous venovenous hemofiltration prevent contrast-agent induced nephropathy in patients with advanced chronic kidney disease after coronary angiography?. Saudi J Kidney Dis Transpl 2011;22:54-60

How to cite this URL:
Ghani AA, Hussain N, Al Helal B. Can continuous venovenous hemofiltration prevent contrast-agent induced nephropathy in patients with advanced chronic kidney disease after coronary angiography?. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Jul 20];22:54-60. Available from: http://www.sjkdt.org/text.asp?2011/22/1/54/74345

   Introduction Top


The incidence of contrast induced nephro­pathy (CIN) is now increasing owing to the in­creasing use of radiocontrast media (CM) in diagnostic imaging as well as interventional procedures. [1] The most widely accepted defini­tion of CIN is an increase of 25% or more, or an absolute increase of 0.5 mg/dL (44 μmol/L) or more in serum creatinine (Cr) from baseline values, at 24-72 hours following exposure to CM. [2] CIN is one of the leading causes of hospital acquired acute renal failure (ARF) and is associated with increased morbidity and mortality. [3]

Among all procedures utilizing CM for diag­nosis or therapeutic purposes, coronary angio­graphy and percutaneous coronary intervention (PCI) are associated with the highest incidence of CIN. [1] The overall incidence of CIN in the general population is reported to be 0.6-2.3%. [4] However, in several patient subsets, the pre­valence of CIN is significantly higher. [5],[6] The incidence of CIN in patients with underlying chronic kidney disease (CKD) is extremely high, ranging from 14.8 to 55%. [6],[7],[8] The higher the baseline Cr value, the greater is the risk of CIN. [9] Nevertheless, an increasing number of patients with CKD are being referred for PCI, owing to the greater prevalence of cardio­vascular diseases among this group of patients. [10]

CIN is a potentially reversible condition, and currently available strategies such as hydration and use of N-acetylcysteine, mannitol, furose­mide, dopamine, fenoldopam, or other reno­protective drugs have been proven effective in patients with normal or mildly impaired renal function. [11],[12]

Methods for prevention of CIN in patients with advanced renal failure remain unknown. Additionally, prophylactic hemodialysis (HD), started immediately after the administration of CM to this group of patients did not show any benefit in CIN prevention. [13] In contrast to HD, continuous venovenous hemofiltration (CVVH) is another alternative strategy for prevention of CIN in high-risk patients. [14],[15] The purpose of this study is to determine the efficacy of prophylactic CVVH in the preven­tion of CIN in patients with advanced CKD.


   Subjects and Methods Top


A prospective, single-center study was con­ducted in chest disease hospital of Kuwait from January 2004 to December 2006. All pa­tients with CKD who were scheduled for PCI were included in the study. Inclusion criteria included age above 25 years, stable serum Cr concentration above 300 μmol/L and creatinine clearance (Cr Cl) of <35 mL/min within one month prior to the procedure. Exclusion crite­ria included presentation with cardiogenic shock, pregnancy, lactation, contraindications to hepa­rinization, intravascular administration of con­trast or exposure to nephrotoxic drugs during the previous two weeks, use of non-steroidal anti-inflammatory drugs during the previous 48 hours, renal transplantation, and patients with end-stage renal disease requiring regular dialysis. Angiotensin converting enzyme inhi­bitors were held on the day of the procedure. Intravenous hydration protocols, mannitol, Ace­tylcysteine, dopamine, were not used during the procedure. All patients signed a written in­formed consent.

The study patients were started on CVVH as soon as possible after the procedure, and the time interval from contrast exposure to initia­tion of dialysis was recorded. CVVH was per­formed through a double lumen intravenous femoral catheter (Quinton, Bothell, WA, USA) placed by the attending nephrologists before the procedure. CVVH for 18-24 hours was star­ted using Prisma continuous fluid management system (by Gambro Lakewood Co. Sweden) using M100 dialyzer sets (AN69 membrane), with surface area of 0.90 m 2 , with bicarbonate buffered solution for continuous renal replace­ment therapy (CRRT) from Hospal having the following solute composition in mmol/L: cal­cium Ca 2+ : 1.75, magnesium mg 2+ : 0.5, sodium Na + : 140, chloride Cl - : 109.5, lactate - : 3, bicarbonate HCO3 ~: 32. Blood flow rate was set at 100 mL/min and the substitution fluid rate was 2 L/hour without any fluid removal. Anti­coagulation was achieved by giving heparin bolus of 500 IU at the start of CVVH and then constant heparin infusion to maintain activated partial thromboplastin time between 130 and 150 seconds.

Blood urea nitrogen (BUN) and serum Cr were measured before the procedure, at the end of the CVVH session, then daily for the follo­wing three days, at hospital discharge, and 15 days after the day of the procedure. Cr Cl was calculated at the same time using Cockcroft and Gault equation. [16] The incidence of contrast nephropathy defined as >25% increase from baseline serum Cr values was calculated. Emer­gency CRRT was performed if there was oli­guria for more than 48 hours despite adminis­tration of more than 1 g of furosemide over 24 hours, or if there was evidence of congestive heart failure, or if serum potassium was above 6 mmol/L. CRRT was discontinued when there was evidence of recovery of renal function with the restoration of urine output of >500 mL/day. The need for permanent HD was per­sistent with Cr Cl < 5 mL/min. The incidence of CIN, in-hospital mortality, and the need for long-term dialysis were calculated.


   Statistical Analysis Top


Data were analyzed using SPSS for windows version 13 (SPSS, Inc., Chicago, IL, USA). Numerical variables were expressed as mean ± SD, whereas categorical variables were ex­pressed as frequencies and percentages.


   Results Top


Ninety-eight patients were enrolled in the study [52 (53.1%) were males, and 46 (46.9%) were females]. Patients' clinical data are shown in [Table 1]. Pre procedure serum Cr ranged from 302 - 631 μmol/L, with a mean of 411 ± 79.9 μmol/L; pre procedure Cr Cl ranged from 12.2 - 31.1 mL/min, with a mean of 18.0 ± 4.26 mL/min. All patients were subjected to post procedure CVVH. The mean time interval bet­ween the procedure and the start of CVVH was 44.3 ± 18.8 min. The mean duration of the session was 21.3 ± 2.12 hours. None of the studied subjects had femoral catheter related complications, but three patients (3.06%) re­quired catheter replacement for clotting. The dialysis course was smooth without intra dia­lytic complications. The mean serum Cr after CVVH was 143 ± 40.4 μmol/L, and was 310 ± 46.4 μmol/L at 48 hours after the procedure, 398 ± 63.2 μmol/L at 72 hours after the procedure, 403 ± 88.4 μmol/L at the time of discharge and 422 ± 88.9 μmol/L 15 days after the procedure [Figure 1]. The mean Cr Cl was 18.5 ± 4.61 mL/min and 17.6 ± 4.27 mL/min at the time of discharge and 15 days after the procedure, res­pectively [Figure 2]. One patient (1.02%) de­veloped CIN that required repeated CVVH se­ssions during hospitalization and ended up on regular long-term hemodialysis treatment. There was no in-hospital mortality in the study patients.
Table 1: Patients' clinical characteristics (n = 98).

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Figure 1: Changes in serum creatinine after the procedure.

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Figure 2: Changes in creatinine clearance after the procedure.

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   Discussion Top


Patients with CKD have a predisposition to accelerated atherosclerosis; thus, they repre­sent an increasing percentage of the patients undergoing PCI. [17] The clinical outcome of pa­tients in whom CIN develops after PCI is par­ticularly poor, with a reported in-hospital mor­tality rate of more than 20% and cumulative one year mortality rate of more than 35%. [3],[18],[19],[20],[21]

Mortality even increased to 45-62% if dialysis was required. [19],[21] Given the clinical and prognostic implications, strategies to reduce the incidence of CIN are needed particularly in high-risk patients. [22] Several strategies have been evaluated for the prevention of CIN. Among these strategies, only saline hydration, [23],[24] the use of low-osmolality contrast agents, [25] and treatment with N-acetylcysteine [26],[27],[28] or fenoldo­pam [29],[30] have been shown to provide some pro­tection and to reduce the incidence of CIN. However, the efficacy of these measures is still controversial in patients with severe renal im­pairment. [27] The pharmacokinetic properties of water-soluble iodinated CM disclose only its extracellular fluid distribution, are minimally protein bound, are not metabolized and are ex­creted mainly by the glomerular filtration. [31] In normal subjects, elimination of CM occurs ra­pidly; approximately 50% of the CM is reco­vered in urine within two hours. In subjects with severe CKD, the same 50% will be eli­minated in urine 16-84 hours after injection of the CM. [32] Considering the properties of the iodinated CM, it is hypothesized that it can be removed by dialysis.

Our study showed that doing CVVH as soon as possible after contrast injection in patients with CKD reduced the incidence of CIN to 1.02%, which is significantly less than that re­ported in studies in which other preventive strategies such as saline hydration or N-acetyl­cysteine were used. However, our results are in accordance with the previous studies in which CVVH or HD were used. [33],[34],[35],[36] To date, there have been few trials evaluating HD for prevention of CIN, [37],[38] and both HD and CVVH effectively removed iodinated CM from the blood. [39] Despite this a recent systemic review of studies comparing the periprocedural HD with conventional prophylactic measures found that HD does not decrease the risk or the need for acute dialysis associated with CIN. [36] CV­VHF and continuous venovenous hemodiafil­tration (CVVHDF) have also been studied for the prevention of CIN after PCI in patients with CKD .[36] In 2003, Marenzi et al, [34] reported the superiority of CVVH over saline hydration in prevention of CIN after PCI in patients with CKD, where CIN was reported in 5% of the CVVH group versus 50% in the control group. However, Gabutti et al, [40] studied the effect of CVVHDF performed during and after PCI in patients with CKD and concluded that CVV­HDF was not effective in prevention of CIN. Marenzi et al, [35] compared the use of saline hy­dration with the use of pre and post procedure CVVH or the use of post procedure CVVH and concluded that pre and post CVVH was superior to the other two strategies. On the other hand, Vogt et al, [13] did not show any be­neficial effect of prophylactic HD for three hours after the procedure. Moreover, patients who received HD were more likely to have a decline in renal function and required additio­nal HD treatment. A possible explanation for these results is that HD can induce hypovo­lemia and consequently may worsen renal ischemic injury, delay recovery of renal func­tions, and result in a need for prolonged dia­lysis. [41] On the other hand, the beneficial effect of CVVH can be attributed to its association with hemodynamic stability, allowance of better hydration and regulation of volume status, infusion of large volume of bicarbonate contai­ning solution, [42] and removal of CM from the circulation with a resultant reduction in the kidneys' exposure to CM. [14],[15],[43]

Lastly, heparin used during pre procedure CVVH may have a beneficial effect as it may inhibit acute inflammation, attenuate the ische­mic reperfusion injury, and reduce the oxida­tive stress that may be involved in the pathogenesis of CIN. [44],[45] Therefore, considering the relatively high cost and the time consuming nature of CVVH, the limited availability of an intensive care unit (ICU) beds, and the lengthy immobilization of patients, this procedure should be restricted to high-risk patients.

This study was limited because it was a single­ center study and the results may be different in other centers and the effect of CVVH was not compared with the conventional hydration pro­tocols; however, the results were compared with previous reports.

In conclusion, CVVH, despite being expen­ sive and time consuming, has a significantly beneficial effect in preventing CIN after PCI in CKD patients, and it should be considered as a preventive strategy in this group of patients.

 
   References Top

1.Nash K, Hafeez A, Hou S. Hospital acquired renal insufficiency. Am J Kidney Dis 2002; 39:930-6  Back to cited text no. 1
    
2.Mehran R, Nikolsky E. Contrast-induced nephropathy: Definition, epidemiology, and patients at risk. Kidney Int 2006;69:S11-5.  Back to cited text no. 2
    
3.Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality: A cohort analysis. JAMA 1996;275:1489-94.  Back to cited text no. 3
[PUBMED]    
4.Lasser EC, Lyon SG, Berry CC. Reports on contrast media reactions: Analysis of data from reports to the US Food and Drug Admi­nistration. Radiology 1997;203:605-10.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Parfrey PS, Griffiths SM, Barrett BJ, et al. Contras material-induced renal failure in patients with diabetes mellitus, renal insuffi­ciency, or both. A prospective controlled study. N Engl J Med 1989;320:143-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.McCullough PA, Wolyn R, Rocher LL, et al. Acute renal failure after coronary interven­tion: incidence, risk factors, and relationship to mortality. Am J Med 1997;103:368-75.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Gruberg L, Mehran R, dangas G, et al. Acute renal failure requiring dialysis after per­cutaneous coronary interventions. Catheter Cardiovasc Interven 2001;52:409-16.  Back to cited text no. 7
    
8.Rihal CS, Textor SC, Grill DE, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary interven­tion. Circulation 2002;105:2259-64.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Hall KA, Wong RW, Hunter GC, et al. Con­trast induced nephrotoxicity: the effect of vaso­dilator therapy. J Surg Res 1992;53:317-20.  Back to cited text no. 9
[PUBMED]    
10.Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998; 32(Suppl):S112-9.  Back to cited text no. 10
    
11.Gare M, Haviv YS, Ben-Yehuda A, et al. The renal effect of low-dose dopamine in high risk patients undergoing coronary angio-graphy. J Am Coll Cardiol 1999;34:1682-8.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Abizaid AS, Clark CE, Mintz GS, et al. Effects of dopamine and aminophylline on contrast­induced acute renal failure after coronary angioplasty in patients with pre-existing renal insufficiency. Am J Cardiol 1999;83:260-3.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Vogt B, Ferrari P, Schonholzer C, et al. Pro­phylactic hemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful. Am J Med 2001;111:692-8.  Back to cited text no. 13
    
14.Forni LG, Hilton PJ. Continuous hemofiltra­tion in the treatment of acute renal failure. N Engl J Med 1997;336:1303-9.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Marenzi G, Bartorelli AL, Lauri G, et al. Continuous veno-venous hemofiltration for the treatment of contrast-induced acute renal failure after coronary interventions. Catheter Cardiovasc Interv 2003;58:59-64.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41.  Back to cited text no. 16
[PUBMED]    
17.Jungers P, Massy ZA, Khoa TN, et al. Inci­dence and risk factors of atherosclerotic car­diovascular accidents in predialysis chronic renal failure patients: a prospective study. Nephrol Dial Transplant 1997;12:2597-602.  Back to cited text no. 17
    
18.Murphy SW, Barrett BJ, Parfrey PS. Contrast nephropathy. J Am Soc Nephrol 2000;11: 177-82.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  
19.Gruberg L, Mintz GS, Mehran R, et al. The prognostic implications of further renal func­tion deterioration within 48 h of interven-tional coronary procedures in patients with preexisting renal insufficiency. J Am Coll Cardiol 2000;36:1542-8.  Back to cited text no. 19
[PUBMED]  [FULLTEXT]  
20.Rubenstein MH, Harrell LC, Sheynberg BV, et al. Are patients with renal failure good candidates for percutaneous coronary revas­cularization in the new device era? Circulation 2000;102:2966-72.  Back to cited text no. 20
[PUBMED]  [FULLTEXT]  
21.Best PJ, Lennon R, Ting HH, et al. The im­pact of renal insufficiency on clinical out­comes in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol 2002;39:1113-9.  Back to cited text no. 21
[PUBMED]  [FULLTEXT]  
22.Goel R, Berns JS. Can continuous venove-nous hemofiltration prevent contrast induced nephropathy: is the dye already cast? Semin Dial 2007;20(1):93-5.  Back to cited text no. 22
    
23.Solomon R, Werner C, Mann D, et al. Effect of saline, mannitol, and furosemide on acute changes in renal function induced by radio­contrast agents. N Engl J Med 1994;331: 1416-20.  Back to cited text no. 23
[PUBMED]  [FULLTEXT]  
24.Mueller C, Buerkle G, Buettner HJ, et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients under­going coronary angioplasty. Arch Intern Med 2002;162:329-36.  Back to cited text no. 24
[PUBMED]  [FULLTEXT]  
25.Rudnick MR, Goldfarb S, Wexler L, et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial. Kidney Int 1995;47:254-61.  Back to cited text no. 25
[PUBMED]    
26.Tapel M, Van der Giet M, Schwarzfeld C, et al. Prevention of radiographic contrast-agent­induced reductions in renal function by acetylcysteine. N Engl J Med 2000;343:180-4.  Back to cited text no. 26
    
27.Briguori C, Manganelli F, Scarpato P, et al. Acetylcysteine and contrast-agent associated nephrotoxicity. J Am Coll Cardiol 2002;40: 298-303.  Back to cited text no. 27
[PUBMED]  [FULLTEXT]  
28.Diaz-Sandoval LJ, Kosowsky BD, Losordo DW. Acetylcysteine to prevent angiography related renal tissue injury (the APART trial). Am J Cardiol 2002;89:356-8.  Back to cited text no. 28
[PUBMED]  [FULLTEXT]  
29.Kini AS, Mitre CA, Kim M, et al. A protocol for prevention of radiographic contrast neph­ropathy during percutaneous coronary inter­vention: effect of selective dopamine receptor agonist fenoldopam. Catheter Cardiovasc Interv 2002;55:169-73.  Back to cited text no. 29
[PUBMED]  [FULLTEXT]  
30.Madyoon H, Croushore L, Weaver D, et al. Use of fenoldopam to prevent radiocontrast nephropathy in high-risk patients. Catheter Cardiovasc Interv 2001;53:341-5.  Back to cited text no. 30
[PUBMED]    
31.Cattell WR, Fry IK, Spencer AG, et al. Excretion urography. Factors determining the excretion of Hypaque. Br J Radiol 1967;40: 561-71.  Back to cited text no. 31
[PUBMED]    
32.Lorusso V, Taroni P, Alvino S, et al. Phar­macokinetics and safety of iomeprol in healthy volunteers and in patients with renal impairment or end stage renal disease requi­ring hemodialysis. Invest Radiol 2001;36: 309­16.  Back to cited text no. 32
[PUBMED]  [FULLTEXT]  
33.Lee P, Ju Chou K, Liu C, et al. Renal pro­tection for coronary angiography in advanced renal failure patients by prophylactic hemo­dialysis. J Am Coll Cardiol 2007;50(11): 1015-20.  Back to cited text no. 33
    
34.Marenzi G, Marana I, Lauri G, et al. The pre­vention of radiocontrast agent induced neph­ropathy by hemofiltration. N Engl J Med 2003; 349:1333-40.  Back to cited text no. 34
[PUBMED]  [FULLTEXT]  
35.Marenzi G, Lauri G, Campodonico J, et al. Comparison of two hemofiltration protocols for prevention of contrast-induced nephro­pathy in high-risk patients. Am J Med 2006; 119:155-62.  Back to cited text no. 35
[PUBMED]  [FULLTEXT]  
36.Cruz DN, Perazella MA, Bellomo R, et al. Extracorporeal blood purification therapies for prevention of radiocontrast-induced neph­ropathy: a systemic review. Am J Kidney Dis 2006;48:361-71.  Back to cited text no. 36
[PUBMED]  [FULLTEXT]  
37.Sterner G, Frennby B, Kurkus J, et al. Does post-angiographic hemodialysis reduce the risk of contrast-medium nephropathy? Scand J Urol Nephrol 2000;34:323-6.  Back to cited text no. 37
[PUBMED]    
38.Frank H, Werner D, Lorusso V, et al. Simul­taneous hemodialysis during coronary angio­graphy fails to prevent radiocontrast-induced nephropathy in chronic renal failure. Clin Nephrol 2003;60:176-82.  Back to cited text no. 38
[PUBMED]    
39.Schindler R, Stahl C, Venz S, et al. Removal of contrast media by different extracorporeal treatments. Nephrol Dial Transplant 2001;16: 1471-4.  Back to cited text no. 39
[PUBMED]  [FULLTEXT]  
40.Gabutti L, Marone C, Monti M, et al. Does continuous venovenous hemodiafiltration con­comitant with radiological procedures provide a significant and safe removal of the iodinated contrast ioversol? Blood Purif 2003;21:152-7.  Back to cited text no. 40
[PUBMED]  [FULLTEXT]  
41.Murray P, Hall J. Renal replacement therapy for acute renal failure. Am J Respir Crit Care Med 2000;162:777-81.  Back to cited text no. 41
[PUBMED]  [FULLTEXT]  
42.Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized con­trolled trial. JAMA 2004;291:2328-34.  Back to cited text no. 42
[PUBMED]  [FULLTEXT]  
43.Marenzi G, Lauri G, Grazi, et al. Circulatory response to fluid overload removal by extra­corporeal ultrafiltration in refractory conges­tive heart failure. J Am Coll Cardiol 2001;38: 963-8.  Back to cited text no. 43
    
44.Derhaschnig U, Pernerstorfer T, Knechtels­dorfer M, et al. Evaluation of anti-inflam­matory and antiadhesive effects of heparins in human endotoxemia. Crit Care Med 2003; 31:1108-12.  Back to cited text no. 44
    
45.Sela S, Shurtz-Swirksi R, Shapiro G, et al. Oxidative stress during hemodialysis: effect of heparin. Kidney Int (Suppl) 2001;78:S159-63  Back to cited text no. 45
    

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Correspondence Address:
Amal Abdel Ghani
Nephrology Department, Mubarak Al Kabeer Hospital, P.O. Box 43787
Kuwait
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