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Saudi Journal of Kidney Diseases and Transplantation
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   2001| July-September  | Volume 12 | Issue 3  
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Management of Hypotension in Dialysis Patients: Role of Dialysate Temperature Control
Frank M van der Sande, Jeroen P Kooman, Willi H.M van Kuijk, Karel M.L Leunissen
July-September 2001, 12(3):382-386
  23,986 1,141 -
Insertion of Temporary Dialysis Catheters with the Aid of Real-time Ultrasound
Nabeel Aslam, Paul M Palevsky
July-September 2001, 12(3):375-381
Central venous catheters are widely used for both temporary and long-term angioaccess for hemodialysis. Insertion of these catheters is commonly performed using anatomic landmarks to guide vessel cannulation. Using traditional landmark-techniques, internal jugular venous catheter insertion is successful 82-88% of the time, with successful first-attempt cannulation of only 35-38%. Variations in anatomic relationships between the vein and surrounding structures may contribute to difficulty in venous cannulation using these traditional techniques. Real-time ultrasound guidance permits direct visualization of the target vein during catheter placement and is associated with increased successful cannulation (78-83% on first pass; 97-100% overall), a decreased number of attempts and a decreased complication rate. For this reason, we believe that real-time ultrasound-guided catheter insertion is superior to the traditional anatomic-landmark techniques and is emerging as the new standard of care
  13,368 572 -
On-line Urea Monitoring during Hemodialysis: A Review
S Stiller, A Al-Bashir, Helmut Mann
July-September 2001, 12(3):364-374
In recent years, methods of on-line urea concentration and on-line urea clearance monitoring have been proposed for control of dialysis dose (Kt/V) and protein catabolic rate (PCR) in patients on regular dialysis therapy; these offer an alternative to the established methods of urea kinetics based on pre- and post-dialysis measurements of urea concentration. In contrast to such conventional urea kinetics, the new methods deliver results in real time and treatment parameters can be changed instantly. Three on-line measurement methods are to be distinguished: monitoring of urea concentration in ultrafiltrate, monitoring of urea concentration in dialysate (both yield Kt/V and PCR), and monitoring of urea clearance based on conductivity measurements. Some of these approaches are already applied commercially. Here, these methods are compared using results obtained from laboratory and clinical studies. The on-line methods are found to be more accurate than methods based on pre- and post-dialysis urea concentrations, and to be better suited for clinical routine. This paper outlines the principal methods, reviews the present literature, gives an overview of the applications and compares them to conventional pre- and post-dialysis concentration-based methods of urea kinetics. It is concluded that these methods are likely to find a widespread application in the control of dialysis adequacy.
  11,517 1,064 -
Dialysis Centers in the Kingdom of Saudi Arabia
Muhammad Ziad Souqiyyeh, Muhammad Besher A Al-Attar, Haroun Zakaria, Faissal A.M Shaheen
July-September 2001, 12(3):293-304
To help future planning of the dialysis services in the different geographical regions and health sectors in Saudi Arabia, we surveyed its 130 active hemodialysis (HD) centers using a questionnaire about their manpower, hemodialysis equipment, as well as, peritoneal dialysis and transplant patients at the end of the year 2000. Almost all the dialysis centers were on hospital campus but of variable sizes with an average ratio of 14.8 dialysis machines per center (range 2-113 machines per center). The distribution of the dialysis centers according to the geographical regions of Saudi Arabia included 18(14%) in the northern, 25(19%) in the southern, 13(10%) in the eastern, 35(27%) in the western and 39(30%) in the central region. There was a total of 6,694 dialysis patients served on 1,918 hemodialysis machines. There were 1,793(93%) HD machines capable of performing bicarbonate dialysis. There was an average ratio of 3.5 patients per one HD machine. In addition to the hemodialysis, there were 28(22%) centers engaged in peritoneal dialysis (PD) and 56(43%) centers in the follow-up of post transplant patients. The total number of the nephrologists, regardless of their expertise was 212 of whom 180(84%) spoke Arabic; the average ratio was 32 patients per nephrologist (range of 14-58). There were 1320 hemodialysis nurses of whom only 465(35%) spoke Arabic. The average ratio of patients to nurses was five patients per nurse (range of 4-6). There were 72(55%) social workers and 70(54%)dietitians with average patients ratios to these supporting services of 1:93 patients (range of 1:58-137) and 1:96 patients (range of 1:53-137), respectively. The study HD patients had a mean age of 47.8 ± 17.1 years (range: 2-92 years); of them, 52.5% were males and 12% had non-Saudi nationality. Of the hemodialysis patients, 1,815(27%) were diabetics. The calculated net increase of dialysis population was 988 patients per year (14.8%). There were 5,700(85%) patients on regular bicarbonate dialysate. Chronic viral infection were noted in more than half of all the dialysis population: thus 3,380(50%) were positive for hepatitis C viral (HCV) serology, 448(7%) had positive hepatitis B (HBV) antigenemia and six(0.1%) had the human acquired immunodeficiency syndrome. In conclusion, our findings demonstrated a satisfactory advancement achieved in many Saudi dialysis centers in terms of equipment, personnel and patients' care. However, there should be more emphasis in the future on quality care through better self-assessment of the performance of these centers.
  9,712 733 -
Current Opinion and Controversies of Dialyser Reuse
Colin Brown
July-September 2001, 12(3):352-363
Reuse of dialysers has been an integral part of hemodialysis since its inception. Over the past decade, reuse has increased significantly in many countries, most notably in the United States, while vanishing entirely in some other countries, such as Portugal and France. In the United States, which is most widely used as an example because of the large amount of data available, the mortality of dialysis patients has steadily decreased even as reuse has increased. This improvement is probably the result of a complex of factors including understanding the role of comorbidity, treatment unit characteristics, barriers to adequate dialysis, nutrition, anemia, high flux dialysis and dialyser membrane improvements and the desired dialysis dose. Reuse provides a significant economic benefit that allows the use of more efficient and expensive larger biocompatible synthetic membranes to provide high-quality dialysis in the face of cost inflation, limited medical resources and fixed reimbursement. Rather than being legitimized by clinical practice alone, reprocessing, supported by clinical studies, allows the provision of superior treatment to more patients safely and economically. Recent reports concerning dialyser reprocessing have centered not only on morbidity and mortality, but also on questions of the specific effects of different germicides on various types of dialyser membranes (e.g., cellulosic, synthetic, high-flux, etc.) and on the possible role of dialyser reprocessing in the transmission of hepatitis C.
  8,223 816 -
Design and Quality Assurance of New Dialysis Centers
Giuseppe Pontoriero, Ciro Tetta, Mary Lou Wratten, Francesco Locatelli
July-September 2001, 12(3):413-419
  8,088 851 -
Monitoring the Microbial Purity of the Treated Water and Dialysate
Bernard Canaud, Katja Martin, Marion Morena, Jean-Yves Bosc, Helene Leray-Moragues, Monji Mahowashi, Frank Stec, Sylvie Hansel
July-September 2001, 12(3):325-326
Dialysate purity has become a major concern in recent years since it has been proven that contamination of dialysate is able to induce the production of proinflammatory cytokines, putatively implicated in the development of dialysis related pathology. In order to reduce this risk, it is advised to use ultrapure dialysate as a new standard of dialysate purity. Ultrapure dialysate preparation may be easily achieved with modern water treatment technologies. The reliable production of ultrapure dialysate requires several prerequisites: use of ultrapure water, use of clean electrolytic concentrates, implementation of ultrafilters in the dialysate pathway to ensure cold sterilization of the fresh dialysate. The regular supply with such high-grade purity dialysate relies on predefined microbiological monitoring of the chain using adequate and sensitive methods, and hygienic handling including frequent disinfection to reduce the level of contamination and to prevent biofilm formation. Reliability of this process requires compliance with a very strict quality assurance process. In this paper, we summarized the principles of the dialysate purity monitoring and the criteria used for surveillance in order to establish good antimicrobial practices in dialysis.
  7,724 783 -
Design of Water Treatment Plants in the Year 2000 and Beyond
G Cappelli, S Perrone, P Inguaggiato, E Ferramosca, A Albertazzi
July-September 2001, 12(3):398-405
  7,112 835 -
Blood Pressure Guided Profiling of Ultrafiltration during Hemodialysis
Reinhard Schmidt, Otfried Roeher, Heiko Hickstein, Steffen Korth
July-September 2001, 12(3):337-344
Hemodialysis-induced hypotension is still a common complication in spite of the progress achieved in hemodialysis (HD) treatment. Due to its multifactorial nature, dialysis-induced hypotension cannot be reliably prevented by conventional profiling of ultrafiltration in open-loop systems since they are unable to adapt themselves to actual decreases in blood pressure. A blood pressure guided closed-loop system for prevention of dialysis-induced hypotension by biofeedback-controlled profiling of ultrafiltration was clinically tested in 94 HD treatments of four patients prone to hypotension. Automatic profiling of ultrafiltration was based on frequent measurements of blood pressure at intervals of five minutes. Proper adaptation of control features to patients' conditions was provided by the lower limit of systolic pressure which was individually set by the physician at the beginning of each treatment. During the initial and medium phases of the HD sessions, ultrafiltration rates up to 200% of the average rates were applied as long as this was tolerated. The additional ultrafiltrate volume was used for blood pressure stabilization by lowering the ultrafiltration rates in the final phase of HD session. Biofeedback­controlled profiling of ultrafiltration provides reliable blood pressure stabilization in all phases of HD. During the first half of treatment, the frequency of hypotensive episodes remained below that with conventional therapy although ultrafiltration rates up to 200% were used. During the second half of treatment, blood pressure guided reduction of ultrafiltration rate provided a decreasing frequency of hypotensive episodes in contrast to the increasing trend during conventional therapy. Stable blood pressure trends during the last hour of HD were achieved in 91% of biofeedback-controlled treatments in comparison with only 32% of conventional treatments. Ultrafiltration rates of 150%-200% and blood pressure measurements at intervals of five minutes were well tolerated, since hypotension­prone patients were better monitored.
  7,087 651 -
Ultrapure Dialysate and its Effect on Patients Outcome
Angel L.M de Francisco, Rafael Perez-Garcia
July-September 2001, 12(3):406-412
  5,775 477 -
Rationale for Antioxidant Supplementation in Hemodialysis Patients
Marion Morena, Maria Martin-Mateo, Jean-Paul Cristol, Bernard Canaud
July-September 2001, 12(3):312-324
Oxidative stress, which results from an imbalance between reactive oxygen species (ROS) production and antioxidant defense mechanisms, is now a well recognized pathogenic process in hemodialysis (HD) patients that could be involved in dialysis-related pathologies such as accelerated atherosclerosis, amyloidosis and anemia. This review is aimed at evaluating the rationale for preventive intervention against oxidative damage during HD as well as the putative causal factors implicated in this imbalance. The antioxidant system is severely impaired in uremic patients and impairment increases with the degree of renal failure. HD further worsens this condition mainly by losses of hydrophilic unbound small molecular weight substances such as vitamin C, trace elements and enzyme regulatory compounds. Moreover, inflammatory state due to the hemo­incompatibility of the dialysis system plays a critical role in the production of oxidants contributing further to aggravate the pro-oxidant status of uremic patients. Prevention of ROS overproduction can be achieved by improvement of dialysis biocompatibility, a main component of adequate dialysis, and further complimented by antioxidant supplementation. This could be achieved either orally or via the extracorporeal circuit. Antioxidants such as vitamin E could be bound on dialyzer membranes. Alternatively, hemolipodialysis consisting of loading HD patients with vitamin C or E via an ancillary circuit made of vitamin E-rich liposomes may be used.
  5,517 720 -
Dialyzer Reuse Impact on Dialyzer Efficiency, Patient Morbidity and Mortality and Cost Effectiveness
Ahmed H Mitwalli, J Abed, N Tarif, A Alam, JS Al-Wakeel, Hassan Abu-Aisha, N Memon, F Sulaimani, B Ternate, MO Mensah
July-September 2001, 12(3):305-311
Since the introduction of dialyzer reuse more than three decades ago, several studies have reported its safety, efficacy and cost effectiveness. Reuse of hemodialyzer was prospectively studied in ten chronic hemodialysis (HD) patients recruited from the renal unit, the King Khalid University Hospital, Riyadh, Saudi Arabia, for three months. During the study period, 66 dialyzers were used for 408 sessions of HD, with a mean reuse of 6.2 ± 5.3 episodes per dialyser, the mean of maximum reuse episodes being 13.7 ± 8.0. The urea reduction ratio was maintained between 73 ± 5% at baseline to 71.2 ± 9.03% (p=0.53) at the maximum reuse. Similarly phosphate reduction with each HD session was maintained; mean decrease in phosphate levels was 0.67 mmol/L. Significant increase in heparin requirement was noted; however, the risk of bleeding was not increased. Hematocrit levels increased from 30.4 ± 4.1% to 33.2 ± 3.6% at the end of the study (p=0.6). Albumin leak in dialysate decreased with each reuse; baseline 8.27 ± 7.93 mg/L to 2.8 ± 0.4 mg/L at maximum reuse (p=0.04). Serum albumin levels remained stable. No short-term adverse effects on patients' morbidity and mortality were noted. Total cost savings of 53% was achieved with the reuse of dialyzers, excluding capital equipment used for preparation for reuse. In conclusion, dialyzer reuse seems to be safe and may provide an economical and efficient dialysis. Studies involving larger number of patients is required to validate this observation.
  5,448 742 -
On-line Hemofiltration in Chronic Renal Failure: Advantages and Limits
Paolo Altieri, Gianbattista Sorba, Piergiorgio Bolasco, Ingrid Ledebo, Ferruccio Bolasco, Marino Ganadu, Franco Cadinu, Rocco Ferrara, Gianfranca Cabiddu
July-September 2001, 12(3):387-397
  4,656 423 -
Sodium Balance During Extra Corporeal Dialysis
Francesco Locatelli, Sara Colzani, Marco D'Amico, Celestina Manzoni, Salvatore Di Filippo
July-September 2001, 12(3):345-351
In order to reduce intradialytic and interdialytic morbidity, it is important to obtain a zero sodium balance at the end of each dialysis session. This can be achieved by matching exactly the interdialytic sodium and water intake with the intradialytic sodium and water removal. A positive sodium balance can be obtained by using hypernatric dialysis or "sodium ramping" or convective techniques. While reducing the intradialytic side effects (hypotension, cramps, nausea, vomiting), these methods may increase the interdialytic side effects (thirst, weight gain, hypertension and pulmonary edema). Given the highly variable amounts of sodium introduced during the interdialytic periods, the use of sodium-conductivity kinetic models allows removing exactly the amount of sodium accumulated in the interdialytic period. This strategy may be advantageous towards cardiovascular stability in patients prone to dialysis hypotension.
  4,431 541 -
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