|
1
|
Abdulaziz HMM, Sabry A, Saleh M, El-Said G. Oral Sodium Bicarbonate vs. Use of Higher Dialysate Bicarbonate in Hemodialysis Patients With Metabolic Acidosis: A Randomized Controlled Trial. Hemodial Int 2025. [PMID: 40084620 DOI: 10.1111/hdi.13230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Revised: 02/27/2025] [Accepted: 03/05/2025] [Indexed: 03/16/2025]
Abstract
INTRODUCTION The optimal strategy for correcting metabolic acidosis and maintaining acid-base balance in hemodialysis patients remains unclear. This study aimed to evaluate and compare the effects of oral bicarbonate administration vs. increased dialysate bicarbonate concentration on predialysis serum bicarbonate levels in hemodialysis patients with metabolic acidosis. METHODS This was a single-center, open-label, randomized controlled trial. Adult hemodialysis patients with metabolic acidosis (serum bicarbonate < 22 mmol/L) were randomly assigned in a 1:1:1 ratio to one of three treatment groups for 16 weeks: (1) standard dialysate (32 mM bicarbonate plus 3 mM acetate), (2) increased dialysate bicarbonate (34 mM bicarbonate plus 3 mM acetate), or (3) standard dialysate with daily oral sodium bicarbonate supplementation (0.3-0.5 mmol/kg). Of the 75 eligible participants, 66 completed the study. The primary outcome was the difference in predialysis serum bicarbonate levels between the groups at 16 weeks. RESULTS Baseline predialysis serum bicarbonate levels averaged approximately 19.5 mmol/L across all three groups. At 16 weeks, there was no statistically significant difference in predialysis serum bicarbonate levels among the groups (p = 0.701). The mean levels were 20.1 (SD 2.16) mmol/L in the standard dialysate group, 20.5 (SD 2.04) mmol/L in the increased dialysate bicarbonate group, and 20.8 (SD 2.61) mmol/L in the oral supplementation group. Compared to baseline, predialysis bicarbonate levels significantly increased within the increased dialysate bicarbonate group (p = 0.010) and the oral supplementation group (p = 0.021), but not in the control (standard dialysate, no oral supplementation) group. CONCLUSION Oral or dialytic bicarbonate supplementation at the doses used in this study demonstrated equivalent effects on predialysis serum bicarbonate concentrations in acidotic hemodialysis patients. However, the amount of supplemental bicarbonate administered via either route was insufficient to achieve the target correction of acidosis (e.g., predialysis serum bicarbonate ≥ 22 mmol/L).
Collapse
Affiliation(s)
- Hoda M M Abdulaziz
- Mansoura Nephrology and Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alaa Sabry
- Mansoura Nephrology and Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Marwa Saleh
- Mansoura Nephrology and Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ghada El-Said
- Mansoura Nephrology and Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| |
Collapse
|
|
2
|
Huang X, Liang B, Huang S, Liu Z, Yao C, Zheng S, Zhang T, Liu Z, Wang Y, Wu Y, Yang J, Liu J, Chen HJ, Xie X. Vertical Graphene-Based Multiparametric Sensing Array for Integration of Smart Catheter to Electrochemically Monitor Peritoneal Dialysis. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2025; 37:e2412302. [PMID: 39568287 DOI: 10.1002/adma.202412302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 11/10/2024] [Indexed: 11/22/2024]
Abstract
Renal failure is typical chronic kidney disease that required peritoneal dialysis as the primary treatment, but current catheter devices lack functionality to monitor changes in chemical analytes during peritoneal dialysis. Fabrication of miniatured sensing modules with good electrochemical performance in tiny catheter devices is the key to realize the smart monitoring of peritoneal dialysis. In this work, a vertical graphene-based multiparametric sensing array (VG-MSA) is developed to continuously measure fluctuations of various analyte concentrations for peritoneal dialysis monitoring. Vertical graphene (VG) electrode with good electrochemical properties serves as the core module in VG-MSA, allowing the development of miniatured sensing modules with sufficient electrochemical performance. The VG-MSA enables sensitive and multiplexed measurement of dialysate components like metabolites (reactive oxygen species, uric acid, and glucose) and ions (K+, Ca2+, and H+). The VG-MSA is demonstrated to effectively detect biochemical signals in peritoneal dialysate in vivo on rat models. The VG-MSA catheter can be inserted into abdominal cavity, allowing full contact with dialysate for in situ, real-time, and continuous collection of biochemical information during peritoneal dialysis. The VG-MSA catheter device offers a valuable tool for monitoring dialysis quality and facilitating treatment adjustments, potentially as a promising platform for high-quality therapy of renal failure.
Collapse
Affiliation(s)
- Xinshuo Huang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Baoming Liang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Shuang Huang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen, 518107, China
| | - Zhengjie Liu
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Chuanjie Yao
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Shantao Zheng
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Tao Zhang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen, 518107, China
| | - Zhibo Liu
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Yunuo Wang
- The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Yuxiang Wu
- Institute of Intelligent Sport and Proactive Health, Department of Health and Physical Education, Jianghan University, Wuhan, 430056, China
| | - Jingbo Yang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen, 518107, China
| | - Jing Liu
- The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Hui-Jiuan Chen
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Xi Xie
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-Sen University, Guangzhou, 510006, China
| |
Collapse
|
|
3
|
Lombardi G, Chesnaye NC, Caskey FJ, Dekker FW, Evans M, Heimburger O, Pippias M, Torino C, Szymczak M, Drechsler C, Wanner C, Gambaro G, Stel VS, Jager KJ, Ferraro PM. Longitudinal serum bicarbonate and mortality risk in older patients with advanced chronic kidney disease: analyses from the EQUAL cohort. Clin Kidney J 2024; 17:sfae254. [PMID: 39669396 PMCID: PMC11635373 DOI: 10.1093/ckj/sfae254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Indexed: 12/14/2024] Open
Abstract
Background We aimed to explore the relationship between serum bicarbonate (SBC) and mortality in advanced chronic kidney disease (CKD) during three distinct treatment periods: during the pre-kidney replacement therapy (KRT) period, during the transition phase surrounding the start of KRT (transition-CKD) and during KRT. Methods Using the European QUALity Study on treatment in advanced CKD (EQUAL) cohort, which includes patients aged ≥65 years and estimated glomerular filtration rate (eGFR) ≤20 mL/min/1.73 m2 from six European countries, we explored the association between longitudinal SBC and all-cause mortality in three separate CKD populations: pre-KRT, transition-CKD and in the KRT populations, using multivariable time-dependent Cox regression models. We evaluated effect modification by pre-specified variables on the relationship between SBC and mortality. Results We included 1485 patients with a median follow-up of 2.9 (interquartile range 2.7) years, during which 529 (35.6%) patients died. A U-shaped relationship between SBC levels and all-cause mortality was observed in the pre-KRT population (P = .03). Low cumulative exposure, defined as the area under the SBC trajectory before KRT initiation, was associated with increased mortality risk after transitioning to KRT (P = .01). Similarly, in the KRT population, low SBC levels showed a trend towards increased mortality risk (P = .13). We observed effect modification by subjective global assessment category (P-value for interaction = .02) and KRT (P-value for interaction = .02). Conclusions A U-shaped relationship describes the association between SBC and mortality in the advanced CKD pre-KRT population, whereas in the KRT population a trend towards an increased mortality risk was observed for low SBC levels.
Collapse
Affiliation(s)
- Gianmarco Lombardi
- Division of Nephrology, Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Nicholas C Chesnaye
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Fergus J Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Evans
- Renal Unit, Department of Clinical Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Olof Heimburger
- Renal Unit, Department of Clinical Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Maria Pippias
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Renal Unit, Bristol, UK
| | - Claudia Torino
- Institute of Clinical Physiology-National Research Council, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Christiane Drechsler
- Department of Clinical Research and Epidemiology, University Hospital Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, University Hospital Würzburg, Würzburg, Germany
| | - Giovanni Gambaro
- Division of Nephrology, Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Pietro Manuel Ferraro
- Division of Nephrology, Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| |
Collapse
|
|
4
|
Molnar AO, Killin L, Bota S, McArthur E, Dixon SN, Garg AX, Harris C, Thompson S, Tennankore K, Blake PG, Bohm C, MacRae J, Silver SA. Association Between the Dialysate Bicarbonate and the Pre-dialysis Serum Bicarbonate Concentration in Maintenance Hemodialysis: A Retrospective Cohort Study. Can J Kidney Health Dis 2024; 11:20543581241256774. [PMID: 38827142 PMCID: PMC11141227 DOI: 10.1177/20543581241256774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/23/2024] [Indexed: 06/04/2024] Open
Abstract
Background It is unclear whether the use of higher dialysate bicarbonate concentrations is associated with clinically relevant changes in the pre-dialysis serum bicarbonate concentration. Objective The objective is to examine the association between the dialysate bicarbonate prescription and the pre-dialysis serum bicarbonate concentration. Design This is a retrospective cohort study. Setting The study was performed using linked administrative health care databases in Ontario, Canada. Patients Prevalent adults receiving maintenance in-center hemodialysis as of April 1, 2020 (n = 5414) were included. Measurements Patients were grouped into the following dialysate bicarbonate categories at the dialysis center-level: individualized (adjustment based on pre-dialysis serum bicarbonate concentration) or standardized (>90% of patients received the same dialysate bicarbonate concentration). The standardized category was stratified by concentration: 35, 36 to 37, and ≥38 mmol/L. The primary outcome was the mean outpatient pre-dialysis serum bicarbonate concentration at the patient level. Methods We examined the association between dialysate bicarbonate category and pre-dialysis serum bicarbonate using an adjusted linear mixed model. Results All dialysate bicarbonate categories had a mean pre-dialysis serum bicarbonate concentration within the normal range. In the individualized category, 91% achieved a pre-dialysis serum bicarbonate ≥22 mmol/L, compared to 87% in the standardized category. Patients in the standardized category tended to have a serum bicarbonate that was 0.25 (95% confidence interval [CI] = -0.93, 0.43) mmol/L lower than patients in the individualized category. Relative to patients in the 35 mmol/L category, patients in the 36 to 37 and ≥38 mmol/L categories tended to have a serum bicarbonate that was 0.70 (95% CI = -0.30, 1.70) mmol/L and 0.87 (95% CI = 0.14, 1.60) mmol/L higher, respectively. There was no effect modification by age, sex, or history of chronic lung disease. Limitations We could not directly confirm that all laboratory measurements were pre-dialysis. Data on prescribed dialysate bicarbonate concentrations for individual dialysis sessions were not available, which may have led to some misclassification, and adherence to a practice of individualization could not be measured. Residual confounding is possible. Conclusions We found no significant difference in the pre-dialysis serum bicarbonate concentration irrespective of whether an individualized or standardized dialysate bicarbonate was used. Dialysate bicarbonate concentrations ≥38 mmol/L (vs 35 mmol/L) may increase the pre-dialysis serum bicarbonate concentration by 0.9 mmol/L.
Collapse
Affiliation(s)
- Amber O. Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University/Hamilton Health Sciences, ON, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Lauren Killin
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Sarah Bota
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Stephanie N. Dixon
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Amit X. Garg
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology, Western University, London, ON, Canada
| | - Claire Harris
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Karthik Tennankore
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Clara Bohm
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, AB, Canada
| | - Samuel A. Silver
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| |
Collapse
|
|
5
|
Wan J, Lin J, Wang W, Fu L, Zhang W, Liu J, Xiang Y, Chen J, He Y, Chen K. Relationship between Dialysate Bicarbonate Concentration and All-Cause Mortality in Hemodialysis Patients. Kidney Blood Press Res 2023; 48:460-467. [PMID: 37253349 DOI: 10.1159/000531267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/23/2023] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION The optimal dialysate bicarbonate concentration (DBIC) for hemodialysis (HD) remains controversial. Herein, we analyzed the effect of dialysate bicarbonate levels on mortality in HD patients. METHODS Patients undergoing maintenance HD were recruited from the HD unit of the Daping Hospital. Patients were categorized into quartiles according to their DBIC level (quartile 1: <31.25 mmol/L, n = 77; quartile 2: 31.25-32.31 mmol/L, n = 76; quartile 3: 32.31-33.6 mmol/L; n = 81; quartile 4: ≥33.6 mmol/L, n = 79). Demographic and clinical data were collected. Survival curves were estimated using the Kaplan-Meier method. A Cox proportional hazards regression model was used to estimate the association between DBIC and all-cause mortality. RESULTS We included 313 patients undergoing maintenance HD with a mean DBIC of 32.16 ± 1.59 mmol/L (range, 27.20-34.72 mmol/L). The patients in quartile 4 were more likely to have higher pre- and post-HD serum bicarbonate concentrations than those in other quartiles. The mortality rate was lowest in quartile 2 (10.53%). The survival time was significantly lower in the quartile 4 group than in the other quartiles (p = 0. 008, log-rank test). After full adjustment, the hazard ratio (per 3 mmol/L higher DBIC) for all-cause mortality was 4.29 (95% confidence interval, 2.11-8.47) in all patients, whereas no significant association was observed between DBIC and initial hospitalization. CONCLUSIONS Our data indicate that DBIC is positively associated with all-cause mortality. A DBIC concentration of 31-32 mmol/L may benefit patient outcomes. This study provides an evidence-based medical basis for optimal dialysis prescription in the future.
Collapse
Affiliation(s)
- Jingfang Wan
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jing Lin
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Weidong Wang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Lili Fu
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Weiwei Zhang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jun Liu
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yang Xiang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jia Chen
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yani He
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Wound Trauma Medical Center, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, China
| | - Kehong Chen
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Wound Trauma Medical Center, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, China
| |
Collapse
|
|
6
|
Sridhar NR, Chen Z, Yu G, Lambert J, Muscarella M, Nanjundegowda M, Panesar M. Effect of dialysate bicarbonate and sodium on blood pH in maintenance hemodialysis-A prospective study. Ther Apher Dial 2023; 27:270-277. [PMID: 36056807 DOI: 10.1111/1744-9987.13920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/17/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The validity of adjusting dialysate bicarbonate based on pre-hemodialysis (HD) serum bicarbonate is unclear. There are no studies of the impact of dialysate sodium on blood pH. AIMS To understand the impact of dialysate bicarbonate and sodium on blood pH. METHODS Two hundred arterialized blood samples were obtained on the third session of HD with four configurations of dialysate: sodium (140, 137 mEq/L) and bicarbonate (38, 32 mEq/L). RESULTS The correlation between pre-HD serum bicarbonate and pH was modest (r = 0.6). A lower dialysate sodium (p = 0.035) and a higher bicarbonate (p = 0.02) associated with a higher post-HD blood pH. The frequency of pre-HD blood pH of <7.4 and a post-HD blood pH of >7.5 did not differ for samples with serum bicarbonate <22, 22-26, or >26 mEq/L. DISCUSSION/CONCLUSIONS Adjusting dialysate buffer based on pre-HD serum bicarbonate is unnecessary. A higher bicarbonate and lower dialysate sodium associate with post-HD alkalemia.
Collapse
Affiliation(s)
- Nagaraja Rao Sridhar
- Department of Nephrology, Buffalo Medical Group, Buffalo, New York, USA.,Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Ziqiang Chen
- School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | - Guan Yu
- School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | - Judy Lambert
- Regional Center of Excellence in Transplantation and Kidney Care, Nursing Department, Outpatient Hemodialysis Unit, Erie County Medical Center, Buffalo, New York, USA
| | - Mary Muscarella
- Regional Center of Excellence in Transplantation and Kidney Care, Nursing Department, Outpatient Hemodialysis Unit, Erie County Medical Center, Buffalo, New York, USA
| | - Madan Nanjundegowda
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Regional Center of Excellence in Transplantation and Kidney Care, Erie County Medical Center, Buffalo, New York, USA
| | - Mandip Panesar
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Regional Center of Excellence in Transplantation and Kidney Care, Erie County Medical Center, Buffalo, New York, USA
| |
Collapse
|
|
7
|
Moghari L, Taghizadeh M, Soleimani A, Akbari H, Sharifi N. Dietary Acid Load and Predialysis Serum Bicarbonate Levels in Patients With End-Stage Renal Disease. J Ren Nutr 2023; 33:172-180. [PMID: 35597317 DOI: 10.1053/j.jrn.2022.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 03/08/2022] [Accepted: 05/01/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Maintaining the predialysis serum bicarbonate at a recommended level is critical in patients undergoing hemodialysis. Therefore, the present study investigated the association between dietary acid load (DAL) and serum predialysis bicarbonate levels in patients with end-stage renal disease. METHODS Adult patients undergoing hemodialysis were enrolled in this cross-sectional study. Diet was assessed using a semiquantitative food frequency questionnaire. DAL was calculated with 2 validated indices: potential renal acid load (PRAL) and net endogenous acid production (NEAP). Values regarding predialysis serum bicarbonate level and serum electrolytes were obtained from the participant's medical records. The multiple linear regression analysis was used to determine the association between DAL indices and predialysis serum bicarbonate level. RESULTS The number of hemodialysis patients eligible for this study was 122. The participants' mean age and body mass index was 57.14 ± 3.8 years and 25.2 ± 4.9 kg/m2, respectively. About 65.6% of participants were male. The mean serum levels of predialysis bicarbonate were 21.59 ± 3.1 mEq/L. Also, 47.5% of patients had predialysis serum bicarbonate levels below the recommended value. The mean values of PRAL and NEAP were -2.8 ± 7.48 and 42.7 ± 10.1 mEq/day, respectively. PRAL significantly and inversely predicted predialysis serum bicarbonate level independent of covariates (standardized β = -0.38; P < .001). Also, NEAP was independently and inversely associated with predialysis bicarbonate level (standardized β = -0.40; P < .001). Consuming vegetables such as lettuce, tomato, cucumber, spinach, and dried fruits as well as low-fat milk, plain yogurt, and cream cheese were positively correlated to predialysis serum bicarbonate level. However, the canned tuna had a negative correlation with the predialysis serum bicarbonate. CONCLUSIONS The study's findings showed that the lower DAL was associated with higher predialysis serum bicarbonate levels in patients with end-stage renal disease. Due to the cross-sectional nature of the present study, prospective cohorts or well-controlled clinical trials are needed to confirm our result.
Collapse
Affiliation(s)
- Leila Moghari
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohsen Taghizadeh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran
| | - Alireza Soleimani
- Department of Internal Medicine, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Akbari
- Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Nasrin Sharifi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran.
| |
Collapse
|
|
8
|
Mudunuru SA, Navarrete J, O'Neill WC. Metabolic alkalosis in hemodialysis patients. Semin Dial 2023; 36:24-28. [PMID: 35384078 DOI: 10.1111/sdi.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hemodialysis solutions typically contain a high alkali concentration designed to counter interdialytic acidosis, but this could result in persistent alkalosis in some patients. The prevalence and significance of persistent alkalosis were therefore examined at four outpatient centers over a 10-year period. METHODS Alkalosis was defined as a pre-dialysis serum [HCO3 ] ≥ 26 meq/L in >6 months of a 12-month period and was persistent if present in a majority of months thereafter. Control patients had a serum [HCO3 ] of 19-23 meq/L > 6 of every 12 months. Standard, citrate-containing dialysate was used in all patients without adjustment of bicarbonate concentration. RESULTS 444 of 1271 patients had alkalosis that persisted in 73. Compared to control patients, persistently alkalotic patients were older, but gender, race, starting weight, comorbidities, and mortality did not differ. Dialysis dose was 7% greater, protein catabolic rate was 11% lower, and interdialytic weight gain was 29% lower, all p < 0.001. Persistently alkalotic patients had double the incidence of cardiac arrhythmias (p = 0.07) and a 20% greater intradialytic blood pressure decrease (p < 0.001). CONCLUSIONS Alkalosis is common in hemodialysis patients and can be persistent, likely due to decreased protein catabolic rate and increased dialysis dose, and may have detrimental cardiovascular effects.
Collapse
Affiliation(s)
- S Arvind Mudunuru
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jose Navarrete
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - W Charles O'Neill
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
|
9
|
Abstract
Introduction Abnormalities in blood bicarbonates (HCO3–) concentration are a common finding in patients with chronic kidney disease, especially at the end-stage renal failure. Initiating of hemodialysis does not completely solve this problem. The recommendations only formulate the target concentration of ≥22 mmol/L before hemodialysis but do not guide how to achieve it. The aim of the study was to assess the acid–base balance in everyday practice, the effect of hemodialysis session and possible correlations with clinical and biochemical parameters in stable hemodialysis patients. Material and methods We enrolled 75 stable hemodialysis patients (mean age 65.5 years, 34 women), from a single Department of Nephrology. We assessed blood pressure, and acid–base balance parameters before and after mid-week hemodialysis session. Results We found significant differences in pH, HCO3– pCO2, lactate before and after HD session in whole group (p < 0.001; p < 0.001; p < 0.001; p = 0.001, respectively). Buffer bicarbonate concentration had only statistically significant effect on the bicarbonate concentration after dialysis (p < 0.001). Both pre-HD acid–base parameters and post-HD pH were independent from buffer bicarbonate content. We observed significant inverse correlations between change in the serum bicarbonates and only two parameters: pH and HCO3– before hemodialysis (p = 0.013; p < 0.001, respectively). Conclusions Despite the improvement in hemodialysis techniques, acid–base balance still remains a challenge. The individual selection of bicarbonate in bath, based on previous single tests, does not improve permanently the acid–base balance in the population of hemodialysis patients. New guidelines how to correct acid–base disorders in hemodialysis patients are needed to have less ‘acidotic’ patients before hemodialysis and less ‘alkalotic’ patients after the session.
Collapse
Affiliation(s)
- Monika Wieliczko
- Department of Nephrology, Dialysis and Internal Disease, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Disease, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
|
10
|
Gennari FJ, Marano M, Marano S. Replenishing Alkali During Hemodialysis: Physiology-Based Approaches. Kidney Med 2022; 4:100523. [PMID: 36032503 PMCID: PMC9411655 DOI: 10.1016/j.xkme.2022.100523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The acid-base goal of intermittent hemodialysis is to replenish buffers consumed by endogenous acid production and expansion acidosis in the period between treatments. The amount of bicarbonate needed to achieve this goal has traditionally been determined empirically with a goal of obtaining a reasonable subsequent predialysis blood bicarbonate concentration ([HCO3-]). This approach has led to very disparate hemodialysis prescriptions around the world. The bath [HCO3-] usually chosen in the United States and Europe causes a rapid increase in blood [HCO3-] in the first 1-2 hours of treatment, with little change thereafter. New studies show that this abrupt increase in blood [HCO3-] elicits a buffer response that removes more bicarbonate from the extracellular compartment than is added in the second half of treatment, a futile and unnecessary event. We propose that changes in dialysis prescription be studied in an attempt to moderate the initial rate of increase in blood [HCO3-] and the magnitude of the body buffer response. These new approaches include either a much lower bath [HCO3-] coupled with an increase in the bath acetate concentration or a stepwise increase in the bath [HCO3-] during treatment. In a subset of patients with low endogenous acid production, we propose reducing the bath [HCO3-] as the sole intervention.
Collapse
|
|
11
|
Ravi KS, Espersen C, Curtis KA, Cunningham JW, Jering KS, Prasad NG, Platz E, Mc Causland FR. Temporal Changes in Electrolytes, Acid-Base, QTc Duration, and Point-of-Care Ultrasound during Inpatient Hemodialysis Sessions. KIDNEY360 2022; 3:1217-1227. [PMID: 35919528 PMCID: PMC9337888 DOI: 10.34067/kid.0001652022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023]
Abstract
Background Of the more than 550,000 patients receiving maintenance hemodialysis (HD) in the United States, each has an average of 1.6 admissions annually (>880,000 inpatient HD sessions). Little is known about the temporal changes in laboratory values, ECGs, and intravascular and extravascular volume during inpatient HD sessions. Methods In this prospective cohort study of hospitalized HD patients, we assessed intradialytic laboratory values (metabolic panels, blood gases, ionized calcium levels), ECGs, and sonographic measures of volume status. Results Among 30 participants undergoing HD (mean age 62 years; 53% men, 43% Black) laboratory values had the largest changes in the first hour of HD. There was no significant change in ionized calcium levels pre- to post-HD (change: -0.01±0.07, P=0.24); 12 of 30 and 17 of 30 patients had levels below the lower reference limit at the beginning and end of HD, respectively. The mean pH increased pre- to post-HD (change: 0.06±0.04, P<0.001); 21 of 30 had a pH above the upper reference limit post-HD. There was a trend toward longer median QTc duration from pre- to post-HD (change: 7.5 msec [-5 msec, 19 msec], P=0.07). The sum of B lines on lung ultrasound decreased from pre- to post-HD (median decrease: 3 [1, 7], P<0.01). The collapsibility index of the inferior vena cava increased pre- to post-HD (median increase: 4.8% [1.5%, 13.4%], P=0.01), whereas internal jugular vein diameter did not change (P=0.24). Conclusions Among hospitalized patients undergoing HD, we found dynamic changes in laboratory values, QTc duration, and volume status. Further research is required to assess whether HD prescriptions can be tailored to alter these variations to potentially improve patient outcomes.
Collapse
Affiliation(s)
- Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Caroline Espersen
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Cardiovascular Noninvasive Imaging Research Laboratory, Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Katherine A. Curtis
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Jonathan W. Cunningham
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Karola S. Jering
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Narayana G. Prasad
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elke Platz
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
|
12
|
Bock L, Keil A, Flury S, Kistler AD. Treatment of Metabolic Acidosis in Hemodialysis Patients Is Biased by Type of Vascular Access. Kidney Int Rep 2022; 7:1694-1698. [PMID: 35812293 PMCID: PMC9263232 DOI: 10.1016/j.ekir.2022.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
|
|
13
|
Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
Collapse
Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
| | | |
Collapse
|
|
14
|
Tantisattamo E, Murray V, Obi Y, Park C, Catabay CJ, Lee Y, Wenziger C, Hsiung JT, Soohoo M, Kleine CE, Rhee CM, Kraut J, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD. Am J Nephrol 2021; 52:304-317. [PMID: 33895727 DOI: 10.1159/000513855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Serum bicarbonate or total carbon dioxide (CO2) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO2 concentrations before ESRD transition with post-ESRD mortality. METHODS A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO2 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO2 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. RESULTS The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO2 were 23 ± 4 mEq/L, and median (interquartile range) change in CO2 were -1.8 [-3.4, -0.2] mEq/L/year. High (≥28 mEq/L) and low (<18 mEq/L) CO2 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO2 and all-cause, CV, and non-CV mortality with the lowest risk approximately at -2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO2 >4 mEq/L/year. CONCLUSION Both high and low pre-ESRD CO2 levels (≥28 and <18 mEq/L) during 6 months prior to dialysis transition and rate of CO2 decline >4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO2 in patients with advanced CKD stages transitioning to ESRD.
Collapse
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Victoria Murray
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Christina J Catabay
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Yuji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jeffrey Kraut
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| |
Collapse
|
|
15
|
Mohammedzein A, Naguib T. Case in Point: Correction of Dialysis-Induced Metabolic Alkalosis. Fed Pract 2021; 38:190-194. [PMID: 34177224 DOI: 10.12788/fp.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Normal saline solution infusion with concurrent removal by ultrafiltration successfully corrected pretreatment metabolic alkalosis when other measures were inadequate for a patient on dialysis.
Collapse
Affiliation(s)
- Assad Mohammedzein
- is a Resident Physician in the Department of Internal Medicine; and is an Associate Professor, Department Chair, Internal Medicine, Division of Nephrology; both at Texas Tech University Health Science Center and Thomas E. Creek Department of Veterans Affairs Medical Center in Amarillo, Texas
| | - Tarek Naguib
- is a Resident Physician in the Department of Internal Medicine; and is an Associate Professor, Department Chair, Internal Medicine, Division of Nephrology; both at Texas Tech University Health Science Center and Thomas E. Creek Department of Veterans Affairs Medical Center in Amarillo, Texas
| |
Collapse
|
|
16
|
Andrade LGMD, Muniz AB, Mondelli AL, Ponce D. Concordance analysis between dosed serum bicarbonate and that calculated by gas analysis in chronic renal patients. J Bras Nefrol 2020; 42:478-481. [PMID: 32406476 PMCID: PMC7860641 DOI: 10.1590/2175-8239-jbn-2019-0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/04/2020] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: The control of metabolic acidosis in dialysis patients focuses on the supply of bicarbonate during the dialysis session, and it is not standard in all hemodialysis to assess serum bicarbonate concentrations. Bicarbonate expressed in blood gas analysis is the most sensitive standard of analysis and it is measured indirectly, using the Henderson-Hasselbalch equation. There are no studies in this population evaluating the concordance between the calculated bicarbonate with the direct method of biochemical analysis. The aim of this study was to analyze the concordance between the measured and calculated serum bicarbonate levels using blood gas analysis. Methods: We analyzed blood samples from chronic kidney patients undergoing hemodialysis, using the same sample of bicarbonate analysis by biochemistry and gasometry. The concordance was assessed using the Bland-Altman method. Results: 51 samples were analyzed. The analysis revealed a high correlation (r = 0.73) and a mean difference (bias) of 1.15 ± 3 mmol/L. The median time between collection and examination was 241 minutes. Discussion: We can conclude that the biochemical bicarbonate analysis compared to that calculated from blood gas analysis in chronic renal patients was consistent. For greater concordance between the data, it is important that the time between the collection of the samples and the referral to the laboratory for carrying out the dosages does not exceed four hours. The serum bicarbonate dosage can result in cost savings when compared to that of bicarbonate in blood gas analysis.
Collapse
|
|
17
|
Valério Alves R, Gonçalves H, Lopes K, Sofia F, Vila Lobos A. Changing the paradigm of bicarbonate (HCO3−) hemodialysis prescription in Portugal: a 24-month prospective study. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-020-00302-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Metabolic acidosis is common in hemodialysis (HD) patients. The KDOQI guidelines therapeutic goal is pre-dialysis HCO3− ≥ 22 mmol/L. The aim of the study was to evaluate an individualized HCO3− hemodialysis prescription as a preventing factor of metabolic changes.
Methods
Twenty-four-month prospective study of patients on online high-flux hemodiafiltration. Every 3 months, HCO3− blood levels were analyzed and hemodialysis HCO3− was changed using the following rules:
HCO3− > 30 mmol/L: reduce 4 mmol/L HCO3−
HCO3− ≥ 25 mmol/L: reduce 2 mmol/L HCO3−
20 mmol/L < HCO3− < 25 mmol/L: no change
HCO3− ≤ 20 mmol/L: increase 2 mmol/L HCO3−
HCO3− < 18 mmol/L: increase 4 mmol/L HCO3−
Data collected comprised demographic information, renal disease etiology, comorbidities, HD treatment information, and lab results. Statistical analysis was performed using SPSS.
Results
Thirty-one patients were enrolled and completed the follow-up period. At baseline, average serum pH was 7.38 ± 0.06, serum HCO3− 25.92 ± 1.82 mmol/L, and every patient had a 32 mmol/L dialytic HCO3− prescription. At time point 9, average serum HCO3− was 23.87 ± 1.93 mmol/L and 58% of the patients had a dialytic HCO3− prescription of 28 mmol/L. Serum HCO3− differed with statistical significance during time and approached the reference serum HCO3− (23 mmol/L) that we have defined as ideal. Through time, the HCO3− prescription deviated more from the 32 mmol/L initial prescription that was defined as standard.
Conclusions
Our findings suggest that the standard HCO3− prescription of 32 mmol/L should be rethought, as an individualized HCO3− prescription could be beneficial for the patient.
Collapse
|
|
18
|
Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, Fouque D, Friedman AN, Ghaddar S, Goldstein-Fuchs DJ, Kaysen GA, Kopple JD, Teta D, Yee-Moon Wang A, Cuppari L. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis 2020; 76:S1-S107. [PMID: 32829751 DOI: 10.1053/j.ajkd.2020.05.006] [Citation(s) in RCA: 985] [Impact Index Per Article: 197.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/29/2020] [Indexed: 12/14/2022]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
Collapse
|
|
19
|
Sargent JA, Yamamoto T, Yamakawa T, De Waal D, Gennari FJ. Hemodialysis using a low bicarbonate dialysis bath: Implications for acid‐base homeostasis. Semin Dial 2020; 33:402-409. [DOI: 10.1111/sdi.12902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
|
20
|
Komaru Y, Yoshida T, Hamasaki Y, Nangaku M, Doi K. Hierarchical Clustering Analysis for Predicting 1-Year Mortality After Starting Hemodialysis. Kidney Int Rep 2020; 5:1188-1195. [PMID: 32775818 PMCID: PMC7403509 DOI: 10.1016/j.ekir.2020.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction For patients with end-stage renal disease (ESRD), due to the heterogeneity of the population, appropriate risk assessment approaches and strategies for further follow-up remain scarce. We aimed to conduct a pilot study for better risk stratification, applying machine learning–based classification to patients with ESRD who newly started maintenance hemodialysis. Methods We prospectively studied 101 patients with ESRD, who were new to maintenance hemodialysis therapy, between August 2016 and March 2018. Baseline values of variables such as blood and urine tests were obtained before the initiation of hemodialysis. Agglomerative hierarchical clustering was conducted with the collected continuous data. The resulting clusters were followed up for the primary outcome of 1-year mortality, as analyzed by the Kaplan-Meier survival curve with log-rank test and the Cox proportional hazard model. Results The participants were divided into 3 clusters (cluster 1, n = 62; cluster 2, n = 15; cluster 3, n = 24) by hierarchical clustering, using 46 clinical variables. Patients in cluster 3 showed lower systolic blood pressures, and lower serum creatinine and urinary liver-type fatty acid-binding protein levels, before the initiation of hemodialysis. Consequently, cluster 3 was associated with the highest 1-year mortality in the study cohort (P < 0.001), and the difference was significant after adjustment for age and sex (hazard ratio: 10.2; 95% confidence interval: 2.94–46.8, cluster 1 as reference). Conclusion In this proof-of-concept study, hierarchical clustering discovered a subgroup with a higher 1-year mortality at the initiation of hemodialysis. Applying machine learning–derived classification to patients with ESRD may contribute to better risk stratification.
Collapse
Affiliation(s)
- Yohei Komaru
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Division of Dialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Teruhiko Yoshida
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Division of Dialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshifumi Hamasaki
- Division of Dialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Division of Dialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
|
21
|
|
|
22
|
Abstract
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
Collapse
|
|
23
|
Sargent JA, Marano M, Marano S, Gennari FJ. Changing dialysate composition to optimize acid‐base therapy. Semin Dial 2019; 32:248-254. [DOI: 10.1111/sdi.12779] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Marco Marano
- Hemodialysis Unit Maria Rosaria Clinic Pompeii, Naples Italy
| | - Stefano Marano
- Department of Information and Electrical Engineering and Applied Mathematics University of Salerno Fisciano, Salerno Italy
| | - F. John Gennari
- University of Vermont College of Medicine Burlington Vermont
| |
Collapse
|
|
24
|
Uribarri J, Oh MS. Alkali delivery in chronic hemodialysis: Would more acetate be helpful? Semin Dial 2019; 32:229-231. [PMID: 30937978 DOI: 10.1111/sdi.12791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The dialysate alkali used in hemodialysis to replace low body alkali levels in end stage renal disease (ESRD) patients has changed over time from bicarbonate to acetate and finally back to bicarbonate with a small addition of acetate. The ideal way to replace alkali in dialysis patients remains uncertain. Elsewhere in this issue of the journal, Sargent and Gennari, who have contributed greatly to our understanding of dialysis and acid-base kinetics, suggest that decreasing the currently used concentration of bicarbonate while increasing concentration of acetate in the dialysate may be a much more physiological approach to alkali delivery during hemodialysis. These recommendations are based on results from a series of hemodialysis simulations using mathematical theoretical methods, with the assumption that acetate metabolism will be sufficiently delayed with the higher acetate dialysate and reduce the rate of correction of metabolic acidosis during dialysis. Although valuable in calling attention to the issues surrounding alkali repletion during hemodialysis, these postulations should be tested in clinical trials. We believe, however, that the available evidence suggests that the rate of gain of bicarbonate during dialysis with the higher acetate dialysate would not be slower and that the replacement of some dialysate bicarbonate with acetate will not alter alkali accretion or intradialytic pH.
Collapse
Affiliation(s)
- Jaime Uribarri
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Man S Oh
- Department of Medicine, SUNY at Brooklyn, Downstate Medical Center, Brooklyn, New York
| |
Collapse
|
|
25
|
Acid-Base Status Disturbances in Patients on Chronic Hemodialysis at High Altitudes. Int J Nephrol 2018; 2018:2872381. [PMID: 30581623 PMCID: PMC6276435 DOI: 10.1155/2018/2872381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022] Open
Abstract
Background Acid-base disorders have been previously described in patients with chronic hemodialysis, with metabolic acidosis being the most important of them; however, little is known about the potential changes in acid-base status of patients on dialysis living at high altitudes. Methods Cross-sectional study including 93 patients receiving chronic hemodialysis on alternate days and living in Bogotá, Colombia, at an elevation of 2,640 meters (8,661 feet) over sea level (m.o.s.l.). Measurements of pH, PaCO2, HCO3, PO2, and base excess were made on blood samples taken from the arteriovenous fistula (AVF) during the pre- and postdialysis periods in the midweek hemodialysis session. Normal values for the altitude of Bogotá were taken into consideration for the interpretation of the arterial blood gases. Results 43% (n= 40) of patients showed predialysis normal acid-base status. The most common acid-base disorder in predialysis period was metabolic alkalosis with chronic hydrogen ion deficiency in 19,3% (n=18). Only 9,7% (n=9) had predialysis metabolic acidosis. When comparing pre- and postdialysis blood gas analysis, higher postdialysis levels of pH (7,41 versus 7,50, p<0,01), bicarbonate (21,7mmol/L versus 25,4mmol/L, p<0,01), and base excess (-2,8 versus 2,4, p<0,01) were reported, with lower levels of partial pressure of carbon dioxide (34,9 mmHg versus 32,5 mmHg, p<0,01). Conclusion At an elevation of 2,640 m.o.s.l., a large percentage of patients are in normal acid-base status prior to the dialysis session (“predialysis period”). Metabolic alkalosis is more common than metabolic acidosis in the predialysis period when compared to previous studies. Paradoxically, despite postdialysis metabolic alkalosis, PaCO2 levels are lower than those found in the predialysis period.
Collapse
|
|
26
|
Lugon J, Pereira G, Strogoff-de-Matos J, Peixoto A. Kinetics of acid-base parameters in conventional hemodialysis. Braz J Med Biol Res 2018; 52:e7974. [PMID: 30539970 PMCID: PMC6301264 DOI: 10.1590/1414-431x20187974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/22/2018] [Indexed: 11/22/2022] Open
Abstract
Details about the acid-base changes in hemodialysis are scarce in the literature but are potentially relevant to adequate management of patients. We addressed the acid-base kinetics during hemodialysis and throughout the interdialytic period in a cross-sectional study of adults undergoing conventional hemodialysis. Samples for blood gas analysis were obtained from the arterial limb of the arteriovenous fistula before the first session of the week (HD1), immediately at the end of HD1, and on sequential collections at 15, 30, 45, 60, and 120 min post-HD1. Additional blood samples were collected after ∼20 h following the end of the first dialysis and immediately prior to the initiation of the second dialysis of the week. Thirty adult patients were analyzed (55±15 years, 50% men, 23% diabetic; dialysis vintage 69±53 months). Mean serum bicarbonate levels increased at the end of HD1 (22.3±2.7 mEq/L vs 17.5±2.3 mEq/L, P<0.001) and remained stable until 20 h after the end of the session. The mean values of pCO2 before HD1 were below reference and at 60 and 120 min post-HD1 were significantly lower than at the start (31.3±2.7 mmHg and 30.9±3.7 mmHg vs 34.3±4.1 mmHg, P=0.041 and P=0.010, respectively). The only point of collection in which mean values of pCO2 were above 35 mmHg was 20 h post-dialysis. Serum bicarbonate levels remained stable for at least 20 h after the dialysis sessions, a finding that may have therapeutic implications. During dialysis, the respiratory response for correction of metabolic acidosis (i.e., pCO2 elevation) was impaired.
Collapse
Affiliation(s)
- J.R. Lugon
- Divisão de Nefrologia, Departamento de Medicina, Faculdade de Medicina, Universidade Federal Fluminense, Niteroi, RJ, Brasil
| | - G.R.M. Pereira
- Curso de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal Fluminense, Niteroi, RJ, Brasil
| | - J.P. Strogoff-de-Matos
- Divisão de Nefrologia, Departamento de Medicina, Faculdade de Medicina, Universidade Federal Fluminense, Niteroi, RJ, Brasil
| | - A.J. Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
|
27
|
Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
Collapse
Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
| |
Collapse
|
|
28
|
Basile C, Rossi L, Lomonte C. Dialysate bicarbonate concentration: Too much of a good thing? Semin Dial 2018; 31:576-582. [PMID: 29885083 DOI: 10.1111/sdi.12716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acid-base equilibrium is a complex and vital system whose regulation is impaired in chronic kidney disease (CKD). Metabolic acidosis is a common complication of CKD. It is typically due to the accumulation of sulfate, phosphorus, and organic anions. Metabolic acidosis is correlated with several adverse outcomes, such as morbidity, hospitalization and mortality. In patients undergoing hemodialysis, acid-base homeostasis depends on many factors: net acid production, amount of alkali given by the dialysate bath, duration of interdialytic period, as well as residual diuresis, if any. Recent literature data suggest that the development of postdialysis metabolic alkalosis may contribute to adverse clinical outcomes. Unfortunately, no randomized studies exist about the effect of different dialysate bicarbonate concentrations on hard outcomes, such as mortality. Like everything else in dialysis, the quest for the "ideal" dialysate bicarbonate concentration is far from over. The Latin aphorism "ne quid nimis" ie "nothing in excess" (excess of neither acid nor base) probably best summarizes our current state of knowledge in this field. For the present, the clinician should understand that target values for predialysis serum bicarbonate concentrations have been established primarily based on observational studies and expert opinion. On the basis of this information, we should keep predialysis serum bicarbonate concentrations at least at 22 mEq/L. Furthermore, a specific focus should be addressed to the clinical and nutritional status of the major outliers on both the acid and alkaline sides of the curve.
Collapse
Affiliation(s)
- Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| |
Collapse
|
|
29
|
Gennari FJ. Acid-base assessment of patients receiving hemodialysis. What are our management goals? Semin Dial 2018; 31:382-387. [PMID: 29495132 DOI: 10.1111/sdi.12682] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acid-base assessment of patients receiving conventional hemodialysis (HD) has been based solely on predialysis serum [total CO2 ], and treatment is currently driven by the KDOQI guideline from 2000. This guideline was directed solely at minimizing metabolic acidosis and thereby improving bone and muscle metabolism. In 2000, no data were available to assess the effects of acid-base status on morbidity and mortality. Since then, new data have emerged from several large cohort studies about the association between variations in predialysis serum [total CO2 ], as well as blood pH, and morbidity and mortality risk. These studies have shown increased risk not only with very low predialysis [total CO2 ] values, but also with predialysis alkaline pH and very high predialysis serum [total CO2 ] values. At present, our major concern is not for patients with metabolic acidosis, but rather for the growing numbers of patients with metabolic alkalosis. This review discusses the controversies around assessing and treating acid-base status in HD patients, and recommends a practical approach based on the results of these recent studies. The new approach provides recommendations for patients both with very low and very high predialysis serum [total CO2 ] values.
Collapse
Affiliation(s)
- F John Gennari
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| |
Collapse
|
|
30
|
Abstract
Acid-base alterations in patients with kidney failure and on hemodialysis (HD) treatment contribute to (1) intradialytic hypercapnia and hypoxia, (2) hemodynamic instability and cardiac arrhythmia, (3) systemic inflammation, and (4) a number of associated electrolyte alterations including potentiating effects of hypokalemia, hypocalcemia and, chronically, soft-tissue and vascular calcification, imparting poor prognosis and mortality. This paper discusses acid-base regulation and pathogenesis of dysregulation in patients with kidney failure. Major organ and systemic effects of acid-base perturbations with a specific focus on kidney failure patients on HD are emphasized, and potential mitigating strategies proposed. The high rate of HD-related complications, specifically those that can be accounted for by rapid and steep acid-base perturbations imposed by HD treatment, attests to the pressing need for investigations to establish a better dialysis regimen.
Collapse
Affiliation(s)
- Qi Qian
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
|
31
|
Marano M, Marano S, Gennari FJ. Beyond bicarbonate: complete acid-base assessment in patients receiving intermittent hemodialysis. Nephrol Dial Transplant 2017; 32:528-533. [PMID: 27001688 DOI: 10.1093/ndt/gfw022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/22/2016] [Indexed: 01/19/2023] Open
Abstract
Background Acid-base assessments in hemodialysis patients have been limited almost entirely to measurements of total CO 2 concentration, and assumptions have been made about the presence of acid-base disorders. To gain a fuller understanding of the acid-base status of stable hemodialysis patients, we analyzed measurements of pCO 2 , pH and HCO 3 - obtained in a cohort of chronic stable hemodialysis patients over a 5-year period. Methods We reviewed acid-base measurements taken pre-dialysis from fistula blood in 53 outpatients receiving hemodialysis thrice weekly between 2008 and 2012. In these patients, pH and pCO 2 were measured using an onsite blood gas analyzer, and HCO 3 - was computed. Relevant clinical and laboratory data were obtained from medical records. Factors affecting serum HCO 3 - were identified. Simple and mixed acid-base disorders were diagnosed using accepted rules. Results Serum HCO 3 - was affected by age, normalized protein catabolic rate, interdialytic weight gain and length of interval between treatments. As expected, metabolic acidosis was the most common acid-base disorder, but respiratory acid-base disturbances, as simple or complex disorders, were found in 41% of the measurements. Respiratory alkalosis was seen more frequently than respiratory acidosis, but the latter disorder was more commonly associated with serious comorbidities. Conclusions Respiratory acid-base disorders are an important component of the acid-base abnormalities seen in hemodialysis patients and are not identified by measuring total CO 2 concentration; hence, complete acid-base measurements are needed to determine the components of hemodialysis patients' acid-base status that are contributing to mortality risk.
Collapse
Affiliation(s)
- Marco Marano
- Hemodialysis Unit, Maria Rosaria Clinic, Pompeii, Naples, Italy
| | - Stefano Marano
- Department of Information and Electrical Engineering and Applied Mathematics, University of Salerno, Fisciano, Salerno, Italy
| | - F John Gennari
- University of Vermont, UVM Medical Center, 1 South Prospect St., Burlington, VT, USA
| |
Collapse
|
|
32
|
Chen W, Abramowitz MK. Epidemiology of Acid-Base Derangements in CKD. Adv Chronic Kidney Dis 2017; 24:280-288. [PMID: 29031354 DOI: 10.1053/j.ackd.2017.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 01/13/2023]
Abstract
Acid-base disorders are in patients with chronic kidney disease, with chronic metabolic acidosis receiving the most attention clinically in terms of diagnosis and treatment. A number of observational studies have reported on the prevalence of acid-base disorders in this patient population and their relationship with outcomes, mostly focusing on chronic metabolic acidosis. The majority have used serum bicarbonate alone to define acid-base status due to the lack of widely available data on other acid-base disorders. This review discusses the time course of acid-base alterations in CKD patients, their prevalence, and associations with CKD progression and mortality.
Collapse
|
|
33
|
Smith WB, Gibson S, Newman GE, Hendon KS, Askelson M, Zhao J, Hantash J, Flanagan B, Larkin JW, Usvyat LA, Thadhani RI, Maddux FW. The dynamics of the metabolism of acetate and bicarbonate associated with use of hemodialysates in the ABChD trial: a phase IV, prospective, single center, single blind, randomized, cross-over, two week investigation. BMC Nephrol 2017; 18:273. [PMID: 28851317 PMCID: PMC5576126 DOI: 10.1186/s12882-017-0683-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 08/04/2017] [Indexed: 11/17/2022] Open
Abstract
Background In the United States, hemodialysis (HD) is generally performed via a bicarbonate dialysate. It is not known if small amounts of acid used in dialysate to buffer the bicarbonate can meaningfully contribute to overall buffering administered during HD. We aimed to investigate the metabolism of acetate with use of two different acid buffer concentrates and determine if it effects blood bicarbonate concentrations in HD patients. Methods The Acid-Base Composition with use of hemoDialysates (ABChD) trial was a Phase IV, prospective, single blind, randomized, cross-over, 2 week investigation of peridialytic dynamics of acetate and bicarbonate associated with use of acid buffer concentrates. Eleven prevalent HD patients participated from November 2014 to February 2015. Patients received two HD treatments, with NaturaLyte® and GranuFlo® acid concentrates containing 4 and 8 mEq/L of acetate, respectively. Dialysate order was chosen in a random fashion. The endpoint was to characterize the dynamics of acetate received and metabolized during hemodialysis, and how it effects overall bicarbonate concentrations in the blood and dialysate. Acetate and bicarbonate concentrations were assessed before, at 8 time points during, and 6 time points after the completion of HD. Results Data from 20 HD treatments for 11 patients (10 NaturaLyte® and 10 GranuFlo®) was analyzed. Cumulative trajectories of arterialized acetate were unique between NaturaLyte® and GranuFlo® (p = 0.003), yet individual time points demonstrated overlap without remarkable differences. Arterialized and venous blood bicarbonate concentrations were similar at HD initiation, but by 240 min into dialysis, mean arterialized bicarbonate concentrations were 30.2 (SD ± 4.16) mEq/L in GranuFlo® and 28.8 (SD ± 4.26) mEq/L in NaturaLyte®. Regardless of acid buffer concentrate, arterial blood bicarbonate was primarily dictated by the prescribed bicarbonate level. Subjects tolerated HD with both acid buffer concentrates without experiencing any related adverse events. Conclusions A small fraction of acetate was delivered to HD patients with use of NaturaLyte® and GranuFlo® acid buffers; the majority of acetate received was observed to be rapidly metabolized and cleared from the circulation. Blood bicarbonate concentrations appear to be determined mainly by the prescribed concentration of bicarbonate. Trial registration This trial was registered on ClinicalTrials.gov on 11 Dec 2014 (NCT02334267). Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0683-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- William B Smith
- Volunteer Research Group and New Orleans Center for Clinical Research at the University of Tennessee Medical Center, 1928 Alcoa Highway, Suite 107, Knoxville, TN, 37920, USA.
| | - Sandy Gibson
- Volunteer Research Group and New Orleans Center for Clinical Research at the University of Tennessee Medical Center, 1928 Alcoa Highway, Suite 107, Knoxville, TN, 37920, USA
| | - George E Newman
- Knoxville Kidney Center, PLLC, 320 Park 40 N Blvd, Knoxville, TN, 37923, USA
| | - Kendra S Hendon
- Knoxville Kidney Center, PLLC, 320 Park 40 N Blvd, Knoxville, TN, 37923, USA
| | | | - James Zhao
- EDETEK, 500 College Road East, Suite 200, Princeton, NJ, 08540, USA
| | - Jamil Hantash
- Tandem Labs, 115 Silvia Street, West Trenton, NJ, 08628, USA
| | - Brigid Flanagan
- Frenova Renal Research, 920 Winter Street, Waltham, MA, 02451, USA
| | - John W Larkin
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| | - Len A Usvyat
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| | - Ravi I Thadhani
- Massachusetts General Hospital Division of Nephrology, 55 Fruit Street #1008, Boston, MA, 02114, USA
| | - Franklin W Maddux
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| |
Collapse
|
|
34
|
Marano M. Evaluation of the expected ventilatory response to metabolic acidosis in chronic hemodialysis patients. Hemodial Int 2017; 22:180-183. [PMID: 28834137 DOI: 10.1111/hdi.12602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Expected pCO2 during metabolic acidosis should be computed to rule out superimposing respiratory acid-base disorders, the latter being featured by too high or too low pCO2 than expected. At least 4 different and inconsistent formulas exist. Based on the common practical rule, the reduction of pCO2 equals 1.2 multiplied by the reduction of serum bicarbonate ([HCO3-]), whereas pCO2 equals to the 2 digit after pH decimal point according to Fulop. Instead, based on Winters' formula, pCO2 equals to 1.5 times [HCO3-] + 8. Finally, a very simple formula has been proposed, it reads pCO2 = [HCO3-] + 15. Beyond the evident simplicity, the latter has been effective in a small hemodialysis cohort but validation in a larger dataset is highly desirable. METHODS Formulas have been applied to 180 hemodialysis patients' blood samples dataset featured by mild metabolic acidosis (HCO3 ≥ 14 mEq/L) and root mean square errors (RMSE) associated with each formula were computed. pCO2 reference range was computed as expected pCO2 ± 2 RMSE. FINDINGS Fulop's rule and Winters' formula are associated with large prediction errors. Conversely, the common practical rule and the very simple formula are both featured by the same low error (1.7 mmHg). They further show good agreement and pick out the same reference range. DISCUSSION Superimposing respiratory acid-base disorders can be promptly and effectively ruled out by computing expected pCO2 as [HCO3-] + 15, a very simple formula proved to be interchangeable with the common practical rule that requires computes and assumptions, but leads to same results.
Collapse
Affiliation(s)
- Marco Marano
- Hemodialysis Unit, Maria Rosaria Clinic, Pompeii, Italy
| |
Collapse
|
|
35
|
Abstract
The optimal approach to managing acid-base balance is less well defined for patients receiving hemodialysis than for those receiving peritoneal dialysis. Interventional studies in hemodialysis have been limited and inconsistent in their findings, whereas more compelling data are available from interventional studies in peritoneal dialysis. Both high and low serum bicarbonate levels associate with an increased risk of mortality in patients receiving hemodialysis, but high values are a marker for poor nutrition and comorbidity and are often highly variable from month to month. Measurement of pH would likely provide useful additional data. Concern has arisen regarding high-bicarbonate dialysate and dialysis-induced alkalemia, but whether these truly cause harm remains to be determined. The available evidence is insufficient for determining the optimal target for therapy at this time.
Collapse
Affiliation(s)
- Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, and
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
|
36
|
Abstract
Dialysate composition is a critical aspect of the hemodialysis prescription. Despite this, trial data are almost entirely lacking to help guide the optimal dialysate composition. Often, the concentrations of key components are chosen intuitively, and dialysate composition may be determined by default based on dialysate manufacturer specifications or hemodialysis facility practices. In this review, we examine the current epidemiological evidence guiding selection of dialysate bicarbonate, calcium, magnesium, and potassium, and identify unresolved issues for which pragmatic clinical trials are needed.
Collapse
Affiliation(s)
- Rita L McGill
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
|
37
|
Raikou VD. Metabolic acidosis status and mortality in patients on the end stage of renal disease. J Transl Int Med 2016; 4:170-177. [PMID: 28191541 PMCID: PMC5290893 DOI: 10.1515/jtim-2016-0036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Uncorrected metabolic acidosis leads to higher death risk in dialysis patients. We observed the relationship between metabolic acidosis status and mortality rate in patients on renal replacement therapy during a median follow up time of 60 months. METHODS We studied 76 patients on an on-line hemodiafiltration. The dialysis adequacy was defined by Kt/V for urea. The Framingham risk score (FRS) points were used to determine the 10-year risk for coronary heart disease. We examined the impact of high or low serum bicarbonate concentrations on mortality rate and on 10-year risk for coronary heart disease via the Kaplan-Meier method. Cox's model was used to evaluate a combination of prognostic variables, such as dialysis adequacy defined by Kt/V for urea, age and serum bicarbonate concentrations. RESULTS We divided the enrolled patients in three groups according to serum bicarbonate concentrations (< 20 mmol/L, 20-22 mmol/L and > 22 mmol/L). Kaplan-Meier survival curve for the impact of serum bicarbonate concentrations on overall mortality was found significant (log-rank = 7.8, P = 0.02). The prevalence of serum bicarbonate less or more than 20 mmol/L on high FRS (> 20%) by Kaplan-Meier curve was also found significant (log-rank = 4.9, P = 0.02). Cox's model revealed the significant predictive effect of serum bicarbonate on overall mortality (P = 0.006, OR = 1.5, 95% CI = 1.12-1.98) in combination to Kt/V for urea and age. CONCLUSION Uncorrected severe metabolic acidosis, defined by serum bicarbonate concentrations less than 20 mmol/L, is associated with a 10-year risk for coronary heart disease more than 20% and high overall mortality in patients on renal replacement therapy.
Collapse
Affiliation(s)
- Vaia D. Raikou
- The First Department of Medicine, Propaedaetic, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| |
Collapse
|
|
38
|
Raikou VD, Kyriaki D. Association between Low Serum Bicarbonate Concentrations and Cardiovascular Disease in Patients in the End-Stage of Renal Disease. Diseases 2016; 4:36. [PMID: 28933414 PMCID: PMC5456320 DOI: 10.3390/diseases4040036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/21/2016] [Accepted: 11/07/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Metabolic acidosis, a common condition particularly in the end-stage of renal disease patients, results in malnutrition, inflammation and oxidative stress. In this study, we focused on the association between low serum bicarbonate and cardiovascular disease in patients on intermittent dialysis. METHODS We studied 52 on-line-pre-dilution hemodiafiltration (on-l HDF) patients, 32 males and 20 females, with a mean age of 58.01 ± 15.4 years old. Metabolic acidosis was determined by serum bicarbonate concentrations less than 22 mmol/L. Residual renal function (RRF) was defined by interdialytic urine volume. Kaplan-Meier curves and Cox regression models were performed to predict coronary artery disease (CAD), defined by ejection fraction <50%, or diastolic dysfunction congestive heart failure (CHF) and peripheral vascular disease (PVD). RESULTS Kaplan-Meier analyses showed that a lower or higher than 22 mmol/L serum bicarbonate metabolic acidosis status was significantly associated with both PVD and diastolic dysfunction (log-rank = 5.07, p = 0.02 and log-rank = 5.84, p = 0.01, respectively). A similar prevalence of serum bicarbonate on CAD or CHF by low ejection fraction was not shown. The RRF was associated with PVD event and serum bicarbonate less than 22 mmol/L (log-rank = 5.49, p = 0.01 and log-rank = 3.9, p = 0.04, respectively). Cox regression analysis revealed that serum bicarbonate and RRF were significant risk factors for PVD after adjustment for confounders. Furthermore, RRF adjusted for covariates was shown to be a significant risk factor for diastolic dysfunction. CONCLUSION Low serum bicarbonate was associated with peripheral vascular disease and diastolic dysfunction in intermittent dialysis. The residual renal function may impact patients' outcomes through its relationship with metabolic acidosis status, particularly for peripheral vascular disease manifestation.
Collapse
Affiliation(s)
- Vaia D Raikou
- 1st Department of Medicine-Propaedaetic, School of Medicine, National & Kapodistrian University of Athens, Athens 11527, Greece.
| | - Despina Kyriaki
- Department of Nuclear Medicine, General Hospital "LAΪKO", Athens 11527, Greece.
| |
Collapse
|
|
39
|
Marano M, D’Amato A, Cantone A. Carbon dioxide: Global warning for nephrologists. World J Nephrol 2016; 5:429-36. [PMID: 27648406 PMCID: PMC5011249 DOI: 10.5527/wjn.v5.i5.429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/02/2016] [Accepted: 08/17/2016] [Indexed: 02/06/2023] Open
Abstract
The large prevalence of respiratory acid-base disorders overlapping metabolic acidosis in hemodialysis population should prompt nephrologists to deal with the partial pressure of carbon dioxide (pCO2) complying with the reduced bicarbonate concentration. What the most suitable formula to compute pCO2 is reviewed. Then, the neglected issue of CO2 content in the dialysis fluid is under the spotlight. In fact, a considerable amount of CO2 comes to patients' bloodstream every hemodialysis treatment and "acidosis by dialysate" may occur if lungs do not properly clear away this burden of CO2. Moreover, vascular access recirculation may be easy diagnosed by detecting CO2 in the arterial line of extracorporeal circuit if CO2-enriched blood from the filter reenters arterial needle.
Collapse
|
|
40
|
Misra M. Opponent's comments. Nephrol Dial Transplant 2016; 31:1229-30. [DOI: 10.1093/ndt/gfw255a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
|
41
|
Chauveau P, Rigothier C, Combe C. Con: Higher serum bicarbonate in dialysis patients is protective. Nephrol Dial Transplant 2016; 31:1226-9. [PMID: 27411724 DOI: 10.1093/ndt/gfw255] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 11/13/2022] Open
Abstract
Metabolic acidosis is often observed in advanced chronic kidney disease, with deleterious consequences on the nutritional status, bone and mineral status, inflammation and mortality. Through clearance of the daily acid load and a net gain in alkaline buffers, dialysis therapy is aimed at correcting metabolic acidosis. A normal bicarbonate serum concentration is the recommended target in dialysis patients. However, several studies have shown that a mild degree of metabolic acidosis in patients treated with dialysis is associated with better nutritional status, higher protein intake and improved survival. Conversely, a high bicarbonate serum concentration is associated with poor nutritional status and lower survival. It is likely that mild acidosis results from a dietary acid load linked to animal protein intake. In contrast, a high bicarbonate concentration in patients treated with dialysis could result mainly from an insufficient dietary acid load, i.e. low protein intake. Therefore, a high pre-dialysis serum bicarbonate concentration should prompt nephrologists to carry out nutritional investigations to detect insufficient dietary protein intake. In any case, a high bicarbonate concentration should be neither a goal of dialysis therapy nor an index of adequate dialysis, whereas mild acidosis could be considered as an indicator of appropriate protein intake.
Collapse
Affiliation(s)
- Philippe Chauveau
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux 33076, France AURAD Aquitaine, Gradignan 33170, France
| | - Claire Rigothier
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux 33076, France Unité INSERM 1026 Bioingénierie tissulaire, Université de Bordeaux, Bordeaux 33000, France
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux 33076, France Unité INSERM 1026 Bioingénierie tissulaire, Université de Bordeaux, Bordeaux 33000, France
| |
Collapse
|
|
42
|
Sherman RA. Briefly Noted. Semin Dial 2016. [DOI: 10.1111/sdi.12460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
|
43
|
Basile C, Rossi L, Lomonte C. The choice of dialysate bicarbonate: do different concentrations make a difference? Kidney Int 2016; 89:1008-1015. [PMID: 26924048 DOI: 10.1016/j.kint.2016.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/07/2016] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
Metabolic acidosis is a common complication of chronic kidney disease; it is typically caused by the accumulation of sulfate, phosphorus, and organic anions. Metabolic acidosis is correlated with several adverse outcomes, such as morbidity, hospitalization, and mortality. Thus, correction of metabolic acidosis is fundamental for the adequate management of many systemic complications of chronic kidney disease. In patients undergoing hemodialysis, acid-base homeostasis depends on many factors including the following: net acid production, amount of alkali given by the dialysate bath, duration of the interdialytic period, and residual diuresis, if any. Recent literature data suggest that the development of metabolic alkalosis after dialysis may contribute to adverse clinical outcomes. Our review is focused on the potential effects of different dialysate bicarbonate concentrations on hard outcomes such as mortality. Unfortunately, no randomized studies exist about this issue. Acid-base equilibrium is a complex and vital system whose regulation is impaired in chronic kidney disease. We await further studies to assess the extent to which acid-base status is a major determinant of overall survival in patients undergoing hemodialysis. For the present, the clinician should understand that target values for predialysis serum bicarbonate concentration have been established primarily based on observational studies and expert opinion. Based on this, we should keep the predialysis serum bicarbonate level at least at 22 mmol/l. Furthermore, a specific focus should be addressed by the attending nephrologist to the clinical and nutritional status of the major outliers on both the acid and alkaline sides of the curve.
Collapse
Affiliation(s)
- Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| |
Collapse
|
|
44
|
Gennari FJ. Acid-Base Status and Mortality Risk in Hemodialysis Patients. Am J Kidney Dis 2015; 66:383-5. [DOI: 10.1053/j.ajkd.2015.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 05/26/2015] [Indexed: 11/11/2022]
|
|
45
|
Glycaemic Control Impact on Renal Endpoints in Diabetic Patients on Haemodialysis. Int J Nephrol 2015; 2015:523521. [PMID: 26457201 PMCID: PMC4592718 DOI: 10.1155/2015/523521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/04/2015] [Accepted: 09/06/2015] [Indexed: 11/18/2022] Open
Abstract
Objective. To identify the number of haemodialysis patients with diabetes in a large NHS Trust, their current glycaemic control, and the impact on other renal specific outcomes. Design. Retrospective, observational, cross-sectional study. Methods. Data was collected from an electronic patient management system. Glycaemic control was assessed from HbA1c results that were then further adjusted for albumin (Alb) and haemoglobin (Hb). Interdialytic weight gains were analysed from weights recorded before and after dialysis, 2 weeks before and after the most recent HbA1c date. Amputations were identified from electronic records. Results. 39% of patients had poor glycaemic control (HbA1c > 8%). Adjusted HbA1c resulted in a greater number of patients with poor control (55%). Significant correlations were found with interdialytic weight gains (P < 0.02, r = 0.14), predialysis sodium (P < 0.0001, r = −1.9), and predialysis bicarbonate (P < 0.02, r = 0.12). Trends were observed with albumin and C-reactive protein. Patients with diabetes had more amputations (24 versus 2). Conclusion. Large number of diabetic patients on haemdialysis have poor glycaemic control. This may lead to higher interdialytic weight gains, larger sodium and bicarbonate shifts, increased number of amputations, and possibly increased inflammation and decreased nutritional status. Comprehensive guidelines and more accurate long-term tests for glycaemic control are needed.
Collapse
|