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      Experiencia en hemodiálisis domiciliaria en España Translated title: Spanish home hemodialysis experience

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          Abstract

          Resumen Antecedentes: existe actualmente un interés creciente, a nivel mundial, por las posibilidades que ofrece la hemodiálisis domiciliaria, la cual se encuentra más extendida en países del norte de Europa, Canadá, Reino Unido, Estados Unidos, Australia y Nueva Zelanda. En España, ha crecido de manera muy lenta, excepto en determinadas regiones como la provincia de Castellón, donde hemos puesto especial interés en la expansión de las técnicas dialíticas domiciliarias. Objetivo: describir la experiencia en el programa de hemodiálisis domiciliaria del Hospital General de Castellón. Metodología: estudio descriptivo de los pacientes incluidos en el programa de hemodiálisis domiciliaria del Hospital General de Castellón, desde su inicio en enero del 2008 hasta diciembre del 2017. Resultados: en su conjunto, entrenamos a 41 pacientes, de los que 36 llegaron a hemodializarse en casa (régimen corto-diario). La edad de los pacientes era 58,3±13,4 años; y el índice de Charlson, 4,1±1,6. 62 % de los pacientes eran hombres, 25,6 % padecían diabetes mellitus; 15,4 % tenían diagnóstico de insuficiencia cardíaca y 32 % eran portadores de fístula de hemodiálisis. El 38,5 % de los pacientes en edad laboral estaba activo. Obtuvimos una supervivencia técnica considerando el evento muerte+fallo técnico, censurando el trasplante, del 79,4 % al año, 75,2 % a los 2 años y 42,1 % a los 5 años. En el análisis univariante, resultaron determinantes la edad, la presencia de diabetes mellitus y la presencia de insuficiencia cardíaca. En el análisis multivariante, solo se mantuvo la insuficiencia cardíaca. Las reducciones semanales de fósforo y beta-2-microglobulina fueron significativamente mayores con hemodiálisis corta diaria, en comparación con la hemodiafiltración on-line. La hemodiafiltración on-line fue superior en la reducción semanal a partir de los 17 800 daltons para la mioglobina. Conclusiones: la hemodiálisis domiciliaria es una técnica posible que ofrece al paciente una adecuada reinserción sociolaboral, buenos niveles de reducción semanal de toxinas urémicas y una aceptable supervivencia técnica en el tiempo.

          Translated abstract

          Abstract Background: There is currently a growing interest, worldwide, for the possibilities offered by home hemodialysis, which is more widespread in northern European countries, Canada, the United Kingdom, the United States, Australia and New Zealand. In Spain, it has grown very slowly, except in certain regions such as the province of Castellón, where we have placed special interest in the expansion of home dialysis techniques. Objective: To describe the experience in the Home Hemodialysis program of the Hospital General de Castellón. Methodology: Descriptive study of the patients included in the home hemodialysis program of the Hospital General de Castellón, from its beginning in January 2008 to December 2017. Results: As a whole, we trained 41 patients, of whom 36 came to hemodialysis at home (short-day regimen). Age 58,3±13,4 years, Charlson index 4,1±1,6, 62 % men, 25,6 % with diabetes mellitus, 15,4 % with diagnosis of heart failure, 32 % with hemodialysis fistula, 38,5 % of working-age patients were active. We obtained a technical survival considering the event death+technical failure, censoring transplant of 79,4 % a year, 75,2 % at 2 years and 42,1 % at 5 years, resulting determinants of the event in the univariate analysis: age, presence of diabetes mellitus and presence of heart failure, and only heart failure in the multivariate. The weekly reductions of phosphorus and beta-2-microglobulin were significantly greater with daily short hemodialysis with respect to on-line haemodiafiltration. Being the on-line hemodiafiltration superior in the weekly reduction from the 17800 daltons of myoglobin. Conclusions: Home hemodialysis is a possible technique that offers the patient an adequate social-labor reintegration with good levels of weekly reduction of uraemic toxins and an acceptable technical survival over time.

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          Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality.

          Patients receiving hemodialysis have high rates of cardiovascular morbidity and mortality that may be related to the hemodynamic effects of rapid ultrafiltration. Here we tested whether higher dialytic ultrafiltration rates are associated with greater all-cause and cardiovascular mortality, and hospitalization for cardiovascular disease. We used data from the Hemodialysis Study, an almost-7-year randomized clinical trial of 1846 patients receiving thrice-weekly chronic dialysis. The ultrafiltration rates were divided into three categories: up to 10 ml/h/kg, 10-13 ml/h/kg, and over 13 ml/h/kg. Compared to ultrafiltration rates in the lowest group, rates in the highest were significantly associated with increased all-cause and cardiovascular-related mortality with adjusted hazard ratios of 1.59 and 1.71, respectively. Overall, ultrafiltration rates between 10-13 ml/h/kg were not associated with all-cause or cardiovascular mortality; however, they were significantly associated among participants with congestive heart failure. Cubic spline interpolation suggested that the risk of all-cause and cardiovascular mortality began to increase at ultrafiltration rates over 10 ml/h/kg regardless of the status of congestive heart failure. Hence, higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular death.
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            The Rise of Expanded Hemodialysis.

            The low water permeability feature of original cellulosic membranes was considered an advantage in the absence of dialysis equipment that are capable of controlling water removal. The advent of ultrafiltration control systems led to the development and use of high-flux (HF) membranes that allowed improved middle molecule removal including β-2 microglobulin. Further advances in technology allowed better control over the structure and permeability of membranes. Different polymers and improved spinning modalities led to significant advances in solute removal and hemocompatibility. Inner surface modification produced a reduction in membrane thrombogenicity and protein-membrane interaction with a less tendency to fouling and permeability decay. Further evolution in technology led to the development of a new class of membranes referred to as protein-leaking membranes or super-flux or high cutoff (HCO). These membranes are more permeable than conventional HF membranes and allow some passage of proteins, including albumin. The rationale for these membranes is the need for increased clearance of low molecular weight proteins and protein-bound solutes. However, albumin loss in protein-leaking HCO membranes represents a limitation whose effect in patients is still controversial. The last evolution in the field of membranes is the development of a new class defined as "high retention onset" (HRO) due to the peculiar high sieving value in the middle to high molecular weight range. The introduction of HRO membranes in the clinical routine has enabled the development of a new concept therapy called "expanded hemodialysis." Its simple set up and application offer the possibility to use it even in patients with suboptimal vascular access or even with an indwelling catheter. The system does not require particular hardware or unusual nursing skill. The quality of dialysis fluid is, however, mandatory to ensure a safe conduction of the dialysis session. This new therapy is likely to modify the outcome of end-stage kidney disease patients, thanks to the enhanced removal of molecules traditionally retained by current dialysis techniques.
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              Buttonhole cannulation and clinical outcomes in a home hemodialysis cohort and systematic review.

              The relative merits of buttonhole (or blunt needle) versus rope ladder (or sharp needle) cannulation for hemodialysis vascular access are unclear.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                rcnef
                Revista Colombiana de Nefrología
                Rev. colom. nefrol.
                Asociación Colombiana de Nefrología e Hipertensión Arterial (Bogotá, Distrito Capital, Colombia )
                2500-5006
                December 2018
                : 5
                : 2
                : 127-136
                Affiliations
                [1] Castellón de la Plana orgnameHospital Universitario General de Castellón orgdiv1Servicio de Nefrología España
                Article
                S2500-50062018000200127
                10.22265/acnef.0.0.307
                1f5b9429-40c5-429b-bb6a-2cb7e4d2ea72

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

                History
                : 11 April 2018
                : 11 July 2018
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 22, Pages: 10
                Product

                SciELO Colombia

                Categories
                Artículo de investigación original

                Home hemodialysis,toxinas urémicas,supervivencia técnica,España,hemodiálisis domiciliaria,uremic toxins,technical survival,Spain

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