Can the Diverse Family of Dialysis Adequacy Indices Be Understood as One Integrated System?

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Abstract

Background: Dialysis adequacy indices are based on the amount of removed solute and systemized into two groups: (1) fractional solute removal (FSR, non-dimensional), and (2) equivalent continuous clearance (ECC, ml/min), which are expressed using appropriate reference method for solute concentration or mass such as: peak, peak average, time average, and treatment time average values. Methods: A review and critical analysis of the recent studies was performed. Results: The indices are mathematically interrelated and depend on kinetic parameters of the treatment, as device clearance, treatment time, solute distribution volume, dialysis frequency. In particular, KT/V and KT can be directly translated to FSR and ECC using the treatment time average reference method. Conclusion: The diverse family of dialysis adequacy indices can be understood as one integrated system and be useful when assessing both standard treatment modalities and newer schedules and modalities (frequent dialysis, hybrid dialysis, dialysis in acute renal failure) of renal replacement therapies.

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Most cited references 36

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Bioimpedance spectroscopy for clinical assessment of fluid distribution and body cell mass.

Carrie Earthman, P D Traughber, Owain W Howell … (2007)

Body composition assessment has been used to evaluate clinical interventions in research trials, and has the potential to improve patient care in the clinical setting. Body cell mass (BCM) is an important indicator of nutrition status; however, its measurement in the clinic has been limited. BCM can be estimated by the measurement of intracellular water (ICW). The assessment of extracellular water (ECW) is also important because many clinical populations undergo alterations in fluid distribution, particularly individuals with wasting, those receiving dialysis, and obese individuals. Bioimpedance spectroscopy (BIS) is a unique bioimpedance approach that differs in underlying basis from the more readily recognized single-frequency bioelectrical impedance analysis (SF-BIA) in that it does not require the use of statistically derived, population-specific prediction equations. It has the potential advantage of not only measuring total body water (TBW), as does SF-BIA, but also offering the unique capacity to differentiate between ECW and ICW and, thus, to provide an estimate of BCM. This literature review was conducted to compare available BIS devices to multiple dilution for measuring fluid compartments or BCM in a number of populations. Variable results regarding the ability of BIS to measure absolute volumes, as well as the observation of wide limits of variation, make BIS problematic for individual assessment in the clinic, particularly in populations with abnormal fluid distribution or body geometry. BIS has been found to be more accurate for measuring changes in fluid volumes or BCM, particularly in post-surgical and human immunodeficiency virus (HIV)-infected individuals. It is certainly possible that population-specific adjustments may improve the accuracy of BIS for assessing individuals in the clinical setting; however, additional research and development is needed before the method can be accepted for routine clinical use.

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Dialysis dose and the effect of gender and body size on outcome in the HEMO Study.

G Eknoyan, William Owen Pickrell, William Chumlea … (2004)

Gender and body size have been associated with survival in hemodialysis populations. In recent observational studies, overall mortality was similar in men and women and higher in small patients. The effect of dialysis dose in each of these subgroups has not been tested in a clinical trial. The HEMO Study was a controlled trial of dialysis dose and membrane flux in 1846 hemodialysis patients followed up for 6.6 years in 15 centers throughout the United States. We examined the effect of dialysis dose on mortality and on selected secondary outcomes in subgroups of patients. Adjusting for age only, overall mortality was lower in patients with higher body weight (P < 0.001), higher body mass index (P < 0.001), and higher body water content determined by the Watson formula (Vw) (P < 0.001), but was not associated with gender (P= 0.27). The RR of mortality comparing the high dose with the standard dose group was related to gender (P= 0.014). Women randomized to the high dose had a lower mortality rate than women randomized to the standard dose (RR = 0.81, P= 0.02), while men randomized to the high dose had a nonsignificant trend for a higher mortality rate than men randomized to the standard dose (RR = 1.16, P= 0.16). Analysis of both genders combined showed no overall dose effect (R = 0.96, P= 0.52), as reported previously. Vw was greater than 35 L in 84% of men compared with 17% of women. However, the RR of mortality for the high versus standard dose remained lower in women than in men after adjustment for the interaction of dose with Vw or with other size parameters, including weight and body mass index. Conversely, the dose effect was not significantly related to size parameters after controlling for the relationship of the dose comparison with gender. The data suggest that mortality and morbidity might be reduced by increasing the dialysis dose above the current standard in women but not in men. This effect was not explained by differences between men and women in age, race, or in several indices of body size. Because multiple comparisons were considered in this analysis, the role of gender on the effect of dialysis dose is suggestive and invites further study.

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Frequent Hemodialysis Network (FHN) randomized trials: study design.

R. S. Suri, A Garg, G Chertow … (2007)

Observational studies suggest improvements with frequent hemodialysis (HD), but its true efficacy and safety remain uncertain. The Frequent Hemodialysis Network Trials Group is conducting two multicenter randomized trials of 250 subjects each, comparing conventional three times weekly HD with (1) in-center daily HD and (2) home nocturnal HD. Daily HD will be delivered for 1.5-2.75 h, 6 days/week, with target eK(t)/V(n) > or = 0.9/session, whereas nocturnal HD will be delivered for > or = 6 h, 6 nights/week, with target stdK(t)/V of > or = 4.0/week. Subjects will be followed for 1 year. The composite of mortality with the 12-month change in (i) left ventricular mass index (LVMI) by magnetic resonance imaging, and (ii) SF-36 RAND Physical Health Composite (PHC) are specified as co-primary outcomes. The seven main secondary outcomes are between group comparisons of: change in LVMI, change in PHC, change in Beck Depression Inventory score, change in Trail Making Test B score, change in pre-HD serum albumin, change in pre-HD serum phosphorus, and rates of non-access hospitalization or death. Changes in blood pressure and erythropoiesis will also be assessed. Safety outcomes will focus on vascular access complications and burden of treatment. Data will be obtained on the cost of delivering frequent HD compared to conventional HD. Efforts will be made to reduce bias, including blinding assessment of subjective outcomes. Because no large-scale randomized trials of frequent HD have been previously conducted, the first year has been designated a Vanguard Phase, during which feasibility of randomization, ability to deliver the interventions, and adherence will be evaluated.

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Author and article information

Journal

Journal ID (publisher-id): BPU

Journal ID (nlm-ta): Blood Purif

Journal ID (doi): 10.1159/issn.0253-5068

Title: Blood Purification

Publisher: S. Karger AG

ISSN (Print): 0253-5068

ISSN (Electronic): 1421-9735

Publication date Subscription-year: 2010

Publication date (Print): December 2010

Publication date (Electronic): 12 November 2010

Volume: 30

Issue: 4

Pages: 257-265

Affiliations

^aInstitute of Biocybernetics and Biomedical Engineering, Warsaw, Poland; ^bDivisions of Baxter Novum and Renal Medicine, Department of Clinical Sciences, Intervention and Technology, South University Huddinge Hospital, Karolinska Institutet, Stockholm, Sweden

Author notes

*Jacek Waniewski, Institute of Biocybernetics and Biomedical Engineering, Trojdena 4, PL–02 109 Warszawa (Poland), Tel. +48 22 659 9143, Fax +48 22 659 7030, E-Mail jacek.waniewski@ibib.waw.pl

Article

Publisher ID: 320764 Other ID: Blood Purif 2010;30:257–265

DOI: 10.1159/000320764

PubMed ID: 21071936

SO-VID: 58bdd7f8-3695-4e38-ae66-c4464b73bc29

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Can the Diverse Family of Dialysis Adequacy Indices Be Understood as One Integrated System?

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Abstract

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Karger: Nephrology

Most cited references 36

Bioimpedance spectroscopy for clinical assessment of fluid distribution and body cell mass.

Dialysis dose and the effect of gender and body size on outcome in the HEMO Study.

Frequent Hemodialysis Network (FHN) randomized trials: study design.

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