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      Long Nocturnal Dialysis

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          Background/Aims: The continuous growth of the dialysis pool in our unit induced us to organize a third long nocturnal dialysis (LND) session, considering the excellent survival and rehabilitation results reported with this method. This paper analyzes the results and assesses the role of LND among the different dialytic treatment options. Methods: Out of 18 patients on LND, 13 (12 males and 1 female, mean age 52 ± 13 years, time on dialysis 21.8 ± 23.8 months) with >6 months’ experience were studied, and 9 underwent a further metabolic evaluation. LND was performed using 1- to 1.4-m<sup>2</sup> Hemophan membranes, bicarbonate buffer, 200–250 ml/min blood flow, and 300–500 ml/min dialysate flow, 8 h three times a week. Kt/V and protein catabolic rate (3-point classic urea kinetics), postdialytic weight, serum albumin, total protein, hemoglobin, Ca<sup>2+</sup>, phosphate, intact parathyroid hormone, bioimpedance body water, blood pressure, and drug use (antihypertensives, phosphate binders, erythropoietin, vitamin D, hypnotics) were evaluated in each patient during hemodialysis and LND. In the metabolic study (done twice), sodium (compared with the Kimura model), potassium, phosphate, and urea were analyzed in blood and inlet and outlet dialysate after 0, 2, 4, 6, and 8 h. Results: The mortality was low (1 death every 247 patient-months). After 19 ± 8.1 months of LND, the postdialytic weight rose from 68.5 ± 9.6 to 70.8 ± 10.7 kg (p ≤ 0.01), and the hemoglobin concentration rose from 10.8 ± 2.2 to 11.8 ± 1.8 g/dl (p ≤ 0.05); phosphate dropped from 5.6 ± 2.0 to 4.4 ± 1.3 mg/ dl (p ≤ 0.01) and the systolic blood pressure from 152 ± 15 to 143 ± 19 mm Hg (p ≤ 0.05). In the metabolic study, the sodium profile was significantly lower during the last 4 h than in the Kimura model. The potassium concentration, stable between 4 and 6 h, rose against the gradient during the last 2-hour period. The behavior of sodium and potassium during the last part of the dialysis session can be taken to indicate exhaustion of the sodium/potassium pump. Phosphate showed a gradual reduction with no intradialytic and only a moderate postdialytic rebound. The postdialytic urea rebound was 23.4%. Conclusions: LND is a useful additional tool for nephrologists in treating chronic renal failure, it is easy to organize, and it shows overall good results. Together with other dialysis methods, this schedule permits individualized treatment for each uremic patient.

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          Long, slow dialysis.

           B Charra,  C Chazot,  G. Jean (2000)
          Long slow hemodialysis (3 x 8 hours/week) has been used in Tassin for 30 years without significant change in the method. It provides excellent results in terms of morbidity and mortality. The better survival than usually reported on shorter dialysis is mainly due to lower cardiovascular mortality. The nutritional state of the patient is good, as well as the correction of anemia with low doses of EPO. But the main feature concerns blood pressure; hypertension is very well controlled without need for antihypertensive medications. The gentle ultrafiltration provided by a long session time associated with a low salt diet and a moderate interdialytic weight gain allows for normalization of the extracellular fluid space in most patients (dry weight) without important intradialytic morbidity. This low salt diet has paradoxically been forgotten in recent years while shortened dialysis time renders it more necessary than ever.
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            Is Post-Dialysis Urea Rebound Significant with Long Slow Hemodialysis?

             G. Jean,  C Chazot,  B Charra (1998)
            Background: According to previous studies, postdialysis urea rebound (PDUR) is achieved within 30–90 min, leading to an overestimation of Kt/V of between 15 and 40% in 3- to 5-hour dialysis. The purpose of the study was to assess the impact of PDUR on the urea reduction ratio (URR), Kt/V and normal protein catabolic rate (nPCR) with long 8-hour slow hemodialysis. Methods: This study was performed in 18 patients (13 males/5 females), 62.5 ± 11.7 years of age, hemodialyzed for 3–265 months. Initial nephropathies were: 3 diabetes; 2 polycystic kidney disease; 3 interstitial nephritis; 2 nephrosclerosis; 3 chronic glomerulonephritis, and 5 undetermined. Residual renal function was negligible. The dialysis sessions were performed using 1- to 1.8-m 2 cellulosic dialyzers during 8 h, 3 times a week. Blood flow was 220 ml/min, dialysate flow 500 ml/min, acetate or bicarbonate buffer was used. Serial measurements of the urea concentration were obtained before dialysis, immediately after dialysis (low flow at t = 0), and at 5, 10, 20, 30, 40, 60, 90 and 120 min, and before the next session. The low-flow method was used to evaluate the access recirculation, second-generation Daugirdas formulas for Kt/V, and Watson formulas for total body water volume estimation. The difference between the expected urea generation (UG) and urea measured after dialysis (global PDUR) defines net PDUR (n-PDUR). Results: The n-PDUR usually became stable after 58 ± 25 (30–90) min. Its mean value was 17 ± 10% of the 30-second low-flow postdialysis urea (3.9 ± 2 mmol/l). This small postdialysis urea value and the importance of UG in comparison with shorter dialysis justify the use of n-PDUR. Ignoring n-PDUR would lead to a significant 4% overestimation (p < 0.001) of the URR (79 ± 7 vs. 76 ± 8%), 12% of Kt/V (1.9 ± 0.4 to 1.7 ± 0.38) and 4% of the nPCR (1.1 ± 0.3 to 1.05 ± 0.3). n-PDUR correlated negatively with postdialysis urea (r = 0.45 p = 0.05), positively with URR (r = 0.31 p = 0.01) and Kt/V (r = 0.3 p = 0.03) but not with K, and negatively with the urea distribution volume (r = 0.33 p = 0.05). Mean total recirculation, ultrafiltration rate, predialysis urea levels and urea clearance did not correlate with n-PDUR. Conclusion: We found a significant PDUR in long-slow hemodialysis after a mean of 1 h after dialysis. This PDUR has a less important impact upon dialysis delivery estimation than short 3- to 5-hour hemodialysis, especially for the lower Kt/V or URR ranges. This is explained by the low-flux, high-efficiency, and long-term dialysis. Its inter-individual variability incites us to calculate PDUR on an individual basis.

              Author and article information

              Blood Purif
              Blood Purification
              S. Karger AG
              15 January 2003
              : 20
              : 6
              : 525-530
              Nephrology and Dialysis Unit, Regional Hospital, Aosta, Italy
              66955 Blood Purif 2002;20:525–530
              © 2002 S. Karger AG, Basel

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              Figures: 2, Tables: 5, References: 11, Pages: 6
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