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      Adjusting Hemodialysis Dose for Protein Catabolic Rate

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          Abstract

          Background: Patients dialyzed with equal eKt/V may have huge variations in their urea concentrations. Methods: Urea generation rate, distribution volume and renal clearance were determined in 205 hemodialysis sessions of 33 patients with double pool urea kinetic modeling using dialyzer clearance from online monitoring. From these data, optimized prescriptions were computed. Results: In simulated dialysis sessions, the HEMO standard-dose equivalent clearance was not sufficient to keep time-averaged concentration (TAC) and average predialysis concentration (PAC) of urea below the defined upper limits (20 and 30 mmol/l), if normalized protein catabolic rate (nPCR) was greater than 1.3 g/kg/day. Protein catabolic rate was taken into account in the optimized prescription by cutting high urea concentrations. Conclusions: If patients having high urea concentrations with conventional clearance will benefit from higher dialysis dose - an unconfirmed hypothesis - this approach helps in identifying those who need more than three sessions per week.

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          Most cited references 11

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          The effect of dialysis dose and membrane flux on nutritional parameters in hemodialysis patients: results of the HEMO Study.

          The effect of standard or high dialysis dose and low or high dialysis flux on nutritional status was ascertained in 1846 maintenance hemodialysis patients enrolled in the HEMO Study. Serum albumin levels, equilibrated protein catabolic rate, and postdialysis weight were obtained monthly, while adjusted protein and energy intake, self-reported appetite assessment, upper arm circumference, and calf circumference were obtained yearly. To account for patient attrition due to death or transfer, three statistical models were used to test the effects of the study interventions on longitudinal changes in nutritional parameters. During the first 3 years of follow-up, neither mean serum albumin levels, which declined by 0.21 g/dL, nor mean postdialysis weight, which declined by 2.7 kg, were significantly affected by either study intervention. Mean levels of all anthropometric measures declined during follow-up. For years 1, 2, and 3, the mean +/- SE declines in upper arm and calf circumferences were 0.35 +/- 0.16 cm (P= 0.031) and 0.31 +/- 0.13 (P= 0.015) cm less, respectively, in the high flux compared to the low flux group. Appetite scores and mean equilibrated protein catabolic rate also declined in all randomized groups; however, the average decline in equilibrated protein catabolic rate during years 1, 2, and 3 was 0.019 +/- 0.007 g/kg/day less in the high dose than the standard dose group (P= 0.007). There was no significant change in either mean energy or protein intake from diet records over time, and neither parameter was affected by the study interventions. Although the dose and flux interventions may subtly influence certain nutritional parameters, neither intervention prevented deterioration in nutritional status over time.
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            The current place of urea kinetic modelling with respect to different dialysis modalities

             F Gotch (1998)
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              The equivalent renal urea clearance: a new parameter to assess dialysis dose.

              Currently the total (dialytic plus renal) urea clearance (KT) is computed as Kt/V plus the equivalent Kt/V (KT/VKR) provided by the renal urea clearance (KR). However, KT/VKR is computed with two different formulae, by Gotch and Keshaviah respectively. Moreover Teschan suggested a weekly KT, that is a multiple of Keshaviah's KT. We suggest the equivalent renal urea clearance (EKR), that kinetically quantifies the "time-averaged KT' and is independent of treatment type and schedule. Computer simulation has been used to analyse the relationship between EKR, as corrected for urea volume (EKRc), and Kt/V. Data from 66 HD patients, of whom eight were on once-weekly and 11 on twice-weekly HD, had been used to compare EKR with current KTs. For each individual schedule, the relationship between EKRc and Kt/V is linear and each ml/min of KR increases EKR by the same amount. For instance, for thrice-weekly HD patients, EKRc = 1 + 10 x Kt/V: so that, the critical Kt/V values of 0.8 and 1.0 correspond to EKRc values of 9.0 and 11 ml/min respectively, independently from treatment type and schedule. As to the clinical data, all once- and twice-weekly patients had a significant KR and excellent clinical status, but most of them had 9 or = 11 ml/min. However, it is likely that EKRc > or = 9 ml/min could suffice for patients with a substantial residual renal function.
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                Author and article information

                Journal
                BPU
                Blood Purif
                10.1159/issn.0253-5068
                Blood Purification
                S. Karger AG
                0253-5068
                1421-9735
                2014
                November 2014
                02 October 2014
                : 38
                : 1
                : 62-67
                Affiliations
                Dialysis Unit, Savonlinna Central Hospital, Savonlinna, Finland
                Author notes
                *Aarne Vartia, MD, Kirkkokatu 9 A 1, FI-57100 Savonlinna (Finland), E-Mail aarne.vartia@gmail.com
                Article
                365347 Blood Purif 2014;38:62-67
                10.1159/000365347
                25277443
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 1, Tables: 4, Pages: 6
                Categories
                Original Paper

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