Search

Agentle ultrafiltration can be achieved using a long and slow hemodialysis. It is easier to achieve gentle ultrafiltration if the interdialytic weight intake is moderate ( i.e., if the patient maintains a low sodium diet) and if diffusion allows for a negative or nil sodium balance during the session ( i.e., dialysate sodium < 140 mmol/L). A gentle ultrafiltration allows control of blood pressure by reducing the extracellular volume to its ideal level, the "dry weight," at the end of the session. Controlling blood pressure reduces cardiovascular mortality, which is by far the foremost cause of death in hemodialysis. Controlling blood pressure means reducing the occurrence of both hypertension and hypotension. Hypotension has been reported to correlate with mortality in hemodialysis as much as or more than hypertension itself. This "U-curve" phenomenon is not paradoxical. It displays two distinct facts on the same figure: an increased early mortality in hypotensive patients (hypotension is a marker of frailty or congestive heart failure, both of which cause increased mortality) and, on the other hand, the well-established, long-term increased mortality in hypertensive patients. Hypotension is not a mandate to undertreat hypertension.

Long, slow hemodialysis (3 × 8 hours/week) has been used without significant modification in Tassin, France, for 30 years with excellent morbidity and mortality rates. A long dialysis session easily provides high Kt/Vurea and allows for good control of nutrition and correction of anemia with a limited need for erythropoietin (EPO). Control of serum phosphate and potassium is usually achieved with low-dose medication. The good survival achieved by long hemodialysis sessions is essentially due to lower cardiovascular morbidity and mortality than in short dialysis sessions. This, in turn, is mainly explained by good blood pressure (BP) control without the need for antihypertensive medication. Normotension in this setting is due to the gentle but powerful ultrafiltration provided by the long sessions, associated with a low salt diet and moderate interdialytic weight gains. These allow for adequate control of extracellular volume (dry weight) in most patients without important intradialytic morbidity. Therefore, increasing the length of the dialysis session seems to be the best way of achieving satisfactory long-term clinical results.

Cardiovascular disease is the main cause of the high mortality of dialysis patients and is largely due to poor control of blood pressure. Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The dry weight concept links ECV and blood pressure by a simple clinical relationship. Dry weight is the ideal postdialysis weight that allows a constantly normal blood pressure to be maintained without using antihypertensive medications. Maintenance of normal ECV requires control of salt intake to reduce interdialytic weight gain ( i.e., saline overload) combined with the diffusive and convective removal of salt and water from the body during dialysis sessions. Several problems are to be faced when using the dry weight method. Clinical evaluation must take into account the following confounding factors: weight varies with nutrition, clinical symptoms are unspecific and sometimes discordant, and there is a lag time between ECV and blood pressure changes. On the other hand, achievement of dry weight is hampered by dialysis times that are too short (and weight gains that are too high), by antihypertensive medications, and by poor heart conditions. A longer session time allows for a slower, easier, and more comfortable ultrafiltration. (Hemodial Int, Vol. 4, 68–74, 2000)

Calciphylaxis (CPX) or calcific uraemic arteriolopathy is a rare life-threatening complication, affecting mainly dialysis patients. The condition is characterized by calcifications and thrombosis of the small cutaneous vessels and small vessels in the fat tissue, resulting in the development of necrotizing and non-healing ulcers. The development of these lesions leads to poor outcomes owing to infectious complications and some frequently associated unfavourable medical conditions: obesity, diabetes, and peripheral vascular disease. We report the case of six patients with different clinical forms of CPX in the past 10 years with favourable outcomes observed in five of the six patients. The diagnosis was based on clinical presentation: bilateral and hyperalgesic necrotic lesions along with a history of mineral metabolism disorder or warfarin use. The therapeutic strategy included the following: daily dialysis, hyperbaric oxygen therapy, treatment of limb artery stenosis, maintenance of the optimal haemodynamic stability, delivery of cutaneous care, administration of analgesics and antibiotics, warfarin and calcium cessation, and additional therapy with cinacalcet or parathyroidectomy and therapy with bisphosphonates or sodium thiosulphate. Healing was observed in five out of six CPX patients by using this strategy that should be rapidly employed in order to decrease the necrotizing areas that result in poor outcomes. Prevention includes identification of at-risk patients in order to optimize the treatment of the identified risk factors for CPX.

Secondary hyperparathyroidism (SHPT) is a frequent complication in chronic kidney disease, especially in hemodialysis (HD) patients. Treatments for SHPT include calcitriol analogues (CA), phosphate binders, cinacalcet (CC), and surgical parathyroidectomy (PTX). This study aimed to assess the incidence and prevalence of SHPT in a single center during the period when native vitamin D (N-VitD) supplementation and CC treatment became available. All incident and prevalent HD patients were prospectively recorded and compared using 3 periods from 2004 to 2005 (period 1), 2006 to 2007 (period 2), and 2008 to 2009 (period 3). SHPT was diagnosed with serum parathyroid hormone (PTH) levels >300 pg/mL or the need for CA, CC, or PTX. Between periods 1 and 3, in incident patients (n=120 and 101), N-VitD prescription increased from 11% to 68% (P 300 pg/mL decreased from 40% to 12% (P 300 pg/mL decreased from 38% to 13% (P

Resume Introduction Le cinacalcet (CC) a transforme le traitement de l’hyperparathyroidie secondaire (HPTS) et tertiaire (HPTT) des patients dialyses. Le but de cette etude est d’evaluer prospectivement l’efficacite et la tolerance du CC dans le traitement de l’HPTS resistante aux therapeutiques conventionnelles et de l’HPTT chez des patients traites par hemodialyse longue dans un meme centre. Patients et methodes Entre septembre 2004 et septembre 2009, nous avons suivi tous les patients hemodialyses traites par CC. Nous decrivons leurs caracteristiques en comparaison de celles des autres patients du centre. Nous avons compare les parametres biologiques et les traitements des patients avant l’introduction du CC (T-0) et aux dernieres nouvelles (T-fin). Les patients etaient dialyses trois fois par semaine avec une duree moyenne de seance de six heures 20 minutes (cinq heures a huit heures). Les criteres de prescriptions de CC etaient une PTH superieure a 300 pg/ml associee a une calcemie superieure a 2,45 mmol/l et a des phosphatases alcalines osseuses superieures a 20 μg/l, ou associee a une calcemie superieure a 2,55 mmol/l temoignant d’une HPTT. Resultats Quatre-vingt-un patients sur 550 prevalents ont ete traites par CC (14,7 %). Ils etaient plus jeunes, avec un index de masse corporelle (IMC) et des apports proteiques (nPCR) plus eleves que le reste de la population. Parmi les patients traites, 6,1 % ont eu un echec therapeutique, 12,3 % un arret pour intolerance digestive severe, 10 % ont du avoir une parathyroidectomie (PTX) et 81,4 % ont poursuivi le traitement avec une posologie finale de CC de 51 ± 30 mg/j. Entre T-0 et T-fin (18 ± 15 mois), la PTH a diminue de 77 %, la calcemie de 10 % et la phosphatemie de 14 % permettant d’ameliorer significativement la proportion des patients dans les cibles biologiques pour la PTH (150–300 pg/ml : de 0 a 50 %), la calcemie corrigee (2,1–2,37 mmol/l : de 6 a 77 %) et la phosphatemie (1,15–1,78 mol/l : de 58 a 84 %). Un sevrage au long cours a ete possible chez huit patients (10 %). Aucune hypocalcemie inferieure a 2 mmol/l n’a ete observee. Les traitements par alfacalcidol (de 68 a 40 %) et sevelamer (de 72 a 50 %) ont diminue, les traitements par CaCO 3 sont restes stables (20 %), ceux par vitamine D native ont augmente (de 55 a 95 %). Conclusion Meme s’il n’est pas toujours bien tolere et efficace, le traitement par CC, associe aux derives de la vitamine D, permet de traiter la grande majorite des HPTS et HPTT des patients dialyses qui ont resiste aux traitements conventionnels, avec une amelioration spectaculaire du metabolisme mineral.

In hemodialysis (HD) patients, mineral metabolism (MM) disorders have been associated with an increased mortality rate. We report the evolution of MM parameters in a stable HD population undergoing long hemodialysis by performing an annual cross-sectional analysis for every year from 1994 to 2008. The therapeutic strategy has changed: the dialysate calcium concentration has decreased from a mean of 1.7 +/- 0.1 to 1.5 +/- 0.07 mmol/L and has been adapted to parathyroid hormone serum levels (from 1 to 1.75 mmol/L). The use of calcium-based and aluminum-based phosphate binders has decreased and they have been replaced by sevelamer; alfacalcidol has partly been replaced by native vitamin D. The percentage of patients with a parathyroid hormone serum level between 150 and 300 pg/mL has increased from 9% to 67% (P0.001); the percentage of patients with phosphataemia between 1.15 and 1.78 mmol/L has increased from 39% to 84% (P0.001). The percentage of those with albumin-corrected calcemia between 2.1 and 2.37 mmol/L has increased from 29% to 61% (P0.001), and that of patients with a calcium-phosphorous product (Ca x P) level4.4 mmol/L decreased from 8.8% to 2% (P=0.02). Although patients undergo long and intensive HD treatment, MM disorders are common. However, an appropriate strategy, mostly consisting of native vitamin D supplementation, progressive replacement of calcium-based phosphate binders with non-calcium-based ones, and individualization of dialysis session duration and dialysate calcium concentration, would result in a drastic improvement.

Resume Introduction Les complications liees aux catheters veineux centraux (CVC) restent une des causes principales de morbidite et de mortalite des patients hemodialyses (HD). Objectif Dans une population d’HD d’un meme centre a dix ans d’intervalle, comparer la prevalence des CVC tunnelises et l’incidence de leurs complications. Methodes De 1994 a 1997 (periode 1) et de 2004 a 2007 (periode 2), nous avons suivi tous les CVC et leurs complications : les bacteriemies (BLC), les infections locales (ILC), les dysfonctions, la consommation de thrombolytiques et les arrachements partiels ou totaux. Resultats Les PermCath® (PC, Quinton, n = 63) et les TwinCath® (TC, MedComp, n = 76) etaient utilises dans la periode 1 chez 95 HD, les split-catheters (ASPC, MedComp, n = 52) et les BioFlex (MedComp, n = 46) dans la periode 2 chez 72 HD. La desinfection utilisait la povidone iodee (periode 1) puis la chlorexidine alcoolique (periode 2). La prevalence des CVC a diminue de 15–18 % a 9–6 %, l’incidence des BLC de 1,1 a 0,23 par 1000 jours-catheter (p Conclusion En dix ans, notre strategie a permis de diminuer la prevalence de CVC de −50 % et l’incidence des complications de CVC de −200 %. Les changements de protocole de desinfection et l’utilisation de CVC plus recents ont ete efficaces pour diminuer les complications infectieuses et mecaniques des CVC.

Background Fibroblast growth factor (FGF)-23, a novel bone-derived phosphaturic factor involved in mineral metabolism, is increased in chronic kidney disease (CKD); in dialysis patients, it has been linked to increased mortality rates and vascular calcification (VC). The present investigation aimed to study the factors associated with elevated serum FGF-23 levels in patients treated with long haemodialysis (LHD) sessions and to determine whether a relationship exists between serum FGF-23 levels and patient survival. Methods All patients treated in one haemodialysis centre from September 2006 were included in the study. Standard laboratory values, medical history, cardiovascular events and risk factors, medication and FGF-23 levels [ELISA (C-Term) Immutopics] were recorded. Patients received haemodialysis three times a week, on a 5- to 8-h schedule. Patient data were analysed according to FGF-23 quartiles. The effect of FGF-23 on the 2-year survival rate was assessed using the Cox proportional hazard model, adjusted for confounding variables and according to the serum phosphate tertiles. Results The study included 219 patients. Serum FGF-23 levels were high: 7060 +/- 13 500 RU/mL (median, 2740 RU/mL). In logistical regressions, only calcaemia (P = 0.002), phosphataemia (P = 0.008) and warfarin use (P = 0.04) were associated with the highest FGF-23 quartile. In the subgroup of patients with an estimated VC score, the third and fourth quartiles of the FGF-23 levels were associated with more severe VC. In multivariate linear regressions, only phosphataemia remained significantly correlated with FGF-23 (P = 0.04). The 2-year mortality rate was significantly higher for haemodialysis patients with serum FGF-23 levels in the higher quartile [P = 0.007; hazard ratio, 2.5 (1.3-5)] than in the first quartile, whereas within the phosphataemia tertiles, the lowest serum FGF-23 quartile was associated with lowered mortality. Conclusion This study demonstrated a high level of circulating FGF-23 in LHD patients, despite infrequent hyperphosphataemia. However, phosphataemia is still the main factor correlating with serum FGF-23. The association of higher serum FGF-23 levels with mortality and VC, regardless of the serum phosphate levels, has thus been confirmed.

Vitamin D deficiency is frequently observed in end-stage renal disease (ESRD) patients; however, the effects of vitamin D supplementation have rarely been reported. We aimed to assess the effects of daily 25(OH)D(3) supplementation on mineral metabolism, bone markers and Kidney Disease Outcomes Quality Initiative (KDOQI) targets in haemodialysis (HD) patients for a period of 6 months.HD patients were included in this study if their serum 25(OH)D level was75 mmol/L. Oral 25(OH)D(3) was administered daily at 10-30 microg/day based on the severity of the deficiency. Characteristics of the patients were compared from the baseline to 6 months on the basis of their response to 25(OH)D(3) administration and the patients were divided into three groups. Patients who showed partial response [serum 25(OH)D75 nmol/L] were placed in group 1, those who showed normal response [serum 25(OH)D ranging from 75 to 150 nmol/L] were placed in group 2 and those who showed excessive response [serum 25(OH)D150 nmol/L] were placed in group 3.Of the 253 HD patients, 225 (89%) showed vitamin D insufficiency or deficiency, 172 were included in the study and 149 patients completed the study. After 6 months of treatment [mean daily 25(OH)D(3): 16 +/- 5 microg/day], the serum 25(OH)D level increased (30 +/- 19 to 126 +/- 46 nmol/ L, P0.001), with 13% of patients in group 1, 57% in group 2 and 30% in group 3. The serum intact parathyroid hormone (iPTH) level decreased (235 +/- 186 to 189 +/- 137 pg/mL, P = 0.05), except in group 1. Bone alkaline phosphatase (BALP) showed a tendency to normalize (23 +/- 16 to 18.3 +/- 11 microg/L, P0.05), leading to a decrease in alfacalcidol administration from 66% to 43% (P0.05), except in group 1. The KDOQI targets achieved increased significantly for serum calcium (76% to 85%) and phosphate levels (66% to 77%) in all patients. The serum albumin level increased in all groups (34.6 +/- 4 to 36.8 +/- 4 g/L, P0.05), without any significant improvement in normalized protein catabolic rate (nPCR) or C-reactive proteins (CRP).With a daily dose ranging from 10 to 30 microg, daily oral 25(OH)D(3) supplementation corrects most vitamin D deficiencies or insufficiencies in HD patients, without any evident toxicity. The main effects observed included correction of excessive bone turnover, despite less alfacalcidol administration, increase in serum albumin level and increase in the percentage of patients with serum calcium and phosphorus levels within the recommendation of the KDOQI guidelines.

The prevalence of hypertension in hemodialysis (HD) patients has increased over the years. In the early days of maintenance HD blood pressure (BP) control was achieved in most patients. As sessions were shortened, the prevalence of hypertension increased. Yet, in principle, dialysis is able to control hypertension. Today, in programs using long HD, most patients are normotensive without antihypertensive medication. The same is true for patients on daily dialysis, but not for those on short thrice-weekly HD. In all studies reporting BP normalization, dry weight is regularly achieved. Why the poor control of hypertension now? At first sight the shortened session duration is the culprit. This is suggested by several epidemiologic observations and strongly supported by a prospective experience of changing the HD schedule (short to long HD or conversely) in the same group of patients. Recent studies, however, using strict volume control show that BP normalization can be obtained in conventional 3 x 4 hr/week dialysis with relatively low delivered Kt/V(urea). Therefore, prolonging the dialysis time and/or increasing the dialysis dose are not required to achieve BP control. Intensive dialysis most probably normalizes BP by getting the extracellular volume and the amount of sodium in the body back to normal. It acts in conjunction with a moderate dietary sodium restriction and the use of reasonably low dialysate sodium. With this approach improved BP control can be achieved in the vast majority of HD patients.

Infection, mainly related to vascular access, is one of the main causes of morbidity and a preventable cause of death in hemodialysis patients. From January 1994 to April 1998 we conducted a prospective study to assess the incidence and risk factors of catheter-related bacteremia. One hundred and twenty-nine tunneled dual-lumen hemodialysis catheters were inserted percutaneously into the internal jugular vein in 89 patients. Bacteremia (n = 56) occurred at least once with 37 (29%) of the catheters (an incidence of 1.1/1,000 catheter-days); local infection (n = 45, 1/1,000 catheter-days) was associated with bacteremia in 18 cases. Death in 1 case was directly related to Staphylococcus aureus (SA) septic shock, and septicemia contributed to deaths in 2 additional cases. Catheters were removed in 48% of the bacteremic episodes. Treatment comprised intravenous double antimicrobial therapy for 15–20 days. Bacteriological data of bacteremia showed 55% involvement of SA. Nasal carriage of SA was observed in 35% of the patients with catheters. Bacteremic catheters were more frequently observed in patients with diabetes mellitus (p = 0.03), peripheral atherosclerosis (p = 0.001), a previous history of bacteremia (p = 0.05), nasal carriage of SA (p = 0.0001), longer catheter survival time (p = 0.001), higher total intravenous iron dose (p = 0.001), more frequent urokinase catheter infusion (p < 0.01), and local infection (p < 0.001) compared with non-bacteremic catheters. Monovariate survival analysis showed that significant initial risk factors for bacteremia were nasal carriage of SA (p = 0.00001), previous bacteremia (p = 0.0001), peripheral atherosclerosis (p = 0.005), and diabetes (p = 0.04). This study confirms the relatively high incidence of bacteremia with tunneled double-lumen silicone catheters and its potential complications. Possible preventive actions are discussed according to the risk factors.

Aims: Hemodialysis tunneled catheters are widely used nowadays. However, their complications, infection and dysfunction, remain much too frequent. Different types of tunneled silicone hemodialysis catheters are available. We prospectively compared the long-term outcome of the two most popular devices, Permcath cuffed double catheter and TwinCath uncuffed twin catheter, both inserted percutaneously. Methods: From January 1994 to April 1998, 125 tunneled catheters were inserted in the internal jugular vein of 86 chronic hemodialysis patients, 63 TwinCath MedComp® (TC) and 62 Permcath Quinton® (PC). They were prospectively followed looking for technical patency, infection and dysfunction rate. Results: TC were used more often for iterative access (52 vs. 25% , p = 0.01) and were inserted more frequently in the left internal jugular vein (59 vs. 16% p < 0.001). Their median technical survival rate was longer (869 vs. 433 days for PC, p < 0.01) with a 1-year patency rate of 80 vs. 53% (p = 0.002). Total catheter extrusion was also slightly less frequent with TC (4.7 vs. 9.6%), but partial extrusion happened more frequently (43 vs. 16%, p = 0.02). No significant difference in infection rate was observed, 0.77 for TC vs. 1.3 local infection/1,000 catheter days; 1.08 vs. 1.30 bacteremia/1,000 catheter days. A persistent catheter thrombosis was observed in 7.9 vs. 20.9% in PC (p = 0.04), the number of dysfunction was 10.5 vs. 24/1,000 days in use (p = 0.0001) and the number of urokinase infusion was 4.4 vs. 12/1,000 days (p = 0.001). PC needed more radiological interventions for dysfunction with endolumenal brushes (4 vs. 0) or fibrin sleeve removal (4 vs. 0). The vena cava thrombosis incidence was not different (2 vs. 3). Conclusion: Although the study was not randomized, TC appears more efficient allowing for a longer patency with a lower dysfunction rate than PC. This was reinforced by less favorable conditions of TC including more left jugular side and more iterative catheters. The cuff does not offer a better bacteriological barrier or protection against extrusion, and the TC seems at a less risk of fibrin sleeves. However, a large randomized study is needed to definitively conclude.

While nephrologists wait for the ideal, non invasive, inexpensive, precise, and reproducible tool to evaluate extracellular volume (ECV), they need to exert their clinical acumen in the quest of that holy grail, dry weight (DW). Estimation of DW using a clinical approach based on blood pressure (BP) and ECV is feasible and reliable as shown by successful experiences in various dialysis modes over more than three decades. But a need still exists to resolve difficulties associated with accurate assessment of BP (methods and circumstances of measurement, and the confounding effects of antihypertensive drugs) and ECV (evaluation of weight changes unrelated to ECV, lack of specificity and sensitivity of clinical symptoms, lag time, confusion in terminology). An essential point in clinical assessment of DW is that a normal BP is at the same time the target and the crucial index of DW achievement. For this reason, a trialand-error "probe" process has to be used at intervals to make sure that the dry weight target point is correctly estimated. The various "non clinical" methods proposed for dry weight assessment increase the complexity and the cost of hemodialysis. They are, in the present state of things, more clinical research than practice tools. They do not replace clinical judgment.

Background. The goal of haemodialysis treatment in end-stage renal disease (ESRD) patients is to correct the complications of the uraemic condition. Among the main complications are fluid overload and subsequent hypertension that are corrected by achievement of 'dry weight'. We report in this study the evolution of post-dialysis body-weight and blood pressure in patients who began their HD treatment in our unit. Methods. We studied the monthly evolution of post-dialysis body-weight (expressed as a percentage of pre-dialysis body-weight at the first HD treatment) and predialysis mean arterial pressure (MAP) over 24 months in 61 patients (21 females; mean age 59.8 years; 20% diabetic), treated with cellulosic membranes for 8 h, 3 times a week. Results. The post-dialysis body-weight decreased between the onset of HD and month 2 (M2) (-4.40±0.52%). Then it went up, reaching -1.56±0.96% at M6, +0.3±1.27% at M12, +1.27±1.38% at M18 and +1.64±1.33% at M24. The post-dialysis body-weight increased by 6% between M2 and M24. The mean arterial pressure (MAP) decreased from 111.3±2.5 mmHg at M0 to 94.4±1.7 at M6, and then remained stable after M6. Between M2 and M6 the post-dialysis body-weight increased, whereas the predialysis MAP continued to decline. The incidence of hypotension episodes was maximal during the first 4 months of HD treatment. Conclusions. After the second month of dialysis treatment, the simultaneous increase of post-dialysis body-weight and decrease of pre-dialysis MAP are related to the effects of two processes, i.e. increased weight as the result of anabolism induced by the HD treatment on the one hand and normalization of blood pressure by fluid removal on the other. Continuous clinical assessment of the patient is necessary to provide adequate prescription of post-dialysis body-weight. During the first months of HD treatment, the nephrologist, like Janus, is a double-faced gatekeeper: he must be willing to decrease post-dialysis weight to achieve 'dry weight' and to normalize blood pressure, but he must also be prepared to increase it to compensate for anabolism and to avoid episodes of hypotension.

The 1989 Morbidity, Mortality, and Prescription of Dialysis Symposium (Dallas, TX) deeply modified the way of prescribing and delivering hemodialysis (HD) in the United States, as elsewhere. Among strategies emerging for end-stage renal disease treatment improvement, increasing the delivered dose has been the central issue, whereas the session time effect has remained an unsettled question. The purpose of this article is to analyze the trends in HD session time over the last decade in Tassin, France, and elsewhere and their relationship to outcome, independent of dialysis dose. The published data indicate that in the United States, there has been an increase in session time. Outside the United States, where session time had been somewhat longer, there has been either no change or a decrease in time without apparent ill effects. The dialysis dose, as measured by the urea Kt/V, has increased everywhere because improved technology allows for efficient toxin removal within a very short dialysis session. In Tassin, a recent limited experience of high-dose shortened dialysis did not show a significant short-term survival difference, but an impaired control of blood pressure (BP) and nutrition. Thus far, the highest HD long-term survival rates have been reported by the groups that used the largest doses and the longer times of HD. Effects of dose and time are, at this point, impossible to disentangle. A longer dialysis time improves extracellular volume (ECV) and BP control and decreases cardiovascular mortality. Shortening the HD session leads to impaired control of BP and increasing cardiovascular morbidity (by far the first cause of mortality on HD). In the future, the length of dialysis session should be governed by the demand of BP control.

A segmental necrosis of the ascending colon sometimes affecting the terminal ileum was observed 13 times in 12 end-stage renal disease patients over a 5400 patient-years observation period. In all but three cases the patient was operated within 24 h of onset of the abdominal pain. Three patients had a bowel perforation; nine had a limited intestinal necrosis. All underwent a partial resection or colectomy. Two died within 1 month. In all cases the mucosa was necrotic, the submucosa small vessels were congested and the mesenteric vessels were normal. Ischaemic bowel disease has been previously reported in uraemic patients, but our cases do not fit with the usual reported features of this complication. The absence of typical mesenteric infarction, vascular thrombosis, stenosis or major atherosclerotic lesions is surprising. The ascending colon topography of the lesions is very unusual. Ischaemia, constipation and other factors may play a role.

Secondary hyperparathyroidism (SHPT) is a frequent complication in chronic kidney disease, especially in hemodialysis (HD) patients. Treatments for SHPT include calcitriol analogues (CA), phosphate binders, cinacalcet (CC), and surgical parathyroidectomy (PTX). This study aimed to assess the incidence and prevalence of SHPT in a single center during the period when native vitamin D (N-VitD) supplementation and CC treatment became available. All incident and prevalent HD patients were prospectively recorded and compared using 3 periods from 2004 to 2005 (period 1), 2006 to 2007 (period 2), and 2008 to 2009 (period 3). SHPT was diagnosed with serum parathyroid hormone (PTH) levels300 pg/mL or the need for CA, CC, or PTX. Between periods 1 and 3, in incident patients (n=120 and 101), N-VitD prescription increased from 11% to 68% (P0.0001), CA prescription remained stable (40%), and patients with PTH300 pg/mL decreased from 40% to 12% (P0.0001). In prevalent HD patients (n=235), N-VitD treatment increased from 55% to 91% (P0.0001), whereas treatment with CA decreased from 67% to 17% (P0.0001). Patients with serum PTH300 pg/mL decreased from 38% to 13% (P0.001), whereas patients with PTH150 pg/mL remained stable (30%). New CC prescriptions decreased from 45 to 3 (P0.0001). Since 2004, SHPT has decreased drastically in incident and prevalent HD patients. The preventive role of N-VitD supplementation appears to be obvious and represents one more argument for its general recommendation in CKD patients.

Survival as an index of adequacy of dialysis. To examine how patient survival substantiates dialysis adequacy, 20-year actuarial survival experience was calculated for 445 unselected hemodialysis (HD) patients (97 patients accepted on a temporary basis—and usually kept on their regular dialysis scheme—were left out). The dose of dialysis has been the same and unchanged for all patients since beginning: 24 square meter hours of, Kiil dialysis (cuprophane) per week with acetate buffered dialysate. KT/V mean (SD) was 1.67 (0.41). Six months after starting dialysis, 98% of patients were normotensive and off all blood pressure (BP) medication. The mean population hematocrit, excluding the only 6 patients receiving eryhropoietin supplementation, was 28%. Survival rate was 87% at 5 years, 75% at 10 years, 55% at 15 years, and 43% at 20 years of HD. The satisfactory control of BP without using potentially toxic BP drugs and the higher than usual dose of dialysis are two possible explanations for survival data better than usually reported. We suggest that patient survival should be considered as the best overall index of adequacy of dialysis.

Wider patient acceptance criteria in hemodialysis (HD) programs do not seem to completely explain the increasing mortality reported in the United States at a time characterized by reduced treatment time and dose. This raises the question of HD standard and adequacy. It stimulated us to analyze patient survival with unchanged 'old-times' methods. 445 unselected patients have been treated for 22 years by the same unchanged methods (24 m2/week, flat-plate dialyzers, cuprophane membrane, acetate buffer). Their survival data were compared to major HD registries and series. Survival was also evaluated as a function of mean arterial pressure (MAP), urea fractional clearance (Kt/V), and middle-molecule dialysis index (DI). Kaplan-Meier (with log-rank test) analysis and Cox proportional hazard model were used. Survival at short and long term was better in our series. This favorable survival difference was more obvious for older patients at the start of HD. It could not be accounted for by selection bias, but correlated with good MAP control without medication and with higher than usual Kt/V (1.67 +/- 0.41) and DI (1.47 +/- 0.38). Cox analysis including five covariates confirmed that survival was linked to MAP. It suggested that survival improvement might be expected from a DI increment of over 1.38 but not from a Kt/V increment of over 1.60. Adequate dialysis cannot be reduced to numbers; it should include both sufficient small- and middle-molecule diffusion and ultrafiltration with arterial pressure control without need for antihypertensive medication. The long-term satisfactory survival remains the best index of overall dialysis adequacy.

Vascular calcifications (VCs) are frequently observed in chronic kidney disease (CKD) and haemodialysis (HD) patients. They have been associated with numerous factors, particularly hyperphosphataemia, excess calcium load, hypertension and increased mortality rate. The purpose of this study is to measure VCs in long-HD patients with good blood pressure and phosphate control, with the occasional use of sevelamer, using a plain radiological score to identify the associated factors and effects on the 1-year survival rate.We studied HD patients from one centre using a semi-quantitative score ranging from 0 to 3 according to the severity and extent of VCs. The following patients' characteristics were compared according to their VC scores: medical history, treatments, blood pressure, standard biological data, fibroblast growth factor (FGF) 23, osteoprotegerin (OPG), whole PTH, beta-crosslaps, bone alkaline phosphatases and bone mineral density scores. One-year survival analyses were also performed.Among the 250 HD patients of the centre, 161 were studied; the mean age was 67.2 +/- 13 years, 45% of the subjects were females, 35% were diabetics, and they had been on dialysis for between 1-486 months (median: 45 months) with a 3 x 5-3 x 8 h dialysis schedule using 1.5 mmol/l dialysate calcium and providing a mean 2.25 +/- 0.5 Kt/V. Only 17% of the patients were free from VCs and 11% had severe VCs. The factors associated with VCs were classified into 'classic' (age, diabetes, male gender, tobacco use, inflammation, more frequent warfarin treatment and peripheral vascular and cardiac diseases) and 'non-traditional' (higher FGF-23 and OPG serum levels, low albumin serum levels and low alfacalcidol and CaCO(3) use). In logistic regression, only age, diabetes and FGF-23 serum levels were associated with VC scores of 2 and 3. The patients with a score of 3 had a higher 1-year mortality rate (RR 2.1; P = 0.01) as compared to patients with a 0 score.A plain radiological score showed the high prevalence (83%) of VCs in HD patients in spite of a long and intensive dialysis strategy and adherence to guidelines. The main associated factors were classic factors such as ageing and diabetes. No relationship was found with blood pressure and phosphataemia that remained well controlled in long dialysis; the association with FGF-23 serum levels may aggregate some non-traditional risk factors. The harmful effects of VCs on survival require their systematic assessment and optimization of the potentially modifiable associated factors in CKD and HD patients.

Central venous catheters are commonly used for haemodialysis patients and represent, in our centre, about 15% of the permanent vascular accesses with a total number of more than 230 central venous catheters over the last 10 years. Inadequate blood flow may occur and upsets the nurses, the patients, and the nephrologist. The aim of this study was to identify the factors of the catheter dysfunction. We studied prospectively 25 chronic haemodialysed patients with central venous catheters, 14 women and 11 men, 65 +/- 16 (55-89) years of age, treated with haemodialysis for 6.7 +/- 7 (1-26) years. Catheters were tunnelled silicone twin catheters (Permcath Quinton n = 18, Twincath Hemotec n = 7) in right (n = 19) and left internal jugular (n = 6) inserted by percutaneous Seldinger techniques. We studied the localization of the catheter tip (superior vena cava, right atrium, right ventricular, inferior vena cava), the central venous pressure before and after haemodialysis, the blood pressure (BP) before and after haemodialysis, the interdialytic weight gain, the number of symptomatic hypotensions during the 10 last dialyses. The patients were divided into two groups: group I with usual adequate catheter function (n = 18) and group II with frequent dysfunctions (n = 7). Central venous pressure before dialysis was significantly higher in group I with adequate blood flow and the catheter's tip was more frequently found localized in the right cardiac cavities than in the vena cava. When central venous pressure before dialysis was over 5 mmHg, no dysfunction occurred. Blood pressure was not different between the two groups. We found no correlation between central venous pressure and BP, interdialytic weight gain and symptomatic hypotensions. We could not predict the central venous pressure from the mean BP but there was a higher frequency of hypotensions in the hypovolaemic patients. Optimal haemodynamic conditions will be provided by a catheter tip in the right cardiac cavities and a central venous pressure over 5 mmHg which can be provided with vascular filling or dry weight revaluation.

The total amount of sodium present in the body conditions the extracellular compartment volume. In advanced renal failure and in dialysis the sodium balance becomes positive and the extracellular volume inflates. This leads to hypertension and to direct cardiac and vascular changes that explain for a large part the excessive cardiovascular morbidity and mortality in dialysis patients. Controlling body sodium content and extracellular volume allows to reduce hypertension, cardiovascular changes and to improve dialysis patients survival. This can be achieved by reducing the sodium input (low sodium diet and reasonably low sodium dialysate) and/or by increasing sodium output (ultrafiltration by convection in hemodialysis or hemofiltration and osmotic drive in peritoneal dialysis). The intermittent nature of hemodialysis (and hemofiltration) conditions the saw-tooth volume fluctuations that drove to conceiving and implementing the concept of a dry weight, corresponding to normal extracellular volume and blood pressure.

Central venous stenosis (ST) and thrombosis (TB) related to catheter (KT) had been reported mostly for the subclavian vein. We performed a systematic cavographic study to evaluate the prevalence of these complications in 51 hemodialysis patients with present or previous history of tunneled internal jugular catheter. Each of them had used one or several KT (1.8 +/- 1.4 KT) for a mean 28 +/- 26 month cumulative time (i.e. 43,584 days total exposure time). Fifty percent of the KT were PermCath Quinton and 50% were Twincath (uncuffed) or CS 100 (cuffed) Medcomp. Twenty-seven had no ST (53%, group I), 24 had one or several significant ST (47%, group II) of superior Vena Cava (SVC, n = 4), inferior Vena Cava (IVC, n = 1), Brachio-cephalic Vein (BCV, n = 5) and subclavian vein (SC, n = 10), or a TB of SVC (n = 1), IVC (n = 3), BCV (n = 3), SC (n = 2). This accounts for an incidence of 0.55 ST or TB/1000 patient-days. Five of the twelve subclavian ST and TB had no history of previous subclavian catheter. Comparison between the two groups showed no differences according to age, time on dialysis, diabetes, hematocrit, CRP, cumulative time with catheter, catheter-related infections, type of catheter and anticoagulant treatment. IVC catheter tip's position is an important risk factor for TB and ST (4/6). Twelve group II patients had ST or TB-related symptoms, with a functional AV fistula in 9 cases. Eleven patients underwent repeated percutaneous angioplasty with 4 additional Wallstents and in 2 cases an AV fistula need to be closed. Central venous ST and TB after a jugular KT is extremely frequent, mostly without any symptoms. Consequences on peripheral or central vascular access, cost and poor long-term patency rate of angioplasty are of major importance. These results incite us to further reduce the catheter use in dialysis patients.

The incidence and prevalence of diabetes mellitus (DM) in the dialysis population in Europe, and more especially in France, have been lagging behind the impressive United States and Japanese rates. For a decade, things have been changing, and the incidence of DM in hemodialysis (HD) reached almost 40% in Tassin, France in 1999. The prevalence has followed the same trend but increased more slowly. The increase in incidence and prevalence is almost totally accounted for by type 2 DM explosive outbreak and development. The morbidity on dialysis (hypotensive episodes, hospitalization number, and duration) was significantly worse in diabetic patients (without difference between type 1 and 2) than in nondiabetic patients. The mortality rate was higher in diabetic patients than in nondiabetic patients (mean half-life 3 and 13 years, respectively), even after adjustment for age and comorbidity. The mortality rate was higher in type 2 than in type 1 (mean half-life 2.7 and 5.2 years, respectively), a difference which disappears when adjusting for age and comorbidity. Specific causes of death were different in diabetic and nondiabetic HD patients; in diabetics there was a six-fold higher cardiovascular (CV) and three-fold higher infectious mortality, but there was the same mortality from cancer. A strong difference was observed between type 1 and type 2 DM: in type 1 there was no increased infectious mortality and a moderately increased CV mortality compared with nondiabetic patients. Type 2 diabetic patients had a four-fold increased infectious and an eight-fold increased CV mortality. Altogether, the eruption of DM in our unit over the last decade has drastically increased the crude mortality, but the standardized mortality ratio using the USRDS mortality table remained unchanged, about 45% of expected mortality.

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-m2 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.

Unsatisfactory control of blood pressure (BP) leading to an increased rate of cardiovascular events is the main cause of mortality in haemodialysis. BP control has deteriorated since haemodialysis session times have been reduced. Inadequate BP control most often is due to a failure to achieve and maintain dry weight. Dry weight and normotension have been gradually omitted in the goals of dialysis, satisfactory dialysis being reduced to an 'adequate' urea Kt/V. Ideal dry body weight needs a reappraisal. What is dry weight? How should it be clinically assessed, established and maintained in patients? The problems encountered in estimating dry weight can be solved at the bedside in most cases. The additional laboratory, echography and impedancemetry methods are research tools that hopefully can be made simpler and lower in cost so they can be used everyday at the bedside. In the mean time, with the exception of ambulatory blood pressure measurement, one must rely on careful and repeated clinical observation to determine and maintain dry weight.

High blood pressure (BP) is a major factor contributing to the high incidence of cardiovascular morbidity and mortality in haemodialysis (HD) patients. According to predialysis casual BP measurements, long HD has been shown to provide good BP control. To confirm this result during the period between dialysis sessions, we performed ambulatory monitoring of BP in 91 non-selected HD patients (mean age, 58.7 (14.1) years; 14% incidence of nephrosclerosis and diabetes mellitus; treatment duration, 93.0 (77.2) months; 3 x 8 h/week, cuprophane, acetate buffer in 95% of the patients). Only one patient (1.1%) was receiving an antihypertensive medication. Ambulatory BP results were systolic (S) BP, 119.4 (19.9) mmHg; diastolic (D) BP, 70.6 (12.9) mmHg; mean (M) BP, 87.6 (13.9) mmHg. These values were significantly lower than the casual predialysis BP data and close to the reference values reported by Staessen et al. in a meta-analysis including 3476 normotensive subjects. The MBP was inversely correlated with the treatment duration, but not with interdialysis weight gain. The MBP increased significantly in the last part of the interdialysis period, and this rise was not correlated with the interdialysis weight gain. The nocturnal/diurnal ratios for SBP and DBP for the HD patients (0.97 and 0.92) were higher than the reference values reported by Staessen, (0.87 and 0.83), and argued against a nocturnal decrease in BP. We found that 52.1% of the patients had an abnormal nocturnal BP fall (MBP fall < 5%). This feature worsened during the second night of the interdialysis period.(ABSTRACT TRUNCATED AT 250 WORDS)

High blood pressure (BP) is a major factor contributing to the high incidence of cardiovascular morbidity and mortality in haemodialysis (HD) patients. According to predialysis casual BP measurements, long HD has been shown to provide good BP control. To confirm this result during the period between dialysis sessions, we performed ambulatory monitoring of BP in 91 non-selected HD patients (mean age, 58.7 (14.1) years; 14% incidence of nephrosclerosis and diabetes mellitus; treatment duration, 93.0 (77.2) months; 3 x 8 h/week, cuprophane, acetate buffer in 95% of the patients). Only one patient (1.1%) was receiving an antihypertensive medication. Ambulatory BP results were systolic (S) BP, 119.4 (19.9) mmHg; diastolic (D) BP, 70.6 (12.9) mmHg; mean (M) BP, 87.6 (13.9) mmHg. These values were significantly lower than the casual predialysis BP data and close to the reference values reported by Staessen et al. in a meta-analysis including 3476 normotensive subjects. The MBP was inversely correlated with the treatment duration, but not with interdialysis weight gain. The MBP increased significantly in the last part of the interdialysis period, and this rise was not correlated with the interdialysis weight gain. The nocturnal/diurnal ratios for SBP and DBP for the HD patients (0.97 and 0.92) were higher than the reference values reported by Staessen, (0.87 and 0.83), and argued against a nocturnal decrease in BP. We found that 52.1% of the patients had an abnormal nocturnal BP fall (MBP fall5%). This feature worsened during the second night of the interdialysis period.(ABSTRACT TRUNCATED AT 250 WORDS)

Sixty-six haemodialysed (HD) in centre patients (24 h/m2/week, acetate bath, cuprophane membrane), with a mean age of 59.2 years, treated for 16.7 +/- 4.5 years, underwent clinical examination of their hands to determine anatomical and functional alterations. For each hand a functional score was calculated from a medicolegal technique based on sensitivity and angulation amplitude (rating from 0 to 100). Dialysis-related arthropathy (DRA), including carpal-tunnel (CT) syndrome, was scored as well as hand muscle amyotrophia. Trigger fingers, abnormal synovial hypertrophy, and one or more non-functional tendons were found in 15, 26, and 33% of the patients respectively. Thirteen percent had pseudoporphyria. Amyotrophy was moderate or severe in 39%. The global functional score (mean of the two unilateral functional scores) decreased with time spent on haemodialysis and was correlated with the DRA score. The unilateral functional score was linked to tendinous lesions, amyotrophy, and presence of pulses, but not to CT surgery or presence of AV fistula. Hands with ulnar insult at the elbow shown by electromyography had significantly lower functional scores. Repercussions of hand functional alteration may have an important social and psychological impact in daily life. The responsibility of amyloidosis is evidenced by tendinous lesions and nervous entrapment. Ulnar palsy is also important because of the vital motor role of that nerve in hand function.

Sixty-six haemodialysed (HD) in centre patients (24 h/m2/week, acetate bath, cuprophane membrane), with a mean age of 59.2 years, treated for 16.7 +/- 4.5 years, underwent clinical examination of their hands to determine anatomical and functional alterations. For each hand a functional score was calculated from a medicolegal technique based on sensitivity and angulation amplitude (rating from 0 to 100). Dialysis-related arthropathy (DRA), including carpal-tunnel (CT) syndrome, was scored as well as hand muscle amyotrophia. Trigger fingers, abnormal synovial hypertrophy, and one or more non-functional tendons were found in 15, 26, and 33% of the patients respectively. Thirteen percent had pseudoporphyria. Amyotrophy was moderate or severe in 39%. The global functional score (mean of the two unilateral functional scores) decreased with time spent on haemodialysis and was correlated with the DRA score. The unilateral functional score was linked to tendinous lesions, amyotrophy, and presence of pulses, but not to CT surgery or presence of AV fistula. Hands with ulnar insult at the elbow shown by electromyography had significantly lower functional scores. Repercussions of hand functional alteration may have an important social and psychological impact in daily life. The responsibility of amyloidosis is evidenced by tendinous lesions and nervous entrapment. Ulnar palsy is also important because of the vital motor role of that nerve in hand function.

Carpal Tunnel Syndrome (CTS), and Shoulder Pain and Stiffness (SPS) are common in very long-term haemodialysis patients. To know whether this is a fortuitous association or if there is a link between these two manifestations a retrospective analysis of clinical charts, CTS surgical reports, tendon and synovia biopsies (Congo red, Crystal violet and Thioflavin T) was undertaken for 110 patients treated by haemodialysis (HD) for eight years or more. SPS was less frequent (24%) in 58 patients not operated on for CTS than in 52 operated patients (SPS incidence: 77%). Furthermore the 38 patients with amyloid deposits at carpal biopsy had a very significantly (p less than 0.001) higher incidence of SPS (95%) than the 14 operated patients free of amyloid deposits (SPS incidence: 28%). Hence, amyloid deposits represent a pathological link between these two correlated manifestations in very long-term haemodialysis patients.

To the Editor: In a recent issue of Kidney International Arkouche et al compare the survival data of their out-center patients (AURAL) with other series including ours1.