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Effect of citrate based dialysate on anticoagulation in maintenance haemodialysis patients.
Ι. Griveas, Consultant Nephrologist
Backround: During haemodialysis (HD), blood is exposed to an extracorporeal circuit which activates thrombogenic pathways and clotting and may be associated with increased inflammation and acceleration of atherosclerosis. Even subclinical clotting of the dialysis circuit may reduce effective dialyser surface area and pore size, decreasing both small and middle solute clearance. An alternative to systemic heparin anticoagulation for HD is citrate dialysate (CD) which contains a small amount of citric acid. Aim of our study was to investigate whether CD results in reduced cumulative heparin dose (CHD) compared to acetate dialysate (AD) in HD patients.
Methods: 10 patients receiving HD with AD were recruited in our study. The above study population HD prescription converted to session with CD for an 9 month period. Serum total calcium, albumin, bicarbonate, pH, haemoglobin, haematocrit, kt/V and CRP were collected at the beginning of the first HD session of the study, after 4 months and in the end of the protocol. After enrolment, data regarding each patient’s dose of intradialytic heparin were collected and were evaluated according to a visual clotting score.
Results: During study period 647 HD sessions were under notice. 100% of our patients tolerated the procedure with CD well without issues. CHD reduced gradually to 40,5% of the initial dose. None of our patients suffered from bleeding complications. One out of 10 patients appeared to have asymptomatic hypocalcemic episode. We did not have any HD treatment that had to be abandoned because of clotting in the extracorporeal circuit. Metabolic, inflammatory and dialysis adequancy parameters along with hemoglobin levels were stable during the study period.
Conclusions: Our findings suggested that it is feasible to use CD to dialyse patients safely and effectively. With the contribution of CD, it was possible to anticoagulate the extracorporeal circuit with significant less CHD in a safe and simple manner without minor or major adverse reactions for the patients’ clinical condition.
THE EFFICACY OF ASCORBATE-RICH DIALYSATE TO ATTENUATE ANAEMIA IN MAINTENANCE HEMODIALYSIS PATIENTS
Ιοannis Griveas, MD,PhD
Nephrology Department 417 Army Share Fund Hospital (NIMTS), Athens, Greece
Hemodialysis (HD) patients with functional iron deficiency (FID) often develop resistance to recombinant human erythropoietin (Epo). The contributory role of chronic inflammation and oxidative stress in its pathogenesis is poorly understood. Recent studies have shown that intravenous ascorbic acid (IVAA) administration could override rhEPO resistance in HD patients. Yet little is known about whether supplementation of ascorbic acid (vitamin C) via extracorporeal circuit has substantial effects on minifying oxidative impairment and thus improving Hb levels. This study was undertaken to test the effects of Ascorbate-Rich Dialysate to Attenuate anaemia in Maintenance HD Patients.
13 HD patients (mean age: 71.3±14.6 years) were recruited for the study. For a period of 8 months they were receiving Ascorbate-Rich Dialysate (2g/lt) and we compared their anaemia profile (Hb, Hct, ferritin , TSAT, rhEPO dose) during this period with the previous 8 months that they were receiving conventional dialysate. Additionally we evaluated their “chronic inflammation status” estimating CRP and Soluble Urokinase Plasminogen Receptor (Supar) levels over the study period and also lipids and nutritional profile.
CRP levels declined with the use of ascorbate-rich dialysate from 12.28 to 3.86 mg/L while supar levels remained stable over the whole study period (15 mg/ml). Mean Hct levels increased significantly from 35.56±2.37% with conventional dialysate to 39.98±3.64 % with 8 months usage of ascorbate-rich dialysate (p<0.05). The above notice started to appear even after 3 months under vitamin C –rich dialysate (35.56±2.37 vs 37.96 ± 3.06, p<0.05). The same conclusion was noticed with Hb levels (11.23±0.94 vs 12.10±1.04, p<0.05 after 3 months under vit c, 11.23±0.94 vs 12.59±1.38, p<0.05 after 8 months under vitamin C ). Mean rhEPO dose (darbepoetin alfa) decreased from 48.63 to 33.46 mcg/mL per week with usage of ascorbate-rich dialysate. Ferritin (>500), albumin, TSAT (>20) and PTH levels remained stable over the whole study period. Cholesterol, triglycerides and albumin levels did not change significantly with the change of the conventional dialysate to ascorbic-rich one.
Although our study is limited by small numbers of subjects, short durations of follow-up, these results suggest that compared with standard care, ascorbic acid in dialysate bath may result in an increase in hemoglobin concentration and decrease in rHuEPO requirements. Longer term studies are required to confirm these results, provide information about adverse events, and determine whether these changes translate into improved patient outcomes and cost-effectiveness.
Effect of citrate based dialysate on intradialytic heparin dose in maintenance haemodialysis patients.
Ι. Griveas, Consultant Nephrologist
Backround: During haemodialysis (HD), blood is exposed to an
extracorporeal circuit which activates thrombogenic pathways and clotting and may be associated with increased inflammation and acceleration of atherosclerosis. Even subclinical clotting of the dialysis circuit may reduce effective dialyser surface area and pore size, decreasing both small and middle solute clearance. An alternative to systemic heparin anticoagulation for HD is citrate dialysate (CD) which contains a small amount of citric acid. Aim of our study was to investigate whether CD results in reduced cumulative heparin dose (CHD) compared to acetate dialysate (AD) in HD patients.
Methods: 111 patients receiving HD with AD were recruited in our study. The above study population HD prescription converted to session with CD for a 3 month period. Serum total calcium, albumin, haemoglobin, haematocrit and kt/V were collected at the beginning of the first HD session of the study and in the end of the protocol. After enrolment, data regarding each patient’s dose of intradialytic heparin were collected and were evaluated according to a visual clotting score. We compared behavior of our patients on the basis of vascular access type (fistula, graft and central venous catheter), dialysis mode (classic and on-line hemodiafiltration) and age (patients over 65 years old and below 65 years old).
Results: During study period 4329 HD sessions were under notice. 100% of our patients tolerated the procedure with CD well without issues. CHD reduced gradually to 46,57% of the initial dose (from 4429.24±1531.32 to 2080.18±1.259.51). None of our patients suffered from bleeding complications. We did not have any HD treatment that had to be abandoned because of clotting in the extracorporeal circuit. Ca levels remained stable through the study period (8.66±0.63 vs 8.57±0.72). Nutrition (albumin 4.19±0.65 vs 4.20±0.63), dialysis adequancy parameters (kt/v 1.25±0.21 vs 1.25±0.24) along with hemoglobin levels (12.36±1.16 vs 12.09±1.06) were stable during the study period. Type of vascular access, dialysis mode and age do not seem to significantly impact the reduction of heparin dose in any way.
Conclusions: Our findings suggested that it is feasible to use CD to dialyse patients safely and effectively, no matter age of patients, dialysis mode or vascular access type. With the contribution of CD, it was possible to anticoagulate the extracorporeal circuit with significant less CHD in a safe and simple manner without minor or major adverse reactions for the patients’ clinical condition.
USE OF ASCORBATE-RICH DIALYSATE IN HEMODIALYSIS PATIENTS
Ιοannis Griveas, MD,PhD
Nephrology Department 417 Army Share Fund Hospital (NIMTS), Athens, Greece
Background and Aims: Increments of oxidative stress have been addressed as one potential cause for the accelerated atherosclerosis of chronic kidney disease patients. Ascorbate (vitamin-C) represents one of the most prominent antioxidants both in plasma and intracellulary. Unsupplemented dialysis patients have reportedly lower plasma levels of ascorbate in comparison to healthy controls, mostly due to a loss into the dialysate. Purpose of our study was the recording of the experience of the use of Ascorbate-Rich Dialysate in patients under hemodialysis (HD).
Method: 11 HD patients were recruited for the study. During a period of 8 weeks they were receiving Ascorbate-Rich Dialysate (2g/lt). Ascorbic acid levels were estimated before and at the end of the study period. We also monitored patients’ anemia profile (Hb, Hct, ferritin , TSAT, rhEPO dose), lipid and nutrition status.
Results: Ascorbic acid values were towards the lower accepted levels in our patients (3.25±1.01 mg/l) at the beginning of the study period. After 8 weeks receiving Ascorbate-Rich Dialysate, acorbic-acid levels were significantly increased (6.87±1.50 mg/l) without transcending the upper accepted limit. During the notice period, our patients were behaved normally without any sort of adverse events. Mean Hct levels remained stable (39.10±3.70% with conventional dialysate vs 39.67±1.59 % with usage of ascorbate-rich dialysate ). The same conclusion was noticed with Hb levels (12.85±1.20 vs 13.15±0.49). Mean rhEPO dose per week (epoetin- alfa) decreased (9000±5200 iu vs 6250±4300 iu, p=NS) and administration of Fe stopped to all of our patients. Ferritin (>700), TSAT (>35) remained stable over the whole study period. Cholesterol, triglycerides and albumin levels did not change significantly with the change of the conventional dialysate to ascorbic-rich one.
Conclusion: Although our study is limited by small numbers of subjects, short durations of follow-up, our results suggest that compared with standard care, ascorbic acid in dialysate bath is a safe choice to increase ascorbic-acid levels in traditionally vitamic C depleted HD patients within safe limits. This raise seems to favors anemia profile of HD population. Longer term studies are required to confirm these results, determine whether these changes translate into improved patient outcomes and cost-effectiveness.
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in Eastern Attica
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Basement PARKING 13 places
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Perfect operation of the unit with minimization of routes and the excellent relationship between its individual spaces.
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The creation of a pleasant and friendly environment for the comfortable long stay of patients and attendants.
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The clear demarcation of the treatment areas from the rest of the unit and the ensuring as much as possible a sense of privacy to patients.
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Landscaping of the premises in such a way as to ensure the partitioning of the works and to ensure, where desired, isolation to limit the spread of infections.