his slide forum opened with a presentation
by Todd Ing, MD, Hines VA
Hospital, Hines, Illinois, on a
method for estimating the equilibrated
urea reduction ratio (eURR) from samples
taken immediately after hemodialysis
(HD) (spURR). Postdialysis blood samples
were collected 30 minutes prior to the
end of the sessions, immediately after
dialysis, and 30 minutes after dialysis.
The following formulas were developed:
eURR = spURR x 0.83 + 2.2 for short sessions;
and eURR = spURR x 0.92 + 1.6 for
long sessions. Results were equivalent to
those based on samples drawn 30 minutes
after the session in 453 runs in 20 patients.
Given the relative ease of collecting
samples 30 minutes before the end
of the session, this method appears less
burdensome, especially for home
dialysis patients.
Session cochair Robert Lockridge Jr.,
MD, Lynchburg Nephrology, Lynchburg,
Virginia, delivered a report on successful
control of calcium x phosphorus (C x P) and
iPTH with nocturnal home HD (NHHD).
Ten patients were followed for 136 patient-months
(range 3 – 24 months) and all
quickly discontinued phosphate binder
medications. The first 5 patients started
with a 3.0-mEq calcium bath. A cross-sec-tional
analysis 15 months after the start of
the program showed mean serum Ca 9.8
mg/dL, P 3.8 mg/dL, Ca x P 37, alkaline
phosphatase 162 U/L, and iPTH 348 pg/mL,
with evidence of decreasing bone density.
Converting to a 3.5-mEq calcium bath for
9 of 10 patients resulted in mean values of
Ca 10.7 mg/dL, P 3.3 mg/dL, Ca x P 35,
Alk Phos 82 U/L, and iPTH 75 pg/mL, with
improved bone density within 9 months.
Thus, the 3.5-mEq/L calcium bath seems
ideal for maintaining Ca x P less than 45
and iPTH less than 150 pg/mL in NHHD,
which should result in improved morbidity
and mortality.
Carolyn Cacho, MD, University
Hospitals of Cleveland, Ohio, summarized
37 patient-months of nocturnal “Slow
Intensive Home Hemodialysis,” which
started in December, 1997, and involved 9
patients. Patients dialyze 6 – 8 hours, 5
nights/week, through central venous
accesses, maintain unrestricted diets, discontinue
phosphate binders and vitamin
D, and decrease erythropoietin and antihypertensive
drugs. Improvement in phosphate,
PTH, blood pressure, albumin,
appetite, muscle mass, sleep, energy, and
well being were noted, while potassium,
hemoglobin, and bicarbonate levels
remained stable.
Allan Collins, MD, Minneapolis
Medical Research Foundation,
Minneapolis, Minnesota, presented estimates
of the future growth of the USA end-stage
renal disease (ESRD) population
based on historical United States Renal
Data System (USRDS) data from 1982 to
1997. Dr. Collins projected that, by the year
2010, there will be 129,200 incident
patients (4.1% growth/year), 651,330
prevalent patients (6.4% growth/year),
520,240 dialysis patients (7.1% growth/
year), 178,806 functioning transplants
(6.1% growth/year), and 95,550 patients on
transplant waiting lists (8.2% growth/year).
Commensurate expenditures will increase
to US$28 billion annually.
Eepo Honkanen, MD, Helsinki
University Central Hospital, Helsinki,
Finland, described how a home HD program
was set up in May, 1998, in the geographically
extensive (and topographically
challenging) catchment area of this center,
building on their experience operating self-care
satellites. The treatment offered is
three-times weekly and uses dialysis assistants
(14 spouses, 2 friends, 1 parent, 1
nurse, and 1 patient with no partner). As
of September, 1999, 19 patients (18 males)
had entered the program, averaging 5.3
months at home (range 1 – 16 months).
Training time averaged 2 months. Three
patients were transplanted, one died, and
only two required temporary in-center
backup. Ten of the 19 were employed at the
end of follow-up. Blood work parameters
have remained stable.
Christopher Hoy, MD, shared the
initial experience of the Rubin Dialysis
Centers of New York’s NHHD program. The
program, modeled on the Uldall/Pierratos
program in Toronto, Canada, began in
March, 1998. Patients receive 5 – 6 weeks of
training, and then are monitored remotely
by computer as they dialyze 8 – 10 hours,
6 nights/week while sleeping. Preliminary
data from four patients show stable hematocrit
with decreased erythropoietin, better
blood pressure control with fewer or no
medications, improved nutrition,
decreased dialysis symptomatology, and
improved energy, libido, sleep, and rehabilitation.
There is an average of 1.1 alarms per
night; 70% are due to arterial line pressure.
Walter Bender, MD, Dialysis Clinic,
Inc., Kansas City, Missouri, offered pre-liminary
results from 2 patients dialyzing
6 nights/week for 7 – 8 hours through Ash
Split CathTM catheters for 6 and 9 months.
Both have discontinued phosphate binders
and liberalized their diets with drops in
serum phosphorus requiring supplementa-tion
with phosphosoda in the dialysate.
Potassium, creatinine, and BUN levels fell,
while albumin remained unchanged. One
patient discontinued antihypertensive
medication, but no changes in erythropoietin
have been seen. One patient, upon
being called for transplant, refused stating,
“I feel too good for a transplant.”
Giorgiana Piccoli, MD, University of
Torino, Torino, Italy, presented data on how
in-center, self-care, and home HD have
been integrated in a small unit in Italy. She
concluded that daily short dialysis could
be added to the center, using a mathematical
model allowing flexibility in the center’s
schedule for all patients. Dr. Piccoli identified
the importance of the caregiver/
patient relationship in the care of patients
with ESRD.
Paul Heidenheim, MA, London Health
Sciences Centre, London, Ontario, Canada,
presented data on the “Kidney Disease and
Quality of LifeTM Short Form (KDQOL SFTM
)”
scores comparing daily short, nocturnal
daily, and conventional dialysis.
Preliminary data suggest that both daily
and nocturnal home HD contribute to
improved subjective patient quality of life
within the first 3 months.
Mahendra Agraharkar, MBBS,
University of Texas Medical Branch,
Galveston, Texas, presented data
supporting the idea that staff-assisted
home HD in progressively debilitating and
terminally ill patients was a more cost-effective
way of providing quality of care,
compared to in-center outpatient dialysis
and hospital dialysis.
AlaattinYildiz, MD, Istanbul School of
Medicine, Istanbul, Turkey, presented data
comparing left ventricular dimensions
measured by echocardiogram, as well as
QT max, and QT dispersion (QT d) measured
by surface EKG, in 31 healthy controls
and 26 patients receiving HD three
times weekly. Increased QT max and
QT d were demonstrated in the HD patient
group. These findings correlate with wall
thickness, not left ventricular mass.
In another presentation, Dr. Yildiz
related a study of the effect of the Valsalva
maneuver on 20 HD patients and 22
matched controls. In the former group,
QT c max, QT c min, and QT c d were signifi-cantly
shortened after the Valsalva maneu-ver,
while no changes were observed in the
controls. These changes indicate increased
sympathetic activity in HD patients only
partly compensated by the increased
parasympathetic activity of the Valsalva
maneuver.
