Notes on techniques
Follow a recipe to prescribe phosphate during hemodialysis
Receta para prescribir fósforo durante hemodiálisis
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haemodialysis, based on residual renal function, at the initiation of renal replacement therapy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "39" "paginaFinal" => "46" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicación de una pauta de hemodiálisis incremental, basada en la función renal residual, al inicio del tratamiento renal sustitutivo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1779 "Ancho" => 2207 "Tamanyo" => 155706 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of incident patients treated in the haemodialysis unit of the Hospital Universitario del Henares from July 2008 to September 2015. RRF: residual renal function; RRT: renal replacement therapy.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José L. Merino, Patricia Domínguez, Blanca Bueno, Yésika Amézquita, Beatriz Espejo, Vicente Paraíso" "autores" => array:6 [ 0 => array:2 [ "nombre" => "José L." 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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Tamar" "apellidos" => "Talaván Zanón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 8 => array:3 [ "nombre" => "Roberto" "apellidos" => "Alcazar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "Mayra" "apellidos" => "Ortega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 10 => array:3 [ "nombre" => "Marta" "apellidos" => "Puerta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Laboratorio de Bioquímica, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Diálisis, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Receta para prescribir fósforo durante hemodiálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1552 "Ancho" => 1637 "Tamanyo" => 95993 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The figure shows the concentrations of P achieved in the dialysis fluid for each calculation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">At haemodialysis (HD) units we find patients with intermittent or persistent hypophosphatemia (hypoP), which may be symptomatic. The frequency, the causes and the consequences of hypoP in chronic HD patients are not well known.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> During the past year, in our hemodialysis unit a 9.35% of serum phosphate values were less than 2.5<span class="elsevierStyleHsp" style=""></span>mg/dl. HypoP may induce: rhabdomyolysis, haemolysis,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,3</span></a> leucocyte dysfunction, respiratory failure, impaired myocardial function, bone disease, etc.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a> and in the elderly HD patient, hypoP has been associated with an increase in mortality.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are dialysates (LD) containing phosphate (P) for continuous acute dialysis techniques,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">7,8</span></a> but there are no commercial preparations for chronic HD. Phosphate can be added to the dialysis fluid in the form of Casen<span class="elsevierStyleSup">®</span> enema, or other products with a high content of P,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> but no publication shows a practical approach on how to supplement it. Our goal is to describe how to calculate the volume of enema to be added to the acid dialysis concentrate to achieve a given concentration of P in the LD, the validation of this procedure, and the problems that may be encountered with this manoeuvre.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Theoretical basis to obtain the formula</span><p id="par0015" class="elsevierStylePara elsevierViewall">First: How is P added to the LD? It is most common to use Casen<span class="elsevierStyleSup">®</span> enema (Casen-Fleet, S.L. laboratories) containing 13.9<span class="elsevierStyleHsp" style=""></span>g of anhydrous sodium dihydrogen phosphate and 3.2<span class="elsevierStyleHsp" style=""></span>g of anhydrous disodium hydrogen phosphate. In Spain, there are presentations of 80, 140 and 250<span class="elsevierStyleHsp" style=""></span>ml. Each ml contains 43<span class="elsevierStyleHsp" style=""></span>mg of P.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Second: To what solution should we added? Since bicarbonate powder cartridges are the most commonly used, P should be added to the acid concentrate.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Third: How do I calculate how much enema to add?<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a.</span><p id="par0030" class="elsevierStylePara elsevierViewall">What is the dilution acid to water that I use? The standard dilutions are 1:35 or 1:45. In the case of 1:45, every litre of acid result in 45<span class="elsevierStyleHsp" style=""></span>l of LD.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b.</span><p id="par0035" class="elsevierStylePara elsevierViewall">What is the volume of the acid concentrate? In our case, we have: 3.5<span class="elsevierStyleHsp" style=""></span>l bottles (Fresenius 5008<span class="elsevierStyleSup">®</span>) and 5<span class="elsevierStyleHsp" style=""></span>l bags (AK-200<span class="elsevierStyleSup">®</span>). Therefore, using acid dilution of 1:45, 5<span class="elsevierStyleHsp" style=""></span>l will generate 225<span class="elsevierStyleHsp" style=""></span>l of LD (45<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5) and using 3.5 l will end up in 157.5<span class="elsevierStyleHsp" style=""></span>l (45<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c.</span><p id="par0040" class="elsevierStylePara elsevierViewall">What is the target P concentration in the LD ([P]<span class="elsevierStyleInf">LDobj</span>)? If we want 1.5<span class="elsevierStyleHsp" style=""></span>mg/dl, the amount of P required will be the result of multiplying [P]<span class="elsevierStyleInf">LDobj</span> by the total volume previously calculated of LD (1.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2250<span class="elsevierStyleHsp" style=""></span>dl or 1.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1575<span class="elsevierStyleHsp" style=""></span>dl) which results in 3375 or 2362.5<span class="elsevierStyleHsp" style=""></span>mg of P for the AK-200<span class="elsevierStyleSup">®</span> and Fresenius<span class="elsevierStyleSup">®</span> monitors, respectively.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d.</span><p id="par0045" class="elsevierStylePara elsevierViewall">What volume of enema contains such an amount of P? Since 1<span class="elsevierStyleHsp" style=""></span>ml of enema contains 43<span class="elsevierStyleHsp" style=""></span>mg of P, divide the amount of P by 43. If 3375 or 2362.5 are divided by 43, the result is that 78 and 55<span class="elsevierStyleHsp" style=""></span>ml of enema need to added to the 5 and 3.5<span class="elsevierStyleHsp" style=""></span>l acid containers, respectively.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e.</span><p id="par0050" class="elsevierStylePara elsevierViewall">The formula is:</p></li></ul><elsevierMultimedia ident="eq0005"></elsevierMultimedia>where Venema is the volume of enema in ml; <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">LD</span> is the volume of the acid concentrate (in dl); LD is the dilution factor of each specific monitor and [P]<span class="elsevierStyleInf">LDobj</span> is the desired P concentration in LD (mg/dl). It is divided by 43, the amount of P in 1<span class="elsevierStyleHsp" style=""></span>ml of enema.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Validation of the formula</span><p id="par0055" class="elsevierStylePara elsevierViewall">The monitors used were: Fresenius 5008<span class="elsevierStyleSup">®</span> and Gambro AK-200<span class="elsevierStyleSup">®</span>. The amount of enema required to achieve a [P]<span class="elsevierStyleInf">LDobj</span> of 1.5, 2, 2.5, and 3.5<span class="elsevierStyleHsp" style=""></span>mg/dl was calculated with 2 acid concentrates: 3.5<span class="elsevierStyleHsp" style=""></span>l and bottles of 5<span class="elsevierStyleHsp" style=""></span>l bags, with 1:45 dilution (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In AK-200<span class="elsevierStyleSup">®</span>, we used another acid solution of 1<span class="elsevierStyleHsp" style=""></span>l containing citrate, to generate a Ca 3.3<span class="elsevierStyleHsp" style=""></span>mEq/l and K 2<span class="elsevierStyleHsp" style=""></span>mEq/l with a [P]<span class="elsevierStyleInf">LDobj</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>mg/dl. Using the same formula, with a 1:45 dilution, the volume of enema added was 15<span class="elsevierStyleHsp" style=""></span>ml.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The concentration of P in LD ([P]<span class="elsevierStyleInf">LD</span>) was measured 80 times in 2 separate situations:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Sixty-five determinations in the LD of patients receiving P during their dialysis, with enema added to the acid concentrate due to hypophosphatemia (<2.5<span class="elsevierStyleHsp" style=""></span>mg/dl), using a [P]<span class="elsevierStyleInf">LDobj</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.5 or 2<span class="elsevierStyleHsp" style=""></span>mg/dl. All had a calcium concentration of 3<span class="elsevierStyleHsp" style=""></span>mEq/l, except those dialysed with a LD containing citrate. The potassium concentrate was: 1.5<span class="elsevierStyleHsp" style=""></span>mEq/l (in 39), 2<span class="elsevierStyleHsp" style=""></span>mEq/l (in 13) and 3<span class="elsevierStyleHsp" style=""></span>mEq/l (in 19).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">The remaining 15 were obtained from LD with [P]<span class="elsevierStyleInf">LDobj</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.5 or 3.5<span class="elsevierStyleHsp" style=""></span>mg/dl. This LD was not used in patients.</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">The P was added to the acid concentrate before starting the monitor and it was shaken. The dialysis was prepared as usual. Twenty minutes after monitor indication that the LD was ready, samples were extracted. Any incidence during the preparation of the monitor, addition of P to the concentrate or sampling, was recorded.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Laboratory methods</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pre-analytic preparation of the samples was not necessary because the LD lacks cells. P, Na, K, and Mg were determined using the Dimension EXL (Siemens) analyser. Direct colorimetric methods were used to determine P (phosphomolybdate method) and Mg; indirect potentiometry for Na, and K and direct potentiometry for ionic Ca in the Rapidlab 1265 (Siemens) gas analyser. To verify reproducibility, each sample was analysed with 2 identical machines.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Stability of the dilution was evaluated in 8 samples of LD that were collected and stored between 2 and 10<span class="elsevierStyleHsp" style=""></span>°C. The values were measured 4 times a day, at 3<span class="elsevierStyleHsp" style=""></span>h intervals for 3 days. Stability was evaluated with a metrological criterion according to the intra-trial and inter-daily analytical variation and a biological criterion based on intra-individual biological variation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Statistics</span><p id="par0095" class="elsevierStylePara elsevierViewall">All data were introduced in an Excel database and mean values and standard deviation (SD) were calculated. A data comparison was performed by Student <span class="elsevierStyleItalic">t</span>.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Concentrations obtained</span><p id="par0100" class="elsevierStylePara elsevierViewall">The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The rest biochemical determinations (results not shown) matched the expected values of LD without P added.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The [P] obtained in the LD with citrate (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10) was mean (SD) 0.38 (0.21) mg/dl. After further evaluation, it was found that the dilution was 1:200. It would have been needed 70<span class="elsevierStyleHsp" style=""></span>ml of enema to obtain a [P]<span class="elsevierStyleInf">LD</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>mg/dl.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Laboratory methods</span><p id="par0110" class="elsevierStylePara elsevierViewall">There were no statistically significant differences according to the analyser used. The stability study showed that the analysed samples remained stable during the 72<span class="elsevierStyleHsp" style=""></span>h of study period.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Practical problems</span><p id="par0115" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">(a)</span><p id="par0120" class="elsevierStylePara elsevierViewall">In relation to the preparation of the LD: The AK200<span class="elsevierStyleSup">®</span> monitors did not pass the initial tests if the enema is added when the monitor is being turned-on; it is necessary to reinitiate the monitor with an acid concentrate with no enema added and the enema should be added 10<span class="elsevierStyleHsp" style=""></span>min later.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">(b)</span><p id="par0125" class="elsevierStylePara elsevierViewall">Addition of the enema:</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">In some cases, enema was added to containers that were not totally full, consequently higher [P]<span class="elsevierStyleInf">LD</span> were obtained.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">The Casen<span class="elsevierStyleSup">®</span> enema is marketed in a flexible plastic container with a cannula that cannot be completely emptied, so the actual volume administered may be less than that calculated.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">In one container of litre citrate acid (SelectBag Citrate<span class="elsevierStyleSup">®</span>), with 50<span class="elsevierStyleHsp" style=""></span>ml, a LD with [P]<span class="elsevierStyleInf">LD</span> of 1.5<span class="elsevierStyleHsp" style=""></span>mg/dl cannot be achieved with Casen<span class="elsevierStyleSup">®</span> enema.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">(c)</span><p id="par0145" class="elsevierStylePara elsevierViewall">No problems were reported during the HD session.</p></li></ul></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">This manuscript presents an easy and practical method to calculate the volume of enema that needs to be added to the LD to obtain a target concentration of [P]<span class="elsevierStyleInf">LDobj</span>.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Several publications show that adding P to the LD is a safe method to prevent the loss of P during the HD procedure.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10,11</span></a> Its utility is evident and there are variety of clinical indications.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> We used a [P]<span class="elsevierStyleInf">LDobj</span> of 1.5–2<span class="elsevierStyleHsp" style=""></span>mg/dl if pre-dialysis serum P were maintained below 2.5<span class="elsevierStyleHsp" style=""></span>mg/dl despite dietary intervention. There were several unanswered questions: how to add phosphate?; The calculation of how much enema should be added?, When?, Does it affect the monitor?, Can I measure the actual P concentration in the LD? All these questions were addressed in our study.</p><p id="par0160" class="elsevierStylePara elsevierViewall">We decided to add P in the form of a Casen<span class="elsevierStyleSup">®</span> enema because as compared with other commercial preparations the number of excipients is lower, it has a high P concentration. Casen<span class="elsevierStyleSup">®</span> enema contains methyl parahydroxybenzoate that acts against moulds and yeasts; it is used in foods, cosmetics, and drugs and may produce allergic reactions. In our patients we have not seen adverse events, so we do not believe that it is a contraindication for its use. The Casen<span class="elsevierStyleSup">®</span> enema does not contain endotoxins and cultures were negative.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> If the amount of phosphate in other preparations known, the calculation will be the same, but we have used only Casen<span class="elsevierStyleSup">®</span> enema.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our results show that the calculated volume is correct and easy to do. The difference between the P obtained and the calculated P is minimal; if the values were different there was an identifiable error that could have been anticipated. The experience with citrate illustrate that it is necessary to know the dilution of LD, and to be aware of any modification in the monitor.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Practice showed that with some monitors the enema cannot be added to the acid concentrate before the monitor is turned on. The enema adds sodium and other substances that, without modifying the electrolytic composition of the LD, may affect the initiation process of the AK200<span class="elsevierStyleSup">®</span> monitor; although, we do not have an explanation for this. Waiting 10<span class="elsevierStyleHsp" style=""></span>min before addition of the enema avoids the problem with the monitor, there is a minimal consumption of volume and does not alter the [P]<span class="elsevierStyleInf">LDobj</span>. This operation may make nursing work just a little more difficult. The one-litre citrate containers do not have enough capacity to receive the adequate volume of enema.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Prior publications indicates that it is necessary to shake vigorously, even during 10–15<span class="elsevierStyleHsp" style=""></span>min, to assure the dilution of the enema<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a>; in our experience, such a vigorous shaking is not necessary.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Other were relate to the volume administered. First, adding the enema calculated in volumes of acid that were lower than anticipated resulted in higher [P]<span class="elsevierStyleInf">LD</span>. This may occur if the volume of acid remaining in the bottles is not discarded. For example, adding 55<span class="elsevierStyleHsp" style=""></span>ml of enema in 2<span class="elsevierStyleHsp" style=""></span>l of acid will produce a LD with [P]<span class="elsevierStyleInf">LD</span> of 2.6<span class="elsevierStyleHsp" style=""></span>mg/dl instead of 1.5<span class="elsevierStyleHsp" style=""></span>mg/dl. Second, it is necessary to avoid human errors by checking the volume administered, being careful of the commercial presentation and the need to use different volumes according to acid and the [P]<span class="elsevierStyleInf">LDobj</span>. Finally, it the enema is added directly with the cannula, some volume may be left en the recipient producing underdosing.</p><p id="par0185" class="elsevierStylePara elsevierViewall">We would like to emphasise that the aim of our work is not to recommend the administration of P in LD for all patients. In fact, in patients with serum P lower that 2.5<span class="elsevierStyleHsp" style=""></span>mg/dl it is necessary to check dietary problems and P binders. The purpose of adding P to the dialysate is to avoid a negative P balance in patients with chronic hypophosphatemia. It remains to be seen whether it would be beneficial to produce P repletion or positive balance.</p><p id="par0190" class="elsevierStylePara elsevierViewall">There is no information on what should be the P level after dialysis; in our opinion a post dialysis serum P ranging from 1 to 2<span class="elsevierStyleHsp" style=""></span>mg/dl, may be appropriate taking into account the rebound of P. Although without symptomatology, a serum P less than 1<span class="elsevierStyleHsp" style=""></span>mg/dl, P depletion may cause cell malfunction that is not easy to detect. In any case, we do not use LD concentrations greater than 2<span class="elsevierStyleHsp" style=""></span>mg/dl, in patients with pre-dialysis serum P that are not greater than 2.5–3<span class="elsevierStyleHsp" style=""></span>mg/dl unless the intake increases. Nevertheless the post-dialysis serum P concentration can be measured to prove that a satisfactory phosphatemia has been achieved at the end of the session. The post dialysis serum P using 1.5–2<span class="elsevierStyleHsp" style=""></span>mg/dl of P in the dialysate have not exceeded concentrations of 2.5<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally, the determination of [P]<span class="elsevierStyleInf">LD</span> will assure that P being administered is adequate. This is an easy and reproducible method to demonstrate that our practice is correct. Other published works do not discuss this aspect. The fact that the sample of dialysate fluid is stable there is no need for centrifugation facilitates its measurement in non-hospital environments.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The main limitation of our data is that we have not determined the phosphatemias achieved, although this was not the aim of the work. Understanding the short/long term effect it may have opens up an interesting field of work. We also want to emphasise that the formula can only be used with the Casen<span class="elsevierStyleSup">®</span> enema, since the denominator is determined by the content of P in the enema, but the calculation process would be the same using other products.</p><p id="par0205" class="elsevierStylePara elsevierViewall">In summary, we believe that this work provides a practical view of how to deliver P in the LD, with a simple calculation, and presents the day to day problems that may appear and are not shown in any of the other works published. We believe that the number of determinations made is sufficient and shows that the calculation is correct, and offers measurement methods that can be used as quality control.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres818625" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815675" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818626" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815674" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Theoretical basis to obtain the formula" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Validation of the formula" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Laboratory methods" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistics" ] ] ] 7 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Concentrations obtained" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Laboratory methods" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Practical problems" ] ] ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack274703" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-25" "fechaAceptado" => "2016-04-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815675" "palabras" => array:4 [ 0 => "Hypophosphatemia" 1 => "Phosphate" 2 => "Hemodialysate" 3 => "Enema" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec815674" "palabras" => array:4 [ 0 => "Hipofosforemia" 1 => "Fósforo" 2 => "Líquido de diálisis" 3 => "Enema" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The addition of phosphorus (P) to the dialysate (LD) in the form of enema Casen<span class="elsevierStyleSup">®</span> is common practice in patients with hypophosphatemia. The estimation of the amount to be used and the identification of the problems that may occur are not well defined. As a result of our work we propose a practical approach of how to proceed to increase phosphate concentration in the hemodialysate. We present a reasoned formula to calculate how much enema has to be added and the problems that may arise.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La adición de fósforo (P) en el líquido de hemodiálisis (LD) mediante enema con fosfato de sodio (enema Casen<span class="elsevierStyleSup">®</span>) se utiliza habitualmente en pacientes con hipofosforemia. El cálculo de la cantidad y los problemas que puede presentar no se describen en la literatura. Nuestro trabajo hace un abordaje práctico de cómo poner fósforo en LD con una fórmula razonada para calcular cuánto volumen de enema añadir en función del concentrado de diálisis utilizado y los problemas que pueden aparecer.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Albalate M, Ruiz-Alvarez MJ, de Sequera P, Perez-Garcia R, Arribas P, Corchete E, et al. Receta para prescribir fósforo durante hemodiálisis. Nefrologia. 2017;37:34–38.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1552 "Ancho" => 1637 "Tamanyo" => 95993 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The figure shows the concentrations of P achieved in the dialysis fluid for each calculation.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CC: mean concentration of phosphorus reached; SD: standard deviation; <span class="elsevierStyleItalic">N</span>: number of determinations made; <span class="elsevierStyleItalic">V</span>: added volume.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Bold is the obtained P concentration.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Target<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>mg/dl</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Target<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mg/dl</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Target<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.5<span class="elsevierStyleHsp" style=""></span>mg/dl</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Target<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>mg/dl</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AK<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">5008<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AK<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">5008<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AK<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">5008<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AK<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">5008<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">V</span> (ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">130 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">183 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">128 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CC (mg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">1.59</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">1.55</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">1.96</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">1.96</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">2.53</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">2.55</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">3.53</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">3.2</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1375951.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Volume of enema needed to obtain the target P concentration in dialysis fluid and the results obtained.</p>" ] ] 2 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "Venema=VLD×LD×[P]LDobj43" "Fichero" => "STRIPIN_si1.jpeg" "Tamanyo" => 2076 "Alto" => 34 "Ancho" => 207 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hipofosforemia en unidades de diálisis crónica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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| 2021 July | 59 | 34 | 93 |
| 2021 June | 76 | 43 | 119 |
| 2021 May | 56 | 42 | 98 |
| 2021 April | 105 | 62 | 167 |
| 2021 March | 92 | 64 | 156 |
| 2021 February | 107 | 23 | 130 |
| 2021 January | 70 | 34 | 104 |
| 2020 December | 83 | 24 | 107 |
| 2020 November | 62 | 21 | 83 |
| 2020 October | 59 | 31 | 90 |
| 2020 September | 67 | 30 | 97 |
| 2020 August | 80 | 39 | 119 |
| 2020 July | 67 | 8 | 75 |
| 2020 June | 109 | 41 | 150 |
| 2020 May | 105 | 79 | 184 |
| 2020 April | 74 | 20 | 94 |
| 2020 March | 58 | 18 | 76 |
| 2020 February | 62 | 23 | 85 |
| 2020 January | 81 | 29 | 110 |
| 2019 December | 67 | 25 | 92 |
| 2019 November | 66 | 25 | 91 |
| 2019 October | 74 | 12 | 86 |
| 2019 September | 93 | 14 | 107 |
| 2019 August | 53 | 11 | 64 |
| 2019 July | 53 | 22 | 75 |
| 2019 June | 61 | 24 | 85 |
| 2019 May | 53 | 30 | 83 |
| 2019 April | 105 | 43 | 148 |
| 2019 March | 65 | 25 | 90 |
| 2019 February | 35 | 22 | 57 |
| 2019 January | 48 | 25 | 73 |
| 2018 December | 157 | 46 | 203 |
| 2018 November | 265 | 24 | 289 |
| 2018 October | 240 | 16 | 256 |
| 2018 September | 94 | 28 | 122 |
| 2018 August | 57 | 14 | 71 |
| 2018 July | 54 | 12 | 66 |
| 2018 June | 63 | 15 | 78 |
| 2018 May | 81 | 13 | 94 |
| 2018 April | 100 | 8 | 108 |
| 2018 March | 87 | 15 | 102 |
| 2018 February | 98 | 5 | 103 |
| 2018 January | 64 | 8 | 72 |
| 2017 December | 105 | 8 | 113 |
| 2017 November | 66 | 19 | 85 |
| 2017 October | 41 | 6 | 47 |
| 2017 September | 44 | 8 | 52 |
| 2017 August | 50 | 10 | 60 |
| 2017 July | 55 | 7 | 62 |
| 2017 June | 55 | 6 | 61 |
| 2017 May | 70 | 13 | 83 |
| 2017 April | 52 | 5 | 57 |
| 2017 March | 47 | 6 | 53 |
| 2017 February | 19 | 7 | 26 |
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