Hemodialysis dose. Difficulty in measuring it
Dosis de hemodiálisis. Dificultad de su medida
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Difficulty in measuring it" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "28" "paginaFinal" => "29" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Jose Luis Teruel Briones, M. Fernández Lucas" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Jose Luis" "apellidos" => "Teruel Briones" "email" => array:1 [ 0 => "jteruel.hrc@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "M." "apellidos" => "Fernández Lucas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => " Hospital Ramón y Cajal, Madrid, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dosis de hemodiálisis. Dificultad de su medida" ] ] "textoCompleto" => "<p class="elsevierStylePara">Standardized urea clearance (Kt/V) and the percentage of urea reduction (PUR) are the parameters currently accepted to calculate the hemodialysis dose. The Kt/V is the quotient between two volume magnitudes: the volume of depurated body fluid throughout the hemodialysis session (Kt) and the urea steady state volume (V), which is equivalent to the volume of body water. The numerator in the equation indicates the hemodialysis dose that the patient has received and the denominator is the anthropometrical parameter selected to correct that dose according to body size.</p><p class="elsevierStylePara">Observational studies performed on a large number of patients verified that the relationship between dose and mortality described a J-shaped curve: the risk for death increases with the highest Kt/V or PUR values.<span class="elsevierStyleSup">1-4</span> The analysis of these data may be interpreted in two ways: either hemodialysis overdose is harmful for the patients or the measurement method entails some confounding phenomenon.</p><p class="elsevierStylePara">In 1985, the Kt/V was established as an index to estipulate a minimal hemodialysis dose after a secondary analysis of the data from the National Cooperative Dialysis Study.<span class="elsevierStyleSup">5 </span>At that time, it was not known that body size had a prognostic value in dialyzed patients. Further studies observed a direct relationship between survival and several anthropometrical parameters, among which was V.<span class="elsevierStyleSup">6-8</span> The Kt/V is a mathematical construct that may induce to interpretation errors since it is a quotient between two parameters having a positive influence on progression. Pathological decreases of V increase the Kt/V value and are related to poorer prognosis. The PUR presents the same problems: with the same hemodialysis dose, the PUR is negatively proportional to body size.<span class="elsevierStyleSup">6</span> The cause for a higher mortality risk observed in the population with the highest Kt/V or PUR values was clarified when it was verified that that group of patients included those with higher hyponutrition status.<span class="elsevierStyleSup">2</span> To avoid the interference between hyponutrition and hemodialysis dose, in 1999, Lowrie proposed using the Kt as a new measurement index.<span class="elsevierStyleSup">6</span> The relationship between Kt and survival is always positive and the highest Kt values are not associated to hyponutrition or greater mortality risk.<span class="elsevierStyleSup">2, 6</span></p><p class="elsevierStylePara">The first problem considered when using the Kt was the procedure to calculate it. Whereas the Kt/V may be calculated from formulas derived from the PUR, and V may be determined by anthropometrical equations, direct calculation of the Kt during a hemodialysis session is difficult to perform due to the complexity that entails «in vivo»determination of K. In the first studies,  the Kt was calculated indirectly by dividing the Kt/V obtained from Lowrie¿s formula (ln UreaPre ¿ ln UreaPost) by the V obtained through Chertow¿s equation.<span class="elsevierStyleSup">3, 6</span> This is a complicated procedure for daily clinical practice since it requires previous determination of Kt/V and V, and this work overload was one of the causes making difficult its applicability.</p><p class="elsevierStylePara">The advent of monitors measuring ionic dialysance resolved this problem. Ionic dialysance is similar to urea clearance (K). The ionic dialysance monitor automatically provides the Kt at each hemodialysis session. The Kt obtained by ionic dialysance also has a direct relationship with survival at any range.<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">In the current issue of the Nephrology Journal, Maduell et al. publish the results of the follow-up for three months of the hemodialysis dose through the Kt and the usual Kt/V and PUR indexes.<span class="elsevierStyleSup">9</span> The Kt is obtained at all hemodialysis sessions by ionic dialysance and the other two parameters by means of monthly laboratory work-up. The most relevant outcome is that 100% of the patients received an adequate dialysis dose according to the Kt/V, 90% according to PUR, and however 31% did not reach the required Kt value.</p><p class="elsevierStylePara">There are three aspects to comment on the Kt values considered acceptable. In the first place, there are no concordance studies between the two procedures used to measure the Kt. The Kt values recommended by Lowrie et al. in their original work (40-45 liters in women and 45-50 liters in men) correspond to a Kt determined from the Kt/V (obtained by laboratory) and the V (obtained by the anthropometrical formula), as it has been previously mentioned.<span class="elsevierStyleSup">6</span> The same authors did not establish the minimal Kt values obtained by ionic dialysance (the mortality progressively decreases as the Kt increases without a tendency of the curve to plateau).<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">In the second place, we should consider the type of monitor used to measure the Kt by ionic dialysance. There are two types of ionic dialysance monitors: Diascan (Hospal) and OCM (Fresenius). In the works by Lowrie et al.,<span class="elsevierStyleSup">4, 10, 11</span> the Kt was obtained by using an OCM monitor. In the work by Maduell, both monitors were used. Maduell himself has recently verified relevant differences between both: the Kt values yielded by Diascan are 15-17% lower than those by OCM.<span class="elsevierStyleSup">12</span> The Kt values obtained by Lowrie by ionic dialysance came from the monitor yielding higher values, and thus they are not valid if the Diascan monitor is used. The type of monitor used has to be taken into account at the time of establishing the reference values.</p><p class="elsevierStylePara">Lastly, we should consider that the data by Lowrie et al. have been obtained in a population with anthropometrical parameters different from ours. In the last Lowrie¿s series,<span class="elsevierStyleSup">11</span> the mean weight for his population was 10 kg higher than that for Maduell¿s series. In order to achieve similar Kt/V and PUR values, the Spanish population would need lower Kt values than the North American population.</p><p class="elsevierStylePara">Should we get rid of the standardization of the hemodialysis dose and prescribe fixed doses to all patients? Should a patient with a steady weight of 50 kg with no hyponutrition evidence receive the same dialysis dose than another one weighing 80 kg? Lowrie himself reconsidered that issue and proposed to correct the Kt by body surface area.<span class="elsevierStyleSup">10</span> He established a target Kt for each value from a body surface area scale, ranging from 1.20 to 2.80 m<span class="elsevierStyleSup">2.11</span> When Maduell et al. corrected the Kt according to body surface area following Lowrie¿s indications, the percentage of patients not reaching the minimal recommended value went up to 43%.</p><p class="elsevierStylePara">In order to achieve the minimal Kt values proposed by Lowrie, for both the absolute value and the value standardized by body surface area, the patients have to receive a hemodialysis dose measured by the classical Kt/V and PUR indexes very much higher than those recommended by current Clinical Guidelines.<span class="elsevierStyleSup">13</span> The hemodialysis dose that Maduell¿s patients receive is high according to usual measurement indexes (mean PUR values: 79.2% and mono-compartment Daugirdas Kt/V: 1.98), but 31%-43 % of them did not reach the target dose required according to the new criteria by Lowrie et al.. The HEMO study, a randomized and controlled trial, failed to show any clinical benefit by increasing the dialysis dose to values not even reaching those suggested by Lowrie.<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">The excellent work by Maduell et al. contributes to bring data and raises concerns about the unachieved topic of adequate hemodialysis dose and tailored procedure. Until further studies confirm the superiority of the Kt and establish the minimal required values, we should keep on using the classical indexes, always keeping in mind the presence of hyponutrition at the time of interpreting the data. </p>" "pdfFichero" => "P-E-S-A528-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "McClellan WM, Soucie JM, Flanders WD. Mortality in end-stage renal disease is associated with facility-to-facility differences in the adequacy of hemodialysis. 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| 2024 January | 45 | 25 | 70 |
| 2023 December | 39 | 31 | 70 |
| 2023 November | 50 | 27 | 77 |
| 2023 October | 67 | 29 | 96 |
| 2023 September | 84 | 21 | 105 |
| 2023 August | 75 | 21 | 96 |
| 2023 July | 81 | 26 | 107 |
| 2023 June | 50 | 20 | 70 |
| 2023 May | 79 | 31 | 110 |
| 2023 April | 57 | 11 | 68 |
| 2023 March | 66 | 26 | 92 |
| 2023 February | 39 | 21 | 60 |
| 2023 January | 35 | 24 | 59 |
| 2022 December | 33 | 31 | 64 |
| 2022 November | 43 | 27 | 70 |
| 2022 October | 44 | 44 | 88 |
| 2022 September | 34 | 24 | 58 |
| 2022 August | 44 | 43 | 87 |
| 2022 July | 24 | 35 | 59 |
| 2022 June | 25 | 24 | 49 |
| 2022 May | 32 | 42 | 74 |
| 2022 April | 34 | 30 | 64 |
| 2022 March | 35 | 44 | 79 |
| 2022 February | 39 | 33 | 72 |
| 2022 January | 27 | 24 | 51 |
| 2021 December | 36 | 38 | 74 |
| 2021 November | 39 | 40 | 79 |
| 2021 October | 39 | 27 | 66 |
| 2021 September | 27 | 41 | 68 |
| 2021 August | 30 | 42 | 72 |
| 2021 July | 37 | 39 | 76 |
| 2021 June | 19 | 33 | 52 |
| 2021 May | 28 | 31 | 59 |
| 2021 April | 26 | 47 | 73 |
| 2021 March | 34 | 39 | 73 |
| 2021 February | 37 | 22 | 59 |
| 2021 January | 29 | 13 | 42 |
| 2020 December | 30 | 21 | 51 |
| 2020 November | 24 | 18 | 42 |
| 2020 October | 17 | 14 | 31 |
| 2020 September | 12 | 8 | 20 |
| 2020 August | 32 | 10 | 42 |
| 2020 July | 21 | 8 | 29 |
| 2020 June | 29 | 11 | 40 |
| 2020 May | 36 | 13 | 49 |
| 2020 April | 18 | 17 | 35 |
| 2020 March | 31 | 10 | 41 |
| 2020 February | 29 | 20 | 49 |
| 2020 January | 29 | 20 | 49 |
| 2019 December | 31 | 17 | 48 |
| 2019 November | 32 | 17 | 49 |
| 2019 October | 17 | 7 | 24 |
| 2019 September | 27 | 13 | 40 |
| 2019 August | 13 | 8 | 21 |
| 2019 July | 23 | 22 | 45 |
| 2019 June | 17 | 8 | 25 |
| 2019 May | 22 | 13 | 35 |
| 2019 April | 61 | 19 | 80 |
| 2019 March | 21 | 15 | 36 |
| 2019 February | 16 | 17 | 33 |
| 2019 January | 14 | 13 | 27 |
| 2018 December | 66 | 30 | 96 |
| 2018 November | 73 | 16 | 89 |
| 2018 October | 59 | 14 | 73 |
| 2018 September | 71 | 11 | 82 |
| 2018 August | 37 | 21 | 58 |
| 2018 July | 37 | 17 | 54 |
| 2018 June | 36 | 13 | 49 |
| 2018 May | 28 | 15 | 43 |
| 2018 April | 43 | 9 | 52 |
| 2018 March | 41 | 9 | 50 |
| 2018 February | 40 | 5 | 45 |
| 2018 January | 52 | 5 | 57 |
| 2017 December | 45 | 13 | 58 |
| 2017 November | 39 | 14 | 53 |
| 2017 October | 41 | 5 | 46 |
| 2017 September | 34 | 11 | 45 |
| 2017 August | 34 | 15 | 49 |
| 2017 July | 36 | 16 | 52 |
| 2017 June | 20 | 13 | 33 |
| 2017 May | 36 | 13 | 49 |
| 2017 April | 31 | 10 | 41 |
| 2017 March | 19 | 7 | 26 |
| 2017 February | 19 | 9 | 28 |
| 2017 January | 10 | 6 | 16 |
| 2016 December | 63 | 12 | 75 |
| 2016 November | 80 | 9 | 89 |
| 2016 October | 108 | 6 | 114 |
| 2016 September | 121 | 6 | 127 |
| 2016 August | 177 | 2 | 179 |
| 2016 July | 153 | 0 | 153 |
| 2016 June | 114 | 0 | 114 |
| 2016 May | 110 | 0 | 110 |
| 2016 April | 81 | 0 | 81 |
| 2016 March | 71 | 0 | 71 |
| 2016 February | 101 | 0 | 101 |
| 2016 January | 84 | 0 | 84 |
| 2015 December | 98 | 0 | 98 |
| 2015 November | 57 | 0 | 57 |
| 2015 October | 74 | 0 | 74 |
| 2015 September | 61 | 0 | 61 |
| 2015 August | 56 | 0 | 56 |
| 2015 July | 62 | 0 | 62 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 51 | 0 | 51 |
| 2015 April | 5 | 0 | 5 |
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