Guidelines for automated manual infusion: a practical way of prescribing postdilution on-line haemodiafiltration
Pauta de infusión manual automatizada: una forma práctica de prescribir la hemodiafiltración on-line posdilucional
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"apellidos" => "Sentis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 9 => array:3 [ "Iniciales" => "C." "apellidos" => "Durán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 10 => array:3 [ "Iniciales" => "E." "apellidos" => "Bergada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 11 => array:3 [ "Iniciales" => "A." "apellidos" => "Cases" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 12 => array:3 [ "Iniciales" => "J.M." "apellidos" => "Campistol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Clínic Barcelona, Barcelona, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pauta de infusión manual automatizada: una forma práctica de prescribir la hemodiafiltración on-line posdilucional" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10445_18030_5616_en_figure1_copy1.jpg" "Alto" => 297 "Ancho" => 381 "Tamanyo" => 83263 ] ] "descripcion" => array:1 [ "en" => "Replacement volume (l) in the different study situations used." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Haemodiafiltration (HDF) with high levels of replacement fluid is an established renal replacement therapy that has undergone sustained growth over the last few years, since it achieves optimal elimination of uraemic toxins. Currently, postdilution on-line haemodiafiltration (OL-HDF) has been shown to be the most effective infusion mode to obtain the maximum clearance of uraemic toxins, with a recommended infusion flow (Qi) of 25% of the blood flow (Qb). The main limitation has been the number of alarms during sessions as a result of haemoconcentration.<span class="elsevierStyleSup">1-5 </span></p><p class="elsevierStylePara"> Recent technical advances and last generation monitors make it possible to automatically prescribe Qi if haematocrit values (Ht) and total protein (TP) are specified; Qi is automatically regulated throughout treatment. As it is not possible to know the values of Ht and TP for each session, a practical manner of determining postdilution OL-HDF is to prescribe automatically, by adjusting the values of Ht and TP at the beginning of each session, to obtain the indicated manual prescription, which we will name automated manual prescription (A-M). In this way, we have drawn up replacement therapy guidelines that have the advantage of using automatic auto-regulation.</p><p class="elsevierStylePara"> The aim of this study was to compare postdilution OLHDF obtained using conventional manual Qi with that obtained using automated manual Qi. <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIALS AND METHODS </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A prospective study was carried out on 30 patients (16 men and 14 women), of 59.9 ± 15 years of age, with a mean period in a haemodialysis program (HD) of 50.1 ± 67 months. The causes of chronic renal failure were: 8 vascular nephropathy, 3 chronic glomerulonephritis, 4 adult polycystic kidney, 2 tubulointerstitial nephritis, 3 diabetic nephritis, 3 systemic disease, 2 due to urological causes and 5 unknown. Each patient underwent 4 (midweek) sessions of postdilution OL-HDF, two with a manual Qi (one with a 4008-S monitor and the other with a 5008 monitor) and two with an automated manual Qi, both with 5008 monitors, one with a Qi equal to the manual one (M-A) and another with an increase in Qi of 20ml/min (M-A+20). To prescribe manual Qi, the replacement rate is adjusted to medical prescription (normally 25% of the Qb indicated) without pressing the automatic button. To prescribe M-A Qi, it is necessary, in the first place, to achieve the Qb indicated, then to activate the automatic button, subsequently TP and Ht values will be adapted to achieve the infusion flow indicated. In the case of M-A+20, the same procedure is followed as with M-A, but we will modify the values of TP and Ht until an initial infusion flow is obtained equal to the one indicated plus 20ml/min.</p><p class="elsevierStylePara"> The order of each of the four sessions was random. The other dialysis parameters did not vary: 1.5 or 1.8m<span class="elsevierStyleSup">2 </span>helixone filters, time of dialysis 266 ± 39 minutes, blood flow 420 ± 36ml/min, with a dialysate flow of 800ml/min. Dry weight was 65.3 ± 13kg, and the vascular access used was an A-V autologous fistula in 20 patients, a PTFE graft in 1 patient and tunnelised central catheters in 9 patients. In each session Kt was registered and the initial and final recirculation index. Furthermore, the blood pressure, venous pressure, transmembrane pressure (TMP) or haemoconcentration alarms were monitored.</p><p class="elsevierStylePara"> The results are expressed as mean ± standard deviation. For the statistical significance analysis of the quantitative parameters, ANOVA has been used for paired data. A p < 0.05 was considered significant. <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">One-hundred and twenty sessions of OL-HDF were carried out, without any significant incidents, with the exception of a broken filter 5 minutes before the end of one session. Total protein and Ht mean values obtained during the last control analysis were 6.6 ± 0.6 g/dl and 35.9 ± 3.7%, respectively (although these data were not used to modify the monitor). No differences in initial weight were seen in the four sessions: 67.4 ± 14 (manual 4008), 67.6 ± 14 (manual 5008), 67.4 ± 13 (M-A) and 67.4 ± 13 (M-A+20), or in final weight: 65.0 ± 13, 65.3 ± 13, 65.1 ± 13 and 65.3 ± 13, respectively.</p><p class="elsevierStylePara"> Nor were any differences detected in initial or final recirculation rate in the 3 sessions performed with monitor 5008, 12.5 ± 4% and 13.9 ± 5% (manual 5008), 11.9 ± 4% and 14.6 ± 6% with M-A, and 13.1 ± 5% and 13.3 ± 6% with M-A+20, respectively.</p><p class="elsevierStylePara"> The mean value for Qi prescribed was 98.7 ± 10ml/min (with an interval of 80-110ml/min) in the manual sessions and M-A, and in the M-A+20 was 118.7 ± 10ml/min (with an interval of 100-130ml/min). The total infusion volume was 24.9 ± 4 (4008S) and 23.4 ± 4L (5008) with manual Qi (p < 0.01). Total infusion volume was 23.6 ± 4L with M-A and 25.8 ± 5L with M-A+20 (Figure 1).</p><p class="elsevierStylePara"> The dialysis dose determined by ionic dialysance was determined for total Kt obtained at the end of the session, and no significant differences were found (Figure 2). With reference to the presentation or not of alarms during dialysis, in Figure 3 it is possible to see the total number of alarms according to the modality of each session. Although 4 patients (14%) did not have any incidents of alarms, in the case of those patients that did, the number of alarms was significantly greater with manual prescription with 4008 (1.83 ± 2.6 alarms/session) or manual prescription with 5008 (1.33 ± 1.5 alarms/session) with respect to M-A (0.37 ± 0.7 alarms/session, p < 0.01) and even when M-A+20 was prescribed (0.53 ± 1.2 alarms/session, p < 0.01). There were no significant differences between the prescription of M-A and M-A+20ml/min. The alarms with the 4008 monitor were due to venous pressure 33 (60%) and TMP 22 (40%), whereas with the 5008 monitor the alarms were due to haemoconcentrations of more than 90% (Figure 4). <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Given the latest technical advances available in last generation monitors and the progressive generalisation of HDF techniques, in this study we compare different options for Qi prescription in postdilution OL-HDF. In an analysis of 30 patients, each of which underwent two manual Qi sessions and two M-A Qi sessions (one with a Qi equal to manual and the other with an increased Qi of M-A+20), it was seen that with M-A Qi prescription the same convective volume and the same efficacy were obtained, with a significant reduction of alarms during dialysis, which made it possible to increase Qi without increasing the number of alarms.</p><p class="elsevierStylePara"> Large multicentric observational studies, adjusted for demographic factors and comorbidities, have shown a reduction of mortality of 35% in patients who underwent HDF with more than 15 litres of replacement fluid.<span class="elsevierStyleSup">6-7 </span>The prospective observational study RISCAVID<span class="elsevierStyleSup">8 </span>has also shown, in patients that were undergoing OL-HDF, a reduction in mortality in comparison with those patients that underwent HDF with replacement bags, and this was even more significant in comparison with those that underwent HD. Furthermore, a comparative long term study,<span class="elsevierStyleSup">9 </span>in 232 patients predominantly in an OL-HDF programme in comparison with 626 patients in a high-flux HD programme, showed a RR of death of 0.45. Several randomised, multicentric ongoing studies compare low to high-flux HD with OL-HDF with pre- or postdilution infusion.</p><p class="elsevierStylePara"> With reference to the mode of infusion, postdilution OLHDF is currently the most used method, since there is high clearance of small and large solutes, even when this mode can cause a greater number of complications related to haemoconcentration and TMP.<span class="elsevierStyleSup">10 </span>Although the postdilution mode partially solves technical problems, it also reduces the transference of solutes as a consequence of haemodilution.<span class="elsevierStyleSup">11,12 </span>«Mid»-dilution is a recent alternative with infusion of half the dialyser, the first part as a postdilution HDF and the second half as a predilution HDF, showing similar results or even better ones than the postdilution mode.<span class="elsevierStyleSup">13,14 </span>We are waiting for the practical application and results of mixed HDF, with simultaneous pre- and postdilution and autoregulation of both flows, which could optimise efficacy and prevent the disadvantages of haemoconcentration.<span class="elsevierStyleSup">15 </span></p><p class="elsevierStylePara"> In this way, HD research is currently directed to obtaining safer, more practical and effective systems, and this depends, to a large extent, on technical advances to improve the monitors. Concretely, to adjust the replacement rate of a manual postdilution OL-HDF treatment, the recommended Qi is 25% of Qb. Some of these monitors (Fresenius 5008) offer the possibility of automatically adjusting Qi after applying the following formula, in which it is necessary to use real values for TP and Ht.</p><p class="elsevierStylePara"> Q<span class="elsevierStyleSup">i </span>< Q<span class="elsevierStyleSup">b </span>[1- Ht /100 ]. [1- (7·TP)/100 ]–TUF</p><p class="elsevierStylePara"> T<span class="elsevierStyleSup">UF</span>: Ultrafiltration rate (ml/min)</p><p class="elsevierStylePara"> This result is adjusted by multiplying by a factor related to the dialyser, between 0.65-1.25, according to the internal diameter of the capillary fibres. Furthermore, during the first minutes of the dialysis session, the ultrafiltration coefficient is measured (Kuf), and subsequently, this is measured every hour or additional measurements are performed if there is any unexpected event; the cyclic pressure test is performed, which estimates and monitors (by means of TMP) the dialyser behaviour curve during treatment, progressively adjusting Qi.</p><p class="elsevierStylePara"> If we decide to graduate Qi manually, the monitor will not modify Qi, and we will have to do so when we detect an alarm or warning on the monitor when TMP increases. If we use the manual automatic or “alarm-free treatment”, we prescribe automatically adjusting Ht and TP values (since it is not possible to have the results of analysis for each session) to obtain a Qi value for manual prescription at the beginning of the session.</p><p class="elsevierStylePara"> Other monitors (GAMBRO 200 Ultra-S<span class="elsevierStyleSup">® </span>monitor) possess an ultracontrol module to adjust the replacement rate. The monitor automatically determines optimum TMP at the beginning of each session and, it adjusts it periodically every 60 minutes, based on the filtration fraction (Qb/Qi 30% ratio) and blood pressure on entry into the dialyser (system pressure), with the aim of achieving high UF volumes. This way, it is also possible to avoid having to increase TMP manually and, with it, the activation of alarms that interrupt dialysis.</p><p class="elsevierStylePara"> In this study we have shown that automated manual prescription in postdilution OL-HDF is able to apply medical prescription (normally a Qi of about 25% of the Qb) with an individual intradialysis adaptation, according to blood viscosity and haemoconcentration during HDF. Furthermore, when applying an automated manual prescription, a similar replacement volume is obtained, with a reduction of 70% in the number of alarms, which means a considerable reduction of excess workload.</p><p class="elsevierStylePara"> We conclude that prescription of automated manual Qi is a practical way of prescribing postdilution OL-HDF in which maximum efficacy and total replacement volume are achieved, with a significant reduction in the number of alarms during dialysis, which means an improvement in the patients’ clinical evolution, without any delays of the end-time. </p><p class="elsevierStylePara"><a href="grande/10445_18030_5616_en_figure1_copy1.jpg" class="elsevierStyleCrossRefs"><img src="10445_18030_5616_en_figure1_copy1.jpg" alt="Replacement volume (l) in the different study situations used."></img></a></p><p class="elsevierStylePara">Figure 1. Replacement volume (l) in the different study situations used.</p><p class="elsevierStylePara"><a href="grande/10445_18030_5617_en_figure3.jpg" class="elsevierStyleCrossRefs"><img src="10445_18030_5617_en_figure3.jpg" alt="Distribution of alarms according to the type of infusion used."></img></a></p><p class="elsevierStylePara">Figure 3. Distribution of alarms according to the type of infusion used.</p><p class="elsevierStylePara"><a href="grande/10445_18030_5618_en_figure2.jpg" class="elsevierStyleCrossRefs"><img src="10445_18030_5618_en_figure2.jpg" alt="Dialysis dose in different types of infusion."></img></a></p><p class="elsevierStylePara">Figure 2. Dialysis dose in different types of infusion.</p><p class="elsevierStylePara"><a href="grande/10445_18030_5619_en_figure4.jpg" class="elsevierStyleCrossRefs"><img src="10445_18030_5619_en_figure4.jpg" alt="Total number of venous pressure (VP), transmembrane pressure (TMP) and haemoconcentration alarms."></img></a></p><p class="elsevierStylePara">Figure 4. Total number of venous pressure (VP), transmembrane pressure (TMP) and haemoconcentration alarms.</p>" "pdfFichero" => "P1-E46-S1862-A10445-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437221" "palabras" => array:1 [ 0 => "Hemodiafiltración on-line posdilucional" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437223" "palabras" => array:1 [ 0 => "Flujo de infusión" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437225" "palabras" => array:1 [ 0 => "Automatización" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437227" "palabras" => array:1 [ 0 => "Alarmas intradiálisis" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437222" "palabras" => array:1 [ 0 => "Postdilution on-line hemodiafiltration" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437224" "palabras" => array:1 [ 0 => "Infusion flow" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437226" "palabras" => array:1 [ 0 => "Automatic" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437228" "palabras" => array:1 [ 0 => "Intradialysis alarms" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic">Post-dilution on-line hemodiafiltration (OL-HDF) is</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">the most efficient infusion mode to obtain maximum</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">clearances of uremic toxins, with a recommended manual</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">infusion flow (Qi) of 25% of the blood flow with the</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">main limitation that causes alarms by hemoconcentration</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">throughout the session. Recent technical advances allow</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">automatic prescription of Qi if hematocrit and total protein</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">(TP) values are specified. As these analytical results are</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">not possible to obtain in each dialysis session, a practical</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">way to prescribe Qi is to make an automatic prescription</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">adjusting the hematocrit and total protein values at the</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">beginning of the session to obtain the manual prescription</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">required and we will call it automatic-manual prescription.</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">The aim of this study was to compare manual Qi with automatic-</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">manual Qi in postdilution OL-HDF. 30 patients</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">(16 men and 14 women), 59.9 ± 15 years old, in hemodialysis</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">program for 50.1 ± 67 months were included. Every patient</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">underwent four OL-HDF sessions, two with manual</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">Qi (4008-S and 5008 monitors) and two with automatic-</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">manual Qi (A-M), one with the same Qi and one with</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">manual Qi +20 (A-M+20). The same usual dialysis parameters</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">were maintained: helixone dialyzer, dialysis</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">time of 266 ± 39 minutes, blood flow of 420 ± 36. Recirculation,</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">Kt and intradialysis alarms were measured at</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">each session. No significant differences in the fistula recirculation</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">or dialysis dose measured using Kt. Total infusion</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">volume was 24.9 ± 4 (4008S), 23.4 ± 4 L (5008)</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">with manual Qi, 23.6 ± 4 L (A-M) Qi (NS) and 25.8 ± 5 L</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">(A-M+20). Only 14% of patients had no incidents. The</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">number of alarms was significantly higher with manual</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">prescription 55 alarms with 4008 and 40 with 5008 vs. AM</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">(11) p <0.01) and A-M+20 (16 alarms) We concluded</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">that automatic-manual Qi is a practical way for post-dilutional</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">OL-HDF prescription where the same efficiency</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">and total reinfusion volume with an important reduction</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">of intradialysis alarms are obtained, allowing to rise Qi</span><span class="elsevierStyleSup"> </span><span class="elsevierStyleItalic">by 20% without increasing intradialysis alarms.</span><span class="elsevierStyleSup"> </span></p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">La hemodiafiltración <span class="elsevierStyleItalic">on-line </span>(HDF-OL) posdilucional es la modalidad más eficaz para obtener la máxima depuración de toxinas urémicas, con un flujo de infusión (Qi) recomendable del 25% del flujo sanguíneo y con el principal inconveniente de provocar alarmas por hemoconcentración a lo largo de la sesión. Recientes avances técnicos permiten la prescripción automática del Qi si se especifican los valores del hematocrito y de las proteínas totales. Como no es posible disponer en cada sesión de estos valores, una forma práctica de pautar la HDF-OL posdilucional es realizar una prescripción automática ajustando el hematocrito y las proteínas totales para obtener al inicio de la sesión la prescripción manual prescrita, a la que llamaremos prescripción manual automatizada. El objetivo del estudio fue comparar la pauta convencional de Qi manual respecto a la manual automatizada. Se incluyeron 30 pacientes (16 varones y 14 mujeres), de 59,9 ± 15 años de edad, en programa de hemodiálisis durante 50,1 ± 67 meses. Cada paciente recibió cuatro sesiones de HDF-OL, dos con Qi manual (monitores 4008-S y 5008) y dos con Qi manual automatizada (M-A), una con Qi igual a la manual y otra incrementando el Qi 20 ml/min (M-A+20). El resto de parámetros de diálisis no variaron: filtro de helixona, tiempo de diálisis 266 ± 39 minutos, flujo de sangre 420 ± 36 ml/min. En cada sesión se recogieron el Kt, la recirculación y las alarmas. No se observaron diferencias significativas en el índice de recirculación ni en la dosis de diálisis medida con el Kt. El volumen total de infusión fue de 24,9 ± 4 l (4008S), 23,4 ± 4 l (5008) con Qi manual, 23,6 ± 4 l (M-A) y 25,8 ± 5 l (M-A+20). En sólo el 14% de los pacientes no hubo incidencias. El número de alarmas fue significativamente superior con la prescripción manual, 55 alarmas con 4008 y 40 con 5008, respecto a la M-A (11, p <0,01) y M-A+20 (16 alarmas). Concluimos que la prescripción del Qi manual automatizada es una forma práctica de prescribir la HDF-OL posdilucional consiguiendo el mismo volumen convectivo y la misma eficacia, con una importante reducción de las alarmas intradiálisis, lo que permite un incremento del Qi un 20% sin aumento del número de alarmas.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10445_18030_5616_en_figure1_copy1.jpg" "Alto" => 297 "Ancho" => 381 "Tamanyo" => 83263 ] ] "descripcion" => array:1 [ "en" => "Replacement volume (l) in the different study situations used." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10445_18030_5617_en_figure3.jpg" "Alto" => 293 "Ancho" => 380 "Tamanyo" => 75686 ] ] "descripcion" => array:1 [ "en" => "Distribution of alarms according to the type of infusion used." ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10445_18030_5618_en_figure2.jpg" "Alto" => 272 "Ancho" => 383 "Tamanyo" => 67237 ] ] "descripcion" => array:1 [ "en" => "Dialysis dose in different types of infusion." ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10445_18030_5619_en_figure4.jpg" "Alto" => 296 "Ancho" => 379 "Tamanyo" => 76905 ] ] "descripcion" => array:1 [ "en" => "Total number of venous pressure (VP), transmembrane pressure (TMP) and haemoconcentration alarms." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Henderson LW, Besarab A, Michaels A, Bluemle LW Jr. Blood purification by ultrafiltration and fluid replacement (diafiltration). 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Kidney Int 2000;58:2155-65. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11044237" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000003/v0_201502091603/X2013251410035913/v0_201502091604/en/main.assets" "Apartado" => array:4 [ "identificador" => "35448" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Technical Notes" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000003/v0_201502091603/X2013251410035913/v0_201502091604/en/P1-E46-S1862-A10445-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410035913?idApp=UINPBA000064" ]
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| 2023 December | 45 | 41 | 86 |
| 2023 November | 59 | 47 | 106 |
| 2023 October | 101 | 51 | 152 |
| 2023 September | 51 | 60 | 111 |
| 2023 August | 39 | 31 | 70 |
| 2023 July | 57 | 64 | 121 |
| 2023 June | 42 | 46 | 88 |
| 2023 May | 52 | 46 | 98 |
| 2023 April | 29 | 28 | 57 |
| 2023 March | 55 | 40 | 95 |
| 2023 February | 39 | 29 | 68 |
| 2023 January | 62 | 33 | 95 |
| 2022 December | 58 | 45 | 103 |
| 2022 November | 43 | 50 | 93 |
| 2022 October | 49 | 65 | 114 |
| 2022 September | 80 | 60 | 140 |
| 2022 August | 66 | 64 | 130 |
| 2022 July | 50 | 73 | 123 |
| 2022 June | 52 | 89 | 141 |
| 2022 May | 59 | 68 | 127 |
| 2022 April | 61 | 81 | 142 |
| 2022 March | 64 | 73 | 137 |
| 2022 February | 55 | 64 | 119 |
| 2022 January | 52 | 45 | 97 |
| 2021 December | 48 | 61 | 109 |
| 2021 November | 56 | 63 | 119 |
| 2021 October | 72 | 73 | 145 |
| 2021 September | 57 | 47 | 104 |
| 2021 August | 65 | 45 | 110 |
| 2021 July | 97 | 53 | 150 |
| 2021 June | 83 | 44 | 127 |
| 2021 May | 86 | 51 | 137 |
| 2021 April | 130 | 51 | 181 |
| 2021 March | 104 | 52 | 156 |
| 2021 February | 85 | 19 | 104 |
| 2021 January | 66 | 24 | 90 |
| 2020 December | 58 | 20 | 78 |
| 2020 November | 47 | 15 | 62 |
| 2020 October | 42 | 18 | 60 |
| 2020 September | 31 | 10 | 41 |
| 2020 August | 44 | 13 | 57 |
| 2020 July | 44 | 13 | 57 |
| 2020 June | 45 | 19 | 64 |
| 2020 May | 46 | 30 | 76 |
| 2020 April | 45 | 22 | 67 |
| 2020 March | 45 | 16 | 61 |
| 2020 February | 55 | 25 | 80 |
| 2020 January | 56 | 26 | 82 |
| 2019 December | 64 | 34 | 98 |
| 2019 November | 58 | 18 | 76 |
| 2019 October | 36 | 11 | 47 |
| 2019 September | 51 | 21 | 72 |
| 2019 August | 24 | 10 | 34 |
| 2019 July | 30 | 27 | 57 |
| 2019 June | 42 | 17 | 59 |
| 2019 May | 34 | 17 | 51 |
| 2019 April | 70 | 36 | 106 |
| 2019 March | 39 | 29 | 68 |
| 2019 February | 59 | 26 | 85 |
| 2019 January | 31 | 17 | 48 |
| 2018 December | 95 | 36 | 131 |
| 2018 November | 93 | 22 | 115 |
| 2018 October | 111 | 24 | 135 |
| 2018 September | 105 | 22 | 127 |
| 2018 August | 57 | 23 | 80 |
| 2018 July | 47 | 22 | 69 |
| 2018 June | 44 | 13 | 57 |
| 2018 May | 49 | 5 | 54 |
| 2018 April | 74 | 14 | 88 |
| 2018 March | 47 | 15 | 62 |
| 2018 February | 38 | 7 | 45 |
| 2018 January | 40 | 10 | 50 |
| 2017 December | 55 | 18 | 73 |
| 2017 November | 42 | 12 | 54 |
| 2017 October | 50 | 9 | 59 |
| 2017 September | 44 | 12 | 56 |
| 2017 August | 43 | 14 | 57 |
| 2017 July | 34 | 12 | 46 |
| 2017 June | 29 | 16 | 45 |
| 2017 May | 42 | 13 | 55 |
| 2017 April | 36 | 12 | 48 |
| 2017 March | 26 | 15 | 41 |
| 2017 February | 22 | 17 | 39 |
| 2017 January | 33 | 12 | 45 |
| 2016 December | 64 | 4 | 68 |
| 2016 November | 94 | 13 | 107 |
| 2016 October | 99 | 10 | 109 |
| 2016 September | 127 | 1 | 128 |
| 2016 August | 175 | 8 | 183 |
| 2016 July | 162 | 11 | 173 |
| 2016 June | 160 | 0 | 160 |
| 2016 May | 175 | 0 | 175 |
| 2016 April | 119 | 0 | 119 |
| 2016 March | 94 | 0 | 94 |
| 2016 February | 142 | 0 | 142 |
| 2016 January | 133 | 0 | 133 |
| 2015 December | 160 | 0 | 160 |
| 2015 November | 119 | 0 | 119 |
| 2015 October | 115 | 0 | 115 |
| 2015 September | 90 | 0 | 90 |
| 2015 August | 80 | 0 | 80 |
| 2015 July | 82 | 0 | 82 |
| 2015 June | 48 | 0 | 48 |
| 2015 May | 68 | 0 | 68 |
| 2015 April | 6 | 0 | 6 |
Show all
