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Therapeutic Apheresis and Dialysis 2014; 18(5):468–472 doi: 10.1111/1744-9987.12157 © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients Helmut Schiffl,1 Rainald Fischer,2 and Susanne M. Lang2,3 1
Department of Internal Medicine IV, 2Department of Internal Medicine V, University Hospital Munich, Munich, and 32. Medizinische Klinik, SRH Wald-Klinikum Gera, Gera, Germany
Abstract: Maintenance dialysis patients are admitted more frequently to the intensive care unit (ICU) and have higher ICU mortality than the general population. It is unclear if such dialysis patients receive adequate dialysis in the ICU setting. Using the Daugirdas formula for calculation of spKt/Vurea, single treatment delivered dialysis dose was assessed in 85 critically ill maintenance hemodialysis patients during their first ICU dialysis session. Weekly delivered spKt/Vurea was determined in the surviving 64 patients and compared with their corresponding delivered outpatient dialysis dosages. Outcome measures were ICU and in-hospital mortality and mortality at 6 and 12 months after discharge. Prescribed dose of the first ICU dialysis was a spKt/Vurea of 1.43 ± 0.11, the single treatment delivered dose was 1.02 ± 0.14. The weekly prescribed ICU
Kt/Vurea was 4.25 ± 0.12 and delivered ICU Kt/Vurea was 3.48 ± 0.19. Patients with sepsis had the lowest mean spKt/ Vurea values (0.87 ± 0.12). Serial measurements of delivered dialysis dose suggest that this gap is explained by variability of volume of urea distribution. ICU mortality was 25% and was related to APACHE II score, but not to delivered intermittent hemodialysis dose. Critically ill maintenance dialysis patients receive suboptimal dialysis doses. The impact of short-term underdialysis on survival of hospitalized maintenance dialysis patients remains unknown. Assessment of dialysis adequacy should be routinely performed in these patients and delivered dialysis should be tracked through the initial clinical course. Key Words: Acute critical illness, Chronic dialysis patients, Intensive care medicine, Intermittent hemodialysis.
The prevalence of end-stage renal disease (ESRD) patients is increasing. This trend has been attributed to an aging population along with increasing rates of diabetes mellitus type II, chronic arterial hypertension and obesity (1). As a result of the changing demographics of this patient population, current ESRD patients are frail. They have an excessive risk for adverse cardiac events and are prone to severe bacterial infections (2–6). Chronic dialysis patients have significantly higher hospital and ICU admission rates (30-fold and more) compared with the general population (7). By the nature of ESRD, these patients require continuation of renal replacement therapy (RRT) during hospitalization, regardless of the setting they are treated in. Well established urea based standards for adequate HD doses exist and recommend a mini-
mally delivered single pool (sp) Kt/V urea of 1.2 per dialysis in patients with minimal or absent residual renal function (8,9). However, the criteria on which to base provision of intermittent HD (IHD) to critically ill ESRD patients are largely unknown (6). Generally, studies evaluating the delivery of IHD in ESRD patients have excluded subjects with acute critical illness. No trial assessing the adequacy of IHD in ICU patients with acute kidney injury has included ESRD patients. In this prospective cohort study we evaluated delivered dialysis dose (sp Kt/ V urea) per treatment during the ICU stay and compared this to the prior dose received at the outpatient clinic in the same patients.
Received July 2013; revised October 2013. Address correspondence and reprint requests to Professor Dr Helmut Schiffl, KfH Nierenzentrum München-Laim, Elsenheimerstr. 63, D-80687 München, Germany. Email: h-schiffl@ t-online.de
Study design This prospective observational study did not involve any intervention, maintained patient confidentiality and anonymity and complied with the
PATIENTS AND METHODS
468
Dialysis Dosing in Maintenance HD Patients Helsinki declaration of 1975. Participating patients received standard intensive care and adequate IHD. All patients or their next of kin gave written informed consent and the institutional review board approved the study protocol. Study patients Adequacy of HD dose was monitored in 85 adult maintenance HD patients with critical illness during their stay in the intensive care unit during 2004 and 2010. Prior to the development of severe medical or surgical disorders these ESRD patients were in a stable condition and received outpatient dialysis treatment. The dry weight of these individuals was regularly judged by clinical acumen, chest X-ray and/or ultrasonographic determinations of the diameter of the inferior vena cava. The adequacy of dialysis was routinely monitored using spKt/Vurea. Acquisition of clinical data On the day of the first HD session in the ICU the following information was extracted from the medical records: age, gender, comorbid diseases, cause of ESRD, dialysis vintage, residual renal function (determined by 24 h urea and creatinine clearance), dialysis prescription, spKt/Vurea per session 3 weeks prior to destabilization of the clinical condition and cause of hospital admission. The APACHE II (Acute Physiology and Chronic Health Evaluation) score and the non-renal Charlson Index were calculated (10,11). Outcome measures Pre-defined primary outcome measures were ICU and in-hospital mortality as well as survival rates at 6 months and one year after discharge from the hospital. IHD therapy Intermittent HD was performed with volumetrically controlled dialysis machines and ultrapure bicarbonate dialysis fluid three times per week. 58 out of 85 maintenance dialysis patients had a functioning arteriovenous fistula. The remaining 27 maintenance IHD patients with thrombosed vascular access had two dialysis catheters placed in two large veins. Blood flow rates were 280 to 380 mL/min, dialysis flow rate was set at 500 mL/min. The duration of each session was 3.5 to 5 h. Single use synthetic high-flux membranes (surface at least 1.6 m2) were used exclusively. Conventional heparin was used for anticoagulation. In patients at risk of bleeding, heparin-free dialysis was performed using citrate. © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
469
Ultrafiltration rate was prescribed according to the individual patient’s needs. Before each dialysis session in the ICU all patients were weighed on an electronic bed scale. Strategies to improve hemodynamic stability included positive sodium and negative thermal balance.The frequency of dialysis was thrice per week for all patients. Dosing of intermittent dialysis in ICU patients Following the NKF adequacy guidelines for stable outclinic patients (8) the target (prescribed) dose for the ICU maintenance dialysis patients (with a residual renal function less than 2 mL/min per 1.73 m2) was a spKt/Vurea of 1.4 per session. Predialysis blood samples for measurements of blood urea nitrogen (BUN) were obtained from the arterial needle prior to connecting the arterial blood tubing. Alternatively, samples were taken from a venous catheter after withdrawing 10 mL of blood to prevent dilution of the blood sample. At the completion of the HD session, postdialysis blood sampling was performed using the slow flow pump sampling technique (8).The delivered dose of IHD was calculated on the basis of spKt/Vurea values corrected for ultrafiltration (12). Weekly IHD dose was calculated as the sum of three single treatment-delivered spKt/Vurea values. No patient received initial RRT with continuous renal replacement techniques (CRRT) or was switched from IHD to CRRT during the ICU stay. Statistics Results are presented as mean ± SD, median (range) or percentage. The Mann–Whitney U-test was used for comparison of continuous variables and the Fisher exact test to compare discrete variables. These statistical tests were two-sided. Multiple logistic regression analysis with forward selection was used to determine the effects of variables such as age, sex, Charlson Index, APACHE II score and delivered dialysis dose on in-hospital mortality. P-values less than 0.05 were considered indicating statistical significance. The statistical analyses were done with the Statistical Package of Social Science software (SPSS 15.0, SPSS, Chicago, IL, USA). RESULTS Characteristics and features of the study cohort The 85 participating chronic HD patients were elderly (mean age 63 years, range 49–81 years) and carried a high burden of comorbid diseases (modified non-renal Charlson Index 3 ± 1). Diabetes and chronic arterial hypertension accounted for 68% of
Ther Apher Dial, Vol. 18, No. 5, 2014
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H Schiffl et al.
TABLE 1. Demographic and renal characteristics of the study population (mean ± SD or percent) Number of patients Age (years) Gender (male) Main cause of ESRD (%) Diabetic nephropathy Hypertensive nephropathy Chronic glomerulonephritis Polycystic kidney disease Chronic tubule-interstitial nephritis Major comorbidities (%) Chronic arterial hypertension Diabetes mellitus type II Coronary heart disease Congestive heart failure Chronic obstructive pulmonary disease Dialysis vintage (years) Residual renal function (%) Absent†
85 63 ± 13 60% 43 25 13 8 8 75 43 38 18 15 6±1 100
†
Absent: defined as less than 2 mL/min per 1.73 m2. ESRD, endstage renal disease.
the ESRD diagnoses. None of the patients had significant residual renal function (Table 1). The majority of critically ill ESRD patients had medical disorders (85%, n = 72). The most common causes of ICU admission were cardiovascular events (acute myocardial infarction, cardiac arrest) and severe pulmonary infection for medical patients, and cardiac surgery for surgical patients. The APACHE II score was high, but the number of failing organs was low (Table 2). 48% of the patients needed mechanical ventilation and 44% received vaso-active agents.
TABLE 2. Reasons of ICU admission, APACHE II score and outcome ESRD patients with acute critical illness (mean ± SD or percent) Number of patients Cause of ICU admission (%) Cardiovascular events Pneumonia/ sepsis Gastrointestinal bleedings Major surgery APACHE II score Number of failing extra-renal organs Length of ICU stay (days) Length of hospital stay (days) Short-term outcome (%) ICU Mortality In-hospital mortality Long-term outcome (%) 6 month mortality 12 month mortality
85 40 29 16 15 26 ± 4 1.2 ± 1.1 6±1 14 ± 4 25 34 43 47
ESRD, end-stage renal disease; ICU, intensive care unit.
Ther Apher Dial, Vol. 18, No. 5, 2014
TABLE 3. Assessment of IHD dose in critically ill patients (first ICU dialysis session) (mean ± SD) Number of patients Predialysis blood chemistry Serum creatinine (mg/dL) Serum urea (mg/dL) Serum potassium (mmol/L) Serum bicarbonate (mEq/L) Interdialytic weight gain (kg) Prescribed IHD dose (spKt/Vurea) Prescribed duration of IHD (min) Actual duration of IHD (min) Prescribed blood flow rate (mL/min) Actual Blood flow rate (mL/min) Delivered IHD dose All patients Patients with catheters, n = 27 Patients with av fistulas, n = 58 Patients with septic shock, n = 17
85 7.5 ± 1.3 114 ± 25 4.9 ± 0.6 20.8 ± 5.4 3.3 ± 2.5 1.43 ± 0.11 260 ± 30 264 ± 18 290 ± 35 305 + 32 1.02 ± 0.14* 0.95 ± 0.15§ 1.06 ± 0.25 0.87 ± 0.12#
*P < 0.05 vs. prescribed IHD dose. §P < 0.05 vs. delivered IHD dose of patients with functioning av fistula. #P < 0.05 vs. delivered IHD dose of all patients. ICU, intensive care unit; IDH, intermittent hemodialysis; spKt/Vurea, single pool Kt/Vurea.
Assessment of IHD dose in critically ill ESRD patients Prescribed and delivered spKt/Vurea values of the first ICU dialysis are given in Table 3. There was no prescription failure in any patient. The mean delivered spKt/Vurea was 1.02 ± 0.14 and 29% lower than the prescribed spKt/Vurea. Compared with patients with functioning fistula the delivered IHD dose was slightly lower in patients with two catheters (P < 0.05). SpKt/Vurea values were lowest in septic patients. The percentage of HD procedures performed with citrate anticoagulation was 28%. Comparison of patients matched according to admission diagnosis who underwent HD procedures with citrate anticoagulation or with heparin anticoagulation revealed no statistical significance of first dialysis efficacy (delivered spKt/V urea 1.05 ± 0.12 vs. 1.10 ± 0.15). Only 19 out of 85 patients (22%) received the minimally accepted dose for stable IHD patients at the first ICU session. Comparison of weekly dialysis dose in a subgroup of ESRD patients during outclinic dialysis and ICU dialysis Twenty-one critically ill patients died during the ICU stay. The weekly delivered IHD doses determined 3 weeks prior to admission to the hospital were significantly higher than those measured during the ICU in the 64 surviving patients. There was no gap between prescribed and delivered IHD in the outpatient setting. Comparison of three subsequent ICU dialysis sessions revealed that the delivered dose increased with duration of the stay (Table 4). © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Dialysis Dosing in Maintenance HD Patients TABLE 4.
471
Weekly IHD dose in 64 maintenance dialysis patients surviving ICU stay (mean ± SD)
Session 1 Session 2 Session 3 Weekly IHD dose
Outclinic setting
ICU stay
1.42 ± 0.12 1.39 ± 0.12 1.43 ± 0.15 1.42 ± 0.10 1.38 ± 0.13 1.41 ± 0.20 4.22 ± 0.14
1.45 ± 0.15 1.08 + 0.18 1.40 ± 0.12 1.15 ± 0.23 1.40 ± 0.10 1.25 ± 0.15 3.48 ± 0.19
Prescribed spKt/Vurea Delivered spKt/Vurea Prescribed spKt/Vurea Delivered spKt/Vurea Prescribed spKt/Vurea Delivered spKt/Vurea Delivered spKt/Vurea
P
Therapeutic Apheresis and Dialysis 2014; 18(5):468–472 doi: 10.1111/1744-9987.12157 © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients Helmut Schiffl,1 Rainald Fischer,2 and Susanne M. Lang2,3 1
Department of Internal Medicine IV, 2Department of Internal Medicine V, University Hospital Munich, Munich, and 32. Medizinische Klinik, SRH Wald-Klinikum Gera, Gera, Germany
Abstract: Maintenance dialysis patients are admitted more frequently to the intensive care unit (ICU) and have higher ICU mortality than the general population. It is unclear if such dialysis patients receive adequate dialysis in the ICU setting. Using the Daugirdas formula for calculation of spKt/Vurea, single treatment delivered dialysis dose was assessed in 85 critically ill maintenance hemodialysis patients during their first ICU dialysis session. Weekly delivered spKt/Vurea was determined in the surviving 64 patients and compared with their corresponding delivered outpatient dialysis dosages. Outcome measures were ICU and in-hospital mortality and mortality at 6 and 12 months after discharge. Prescribed dose of the first ICU dialysis was a spKt/Vurea of 1.43 ± 0.11, the single treatment delivered dose was 1.02 ± 0.14. The weekly prescribed ICU
Kt/Vurea was 4.25 ± 0.12 and delivered ICU Kt/Vurea was 3.48 ± 0.19. Patients with sepsis had the lowest mean spKt/ Vurea values (0.87 ± 0.12). Serial measurements of delivered dialysis dose suggest that this gap is explained by variability of volume of urea distribution. ICU mortality was 25% and was related to APACHE II score, but not to delivered intermittent hemodialysis dose. Critically ill maintenance dialysis patients receive suboptimal dialysis doses. The impact of short-term underdialysis on survival of hospitalized maintenance dialysis patients remains unknown. Assessment of dialysis adequacy should be routinely performed in these patients and delivered dialysis should be tracked through the initial clinical course. Key Words: Acute critical illness, Chronic dialysis patients, Intensive care medicine, Intermittent hemodialysis.
The prevalence of end-stage renal disease (ESRD) patients is increasing. This trend has been attributed to an aging population along with increasing rates of diabetes mellitus type II, chronic arterial hypertension and obesity (1). As a result of the changing demographics of this patient population, current ESRD patients are frail. They have an excessive risk for adverse cardiac events and are prone to severe bacterial infections (2–6). Chronic dialysis patients have significantly higher hospital and ICU admission rates (30-fold and more) compared with the general population (7). By the nature of ESRD, these patients require continuation of renal replacement therapy (RRT) during hospitalization, regardless of the setting they are treated in. Well established urea based standards for adequate HD doses exist and recommend a mini-
mally delivered single pool (sp) Kt/V urea of 1.2 per dialysis in patients with minimal or absent residual renal function (8,9). However, the criteria on which to base provision of intermittent HD (IHD) to critically ill ESRD patients are largely unknown (6). Generally, studies evaluating the delivery of IHD in ESRD patients have excluded subjects with acute critical illness. No trial assessing the adequacy of IHD in ICU patients with acute kidney injury has included ESRD patients. In this prospective cohort study we evaluated delivered dialysis dose (sp Kt/ V urea) per treatment during the ICU stay and compared this to the prior dose received at the outpatient clinic in the same patients.
Received July 2013; revised October 2013. Address correspondence and reprint requests to Professor Dr Helmut Schiffl, KfH Nierenzentrum München-Laim, Elsenheimerstr. 63, D-80687 München, Germany. Email: h-schiffl@ t-online.de
Study design This prospective observational study did not involve any intervention, maintained patient confidentiality and anonymity and complied with the
PATIENTS AND METHODS
468
Dialysis Dosing in Maintenance HD Patients Helsinki declaration of 1975. Participating patients received standard intensive care and adequate IHD. All patients or their next of kin gave written informed consent and the institutional review board approved the study protocol. Study patients Adequacy of HD dose was monitored in 85 adult maintenance HD patients with critical illness during their stay in the intensive care unit during 2004 and 2010. Prior to the development of severe medical or surgical disorders these ESRD patients were in a stable condition and received outpatient dialysis treatment. The dry weight of these individuals was regularly judged by clinical acumen, chest X-ray and/or ultrasonographic determinations of the diameter of the inferior vena cava. The adequacy of dialysis was routinely monitored using spKt/Vurea. Acquisition of clinical data On the day of the first HD session in the ICU the following information was extracted from the medical records: age, gender, comorbid diseases, cause of ESRD, dialysis vintage, residual renal function (determined by 24 h urea and creatinine clearance), dialysis prescription, spKt/Vurea per session 3 weeks prior to destabilization of the clinical condition and cause of hospital admission. The APACHE II (Acute Physiology and Chronic Health Evaluation) score and the non-renal Charlson Index were calculated (10,11). Outcome measures Pre-defined primary outcome measures were ICU and in-hospital mortality as well as survival rates at 6 months and one year after discharge from the hospital. IHD therapy Intermittent HD was performed with volumetrically controlled dialysis machines and ultrapure bicarbonate dialysis fluid three times per week. 58 out of 85 maintenance dialysis patients had a functioning arteriovenous fistula. The remaining 27 maintenance IHD patients with thrombosed vascular access had two dialysis catheters placed in two large veins. Blood flow rates were 280 to 380 mL/min, dialysis flow rate was set at 500 mL/min. The duration of each session was 3.5 to 5 h. Single use synthetic high-flux membranes (surface at least 1.6 m2) were used exclusively. Conventional heparin was used for anticoagulation. In patients at risk of bleeding, heparin-free dialysis was performed using citrate. © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
469
Ultrafiltration rate was prescribed according to the individual patient’s needs. Before each dialysis session in the ICU all patients were weighed on an electronic bed scale. Strategies to improve hemodynamic stability included positive sodium and negative thermal balance.The frequency of dialysis was thrice per week for all patients. Dosing of intermittent dialysis in ICU patients Following the NKF adequacy guidelines for stable outclinic patients (8) the target (prescribed) dose for the ICU maintenance dialysis patients (with a residual renal function less than 2 mL/min per 1.73 m2) was a spKt/Vurea of 1.4 per session. Predialysis blood samples for measurements of blood urea nitrogen (BUN) were obtained from the arterial needle prior to connecting the arterial blood tubing. Alternatively, samples were taken from a venous catheter after withdrawing 10 mL of blood to prevent dilution of the blood sample. At the completion of the HD session, postdialysis blood sampling was performed using the slow flow pump sampling technique (8).The delivered dose of IHD was calculated on the basis of spKt/Vurea values corrected for ultrafiltration (12). Weekly IHD dose was calculated as the sum of three single treatment-delivered spKt/Vurea values. No patient received initial RRT with continuous renal replacement techniques (CRRT) or was switched from IHD to CRRT during the ICU stay. Statistics Results are presented as mean ± SD, median (range) or percentage. The Mann–Whitney U-test was used for comparison of continuous variables and the Fisher exact test to compare discrete variables. These statistical tests were two-sided. Multiple logistic regression analysis with forward selection was used to determine the effects of variables such as age, sex, Charlson Index, APACHE II score and delivered dialysis dose on in-hospital mortality. P-values less than 0.05 were considered indicating statistical significance. The statistical analyses were done with the Statistical Package of Social Science software (SPSS 15.0, SPSS, Chicago, IL, USA). RESULTS Characteristics and features of the study cohort The 85 participating chronic HD patients were elderly (mean age 63 years, range 49–81 years) and carried a high burden of comorbid diseases (modified non-renal Charlson Index 3 ± 1). Diabetes and chronic arterial hypertension accounted for 68% of
Ther Apher Dial, Vol. 18, No. 5, 2014
470
H Schiffl et al.
TABLE 1. Demographic and renal characteristics of the study population (mean ± SD or percent) Number of patients Age (years) Gender (male) Main cause of ESRD (%) Diabetic nephropathy Hypertensive nephropathy Chronic glomerulonephritis Polycystic kidney disease Chronic tubule-interstitial nephritis Major comorbidities (%) Chronic arterial hypertension Diabetes mellitus type II Coronary heart disease Congestive heart failure Chronic obstructive pulmonary disease Dialysis vintage (years) Residual renal function (%) Absent†
85 63 ± 13 60% 43 25 13 8 8 75 43 38 18 15 6±1 100
†
Absent: defined as less than 2 mL/min per 1.73 m2. ESRD, endstage renal disease.
the ESRD diagnoses. None of the patients had significant residual renal function (Table 1). The majority of critically ill ESRD patients had medical disorders (85%, n = 72). The most common causes of ICU admission were cardiovascular events (acute myocardial infarction, cardiac arrest) and severe pulmonary infection for medical patients, and cardiac surgery for surgical patients. The APACHE II score was high, but the number of failing organs was low (Table 2). 48% of the patients needed mechanical ventilation and 44% received vaso-active agents.
TABLE 2. Reasons of ICU admission, APACHE II score and outcome ESRD patients with acute critical illness (mean ± SD or percent) Number of patients Cause of ICU admission (%) Cardiovascular events Pneumonia/ sepsis Gastrointestinal bleedings Major surgery APACHE II score Number of failing extra-renal organs Length of ICU stay (days) Length of hospital stay (days) Short-term outcome (%) ICU Mortality In-hospital mortality Long-term outcome (%) 6 month mortality 12 month mortality
85 40 29 16 15 26 ± 4 1.2 ± 1.1 6±1 14 ± 4 25 34 43 47
ESRD, end-stage renal disease; ICU, intensive care unit.
Ther Apher Dial, Vol. 18, No. 5, 2014
TABLE 3. Assessment of IHD dose in critically ill patients (first ICU dialysis session) (mean ± SD) Number of patients Predialysis blood chemistry Serum creatinine (mg/dL) Serum urea (mg/dL) Serum potassium (mmol/L) Serum bicarbonate (mEq/L) Interdialytic weight gain (kg) Prescribed IHD dose (spKt/Vurea) Prescribed duration of IHD (min) Actual duration of IHD (min) Prescribed blood flow rate (mL/min) Actual Blood flow rate (mL/min) Delivered IHD dose All patients Patients with catheters, n = 27 Patients with av fistulas, n = 58 Patients with septic shock, n = 17
85 7.5 ± 1.3 114 ± 25 4.9 ± 0.6 20.8 ± 5.4 3.3 ± 2.5 1.43 ± 0.11 260 ± 30 264 ± 18 290 ± 35 305 + 32 1.02 ± 0.14* 0.95 ± 0.15§ 1.06 ± 0.25 0.87 ± 0.12#
*P < 0.05 vs. prescribed IHD dose. §P < 0.05 vs. delivered IHD dose of patients with functioning av fistula. #P < 0.05 vs. delivered IHD dose of all patients. ICU, intensive care unit; IDH, intermittent hemodialysis; spKt/Vurea, single pool Kt/Vurea.
Assessment of IHD dose in critically ill ESRD patients Prescribed and delivered spKt/Vurea values of the first ICU dialysis are given in Table 3. There was no prescription failure in any patient. The mean delivered spKt/Vurea was 1.02 ± 0.14 and 29% lower than the prescribed spKt/Vurea. Compared with patients with functioning fistula the delivered IHD dose was slightly lower in patients with two catheters (P < 0.05). SpKt/Vurea values were lowest in septic patients. The percentage of HD procedures performed with citrate anticoagulation was 28%. Comparison of patients matched according to admission diagnosis who underwent HD procedures with citrate anticoagulation or with heparin anticoagulation revealed no statistical significance of first dialysis efficacy (delivered spKt/V urea 1.05 ± 0.12 vs. 1.10 ± 0.15). Only 19 out of 85 patients (22%) received the minimally accepted dose for stable IHD patients at the first ICU session. Comparison of weekly dialysis dose in a subgroup of ESRD patients during outclinic dialysis and ICU dialysis Twenty-one critically ill patients died during the ICU stay. The weekly delivered IHD doses determined 3 weeks prior to admission to the hospital were significantly higher than those measured during the ICU in the 64 surviving patients. There was no gap between prescribed and delivered IHD in the outpatient setting. Comparison of three subsequent ICU dialysis sessions revealed that the delivered dose increased with duration of the stay (Table 4). © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Dialysis Dosing in Maintenance HD Patients TABLE 4.
471
Weekly IHD dose in 64 maintenance dialysis patients surviving ICU stay (mean ± SD)
Session 1 Session 2 Session 3 Weekly IHD dose
Outclinic setting
ICU stay
1.42 ± 0.12 1.39 ± 0.12 1.43 ± 0.15 1.42 ± 0.10 1.38 ± 0.13 1.41 ± 0.20 4.22 ± 0.14
1.45 ± 0.15 1.08 + 0.18 1.40 ± 0.12 1.15 ± 0.23 1.40 ± 0.10 1.25 ± 0.15 3.48 ± 0.19
Prescribed spKt/Vurea Delivered spKt/Vurea Prescribed spKt/Vurea Delivered spKt/Vurea Prescribed spKt/Vurea Delivered spKt/Vurea Delivered spKt/Vurea
P
