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Adequacy of Hemodialysis Data from HENNET.

Adequacy of Hemodialysis Data from HENNET. นพ.ธนชัย พนาพุฒิ อายุรแพทย์โรคไต รพศ.ขอนแก่น 5 กค. 2556. HENNET project. HE modialysis N etwork of the N orth- E ast of T hailand. นพ.ธนชัย พนาพุฒิ นพ.จิรศักดิ์ อนุกุลกนันต์ชัย รพ.ขอนแก่น

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Adequacy of Hemodialysis Data from HENNET.

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  1. Adequacy of HemodialysisData from HENNET. นพ.ธนชัย พนาพุฒิ อายุรแพทย์โรคไต รพศ.ขอนแก่น 5กค. 2556

  2. HENNET project HEmodialysis Network of the North-East of Thailand นพ.ธนชัย พนาพุฒิ นพ.จิรศักดิ์ อนุกุลกนันต์ชัย รพ.ขอนแก่น รศ.นพ.ทวี ศิริวงศ์ รศ.นพ.ชลธิป พงศ์สกุล รศ.พญ.ศิริรัตน์ เรืองจุ้ย รพ.ศรีนครินทร์ นพ. พิสิฐ อินทรวงษ์โชติ รพ.หนองคาย นพ. สุรพงษ์ นเรนทร์พิทักษ์ รพ.อุดรธานี นพ. สัจจะ ตติยานุพันธ์วงศ์ รพ.ชัยภูมิ พญ. ลักษมณ ประเดิม รพ.ร้อยเอ็ด นพ. ชวศักดิ์ กนกกัณฑ์พงษ์ รพ.มหาราชนครราชสีมา พญ. กรรณิการ์ นิวัตยกุล รพ.เลย นพ. ปกรณ์ ตุงคะเสรีรักษ์ รพ.สุรินทร์ นพ. อมฤต สุวัฒนศิลป์ รพ.มหาสารคาม พญ. ทัดสะรัง แก้วบุนมา รพ.ท่าบ่อ

  3. Agenda • What is Adequacy of HD • Data from HENNET Project • Kt/V: Do we really need it ?

  4. Dr. John T. Daugirdas Dr. Daugirdas is Professor of Medicine at the University of Illinois at Chicago.

  5. What is Adequacy of Hemodialysis ? Adequacy of dialysis refers to how well we remove toxins and waste products from the patient’s blood, and has a major impact on their well-being.

  6. How do we know if a Patient is Adequately Dialyzed ? Urea Kinetic Modeling Why can’t I understand it ? It can’t be that difficult !

  7. WHY UREA ? MW 60, only slightly toxic per se a MARKER for small MW uremic toxins Urea removal < ---> other small toxin removal

  8. WHY UREA ? MW 60, only slightly toxic per se a MARKER for small MW uremic toxins Urea removal < ---> other small toxin removal g = rate of UREA generation g < ---> protein catabolic rate (PCR) PCR < ---> dietary protein intake ? g can be derived from pre and post BUN

  9. Monitoring the patient’s urea Predialysis BUN or Time-averaged BUN BAD if HIGH, also BAD if too LOW! Reflect balance of urea removal vs. production BUNpre BUN (mg/dl) BUNpost Time (hour)

  10. Monitoring the patient’s urea Predialysis BUN or Time-averaged BUN BAD if HIGH, also BAD if too LOW! Reflect balance of urea removal vs. production BUNpre BUN (mg/dl) BUNpost Time (hour)

  11. Monitoring the patient’s urea Predialysis BUN or Time-averaged BUN BAD if HIGH, also BAD if too LOW! Reflect balance of urea removal vs. production BUNpre BUN (mg/dl) TAC BUN BUNpost Time (hour)

  12. Monitoring the patient’s urea URR or Kt/V URR% : (Upre – Upost) x 100 Upre Reflect removal of urea and other toxins PRIMARY monitors of dialysis adequacy

  13. What is Kt/V ? Kt/V = fractional urea clearance K = dialyzer clearance (ml/min or L/hr) t = time (min or hr) V = distribution volume of urea (ml or L) K x t = L/hr x hr = LITERS V = LITERS Kt/V = LITERS/LITERS = ratio

  14. K = 10 L/Hr V = 40 liters BUN = 80 BUN = 0 K . t Holding Tank Model

  15. V = 40 liters BUN = 80 URR BUN = 0 1.0 0.63 K . t Holding Tank Model 1.0 Kt/V

  16. V = 40 liters BUN = 80 BUN = 0 20 L K t =

  17. V = 40 liters BUN = 80 BUN = 0 Kt/V = 20 / 40 = 0.50 20 L K t =

  18. V = 40 liters BUN = 80 BUN = 0 Kt/V = 20 / 40 = 0.50 Post BUN = 40 URR = (pre-post) / pre = (80-40) / 80 = 0.50 20 L K t =

  19. V = 40 liters BUN = 80, 70, 60 BUN = 0 K . t Dialyzer outlet fluid returned continually during dialysis

  20. Relationship between Kt/V and URR

  21. Kt/V spKt/V = single pool eqKt/V = equilibrated (Double pool) Std Kt/V = weekly standard

  22. Post-Dialysis rebound

  23. Post-Dialysis rebound Equilibrated Kt/V

  24. Kt/V spKt/V = single pool eqKt/V = equilibrated (Double pool) Std Kt/V = weekly standard

  25. What is the target spKt/V in 2 times/week HD patients ?

  26. K/DOQI 2006: Minimum spKt/V Dialyzer clearance only *not recommended unless Kr > 3 K/DOQI CPG for Hemodialysis Adequacy: update 2006. Am J Kidney Dis 2007; 37: S7-S64.

  27. K/DOQI : Methods for Post Dialysis Blood Sampling • Both samples should be drawn during the same session. • Predialysis BUN should be drawn before treatment began. • Postdialysis BUN, Avoid access recirculation by • Slow flow to 100 ml/min for 15 seconds K/DOQI CPG for Hemodialysis Adequacy: update 2006. Am J Kidney Dis 2007; 37: S7-S64.

  28. Data from HENNET. Exploring Mortality based on Kt/V among ESRD patients undergoing Twice-weekly Hemosialysis

  29. HENNET * * * * ** * * * * * Setting Multi-center cohort study • 11 hemodialysis centers • Accrual period 3 months from Feb. 2011 • Follow up period 1 years

  30. Part1 Baseline Part2 Follow up Part3 Hospitalization note Part4 Discharge summary

  31. HENNET Study design overview Lab record 2 monthly HD 2/wk 1 year Outcomes: Disease-related Death Enrollment • Inclusion • Age 18 – 80 years • HD > 3 months. • Exclusion • Pregnancy, Breast feeding • Advance malignancy • Bed-ridden status Censor: Kidney transplantation Shift to peritoneal dialysis Refer to other centers Change frequency Death from accident

  32. HENNET Results HD 2/wk 1 year Enrollment 504 Death 33 6,928 patients-months were observed. Mortality rate 4.8 / 1,000 patient-months.

  33. HENNET Table1. Baseline characteristics

  34. HENNET Kt/V by Age 1.7±0.4 1.7±0.3

  35. HENNET Distribution of Kt/V Mean 1.7±0.3 Range 0.67 – 2.83

  36. HENNET Distribution of Kt/V Adequate HD 20.6% Mean 1.7±0.3 Range 0.67 – 2.83

  37. Hemodialysis patients with adequate dialysis (URR>65%) CMS ESRD Clinical Performance Measures Project, 2001-2002. Centers for Medicare & Medicaid Services, ESRD Clinical Performance Measures Project, 2002-2006.

  38. HENNET Kt/V among women and men Kt/V 2.4 2.0 1.9±0.3 1.6 1.6±0.3 1.2 0.8 P < 0.001 0.4 Women 214(42.5%) Men 290(57.5%)

  39. HENNET Kt/V by numbers of Dialyzer Reuse N 200 55.4% 44.6% 150 160 152 127 100 50 65 < 15 15 16-20 > 20 No. of Reuse Range 0 – 30

  40. HENNET Kt/V by numbers of Dialyzer Reuse Kt/V N 200 2 150 1.5 1 100 0.5 50 < 15 15 16-20 > 20 No. of reuse

  41. HENNET Prediction of Dead by numbers of Dialyzer Reuse 16-20 > 20 No. of Reuse < 15 15 Dead rate 0.03 0.06 0.08 0.11

  42. Hemodialysis Prescription Determines Adequacy • Hemodialysis component: • Duration of Treatment • Dialyzer Urea Clearance (KOA) • Blood Flow • Dialysate Flow • Heparinization • Access Adequacy of Treatment is Everyone’s Concern !

  43. Improving Adequacy of Hemodialysis: It Takes a Team.

  44. Kt/V : Do we really need it ?

  45. Mortality Risk by Kt/V Categorical and Linear Estimates, 1991 RR = 0.93 / 0.1 Kt/V ( p < 0.01) RR 1.5 1.5 1.0 0.5 0.0 0.8 1.0 1.2 1.4 1.6 1.0 1.20 p=0.11 Kt/V 1.00 (rel) 0.87 p=0.26 0.71 p=0.01 0.69 p=0.01 0.5 N = 463 462 462 462 462 0.0 < 0.91 0.91-1.05 1.06-1.16 1.17-1.32 1.33 + Delivered Kt/V* (Quintiles) * From the Pre/Post BUN and Pre/Post Weight. N = 2,311, Thrice Weekly only.

  46. P = 0.53

  47. HENNET Kt/V among survivors and non-survivors Kt/V 2.4 2.0 1.6 1.7 (1.67-1.72) 1.65 (1.52-1.77) 1.2 0.8 P=0.52 0.4 Survivors Non-survivors

  48. HENNET Kt/V > 2 Kt/V < 2 Log rank test, P=0.41

  49. HENNET Kt/V > 2 Kt/V < 2 1 year survival 94% Log rank test, P=0.41

  50. HENNET Survival probability among patients with Kt/V>2 and <2 according to diabetic status Kt/V > 2 Kt/V < 2 Kt/V > 2 Kt/V < 2 HR 1.0 (0.28-3.75), p=0.9* HR 1.64 (0.38-7.13), p=0.5* DM Non DM *adjusted for age

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