[Show abstract][Hide abstract] ABSTRACT: Unfractionated heparin is the most common anticoagulant used in haemodialysis (HD), although it has many potential adverse effects. Citrate dialysate (CD) has an anticoagulant effect which may allow reduction in cumulative heparin dose (CHD) compared to standard acetate dialysate (AD).
This double-blinded, randomised, cross-over trial of chronic haemodialysis patients determines if CD allows reduction in CHD during HD compared with AD. After enrolment, intradialytic heparin is minimised during a two-week run-in period using a standardised protocol based on a visual clotting score. Patients still requiring intradialytic heparin after the run-in period are randomised to two weeks of HD with AD followed by two weeks of CD (Sequence 1) or two weeks of HD with CD followed by two weeks of AD (Sequence 2). The primary outcome is the change in CHD with CD compared with AD. Secondary outcomes include metabolic and haemodynamic parameters, and dialysis adequacy.
This randomised controlled trial will determine the impact of CD compared with AD on CHD during HD.
[Show abstract][Hide abstract] ABSTRACT: Background
Many arteriovenous fistula (AVF) fail prior to use due to lack of maturation or thrombosis. Determining vascular function prior to surgery may be helpful to predict subsequent AVF success. This is a feasibility study to describe the vascular function in a cohort of chronic kidney disease (CKD) patients who are awaiting AVF creation.
A prospective cohort of 28 CKD patients expected to progress to HD underwent arterial stiffness (pulse wave velocity, PWV) and endothelial function testing (flow mediated dilation FMD, and peripheral arterial tonometry, PAT) one week prior to AVF creation. AVF success was defined as maintaining patency and achieving maturation. Post operative fistula assessment at 8 weeks evaluated maturation (clinical assessment of adequate fistula flowand ultrasound diameter ≥ 0.5 cm).
The median age 72 years (62 - 78), 75% males, eGFR 15 ml/min/1.73 m2 (12 – 18). 20 (71%) patients had successful AVF surgery with a mature AVF at 8 weeks. Patients with AVF success had higher mean PAT values 1.87 ± 0.52 than those with failed AVF 1.41 ± 0.24 p = 0.03.
Microvascular endothelial function as measured using PAT may be useful as a predictor of AVF maturation and function. This simple non invasive marker of vascular function may be a useful tool to predict AVF outcomes.
[Show abstract][Hide abstract] ABSTRACT: Hemodialysis (HD) patients have high hospitalization rates. Benefits of intradialytic exercise have been proven in numerous studies yet exercise programs are still rarely used in the treatment of end-stage kidney disease (ESKD). Our objective was to determine if there was an association between a 6-month intradialytic bicycling program and hospitalization rates and length of stay (LOS) in ESKD patients. This was a retrospective cohort study that took place 6 months prior to and 6 months during an intradialtyic exercise program at an outpatient HD unit in Calgary, Alberta, Canada. Participants comprised 102 patients who had commenced HD <6 months (incident) or >6 months (prevalent) prior to starting exercise. The intervention comprised a 6-month intradialytic bicycling program. Main outcome measures were hospitalization rate, cause of hospitalization, and LOS. Patients were predominantly male (67.6%) aged 65.6 ± 13.5 years and median HD vintage 1 year (range: 0-12). Comorbidities included diabetes mellitus (50%) and cardiac disease (38.2%). The hospitalization incidence rate ratio (IRR) was 0.48 (0.23-0.98; P = 0.04) in incident and 0.89 (0.56-1.42; P = 0.64) in prevalent patients. The LOS decreased from 7.8 (95% confidence interval (CI): 7.3-8.4) to 3.1 (95% CI: 2.8-3.4) days and LOS IRR was 0.39 (0.35-0.45; P < 0.001). The main predictors of hospitalization were lower albumin levels (P = 0.007) and lack of intradialytic exercise program participation (P < 0.001). In conclusion, 6 months of intradialytic exercise was associated with decreased LOS in both incident and prevalent HD patients.
[Show abstract][Hide abstract] ABSTRACT: Fluid removal during dialysis, also known as ultrafiltration (UF), leads to intradialytic hypotension (IDH) in a significant number of patients treated with hemodialysis (HD) and is associated with an increase in morbidity and mortality. At present, there are no accepted standards of practice for the prevention or treatment of IDH. Relative blood volume monitoring (BVM) is based on the concept that the hematocrit increases with UF, relative to the patient's baseline hematocrit. The use of BVM biofeedback, whereby the HD machine automatically adjusts the rate of UF based on the relative blood volume, has been proposed for the prevention of IDH.
This is a 22-week randomized crossover trial. Participants undergo a 4-week run-in phase to standardize medications and dialysis prescriptions. Subsequently, participants are randomized to standard HD or to BVM biofeedback for a period of 8 weeks followed by a 2-week washout phase before crossing over. The dialysis prescription remains identical for both arms. The primary outcome is the frequency of symptomatic IDH as defined by an abrupt drop in the systolic blood pressure of >=20 mm Hg accompanied by headache, dizziness, loss of consciousness, thirst, dyspnea, angina, muscle cramps or vomiting. Secondary outcomes include the number of symptomatic IDH episodes and any reduction in IDH episodes, nursing interventions, dialysis adequacy, total body water, extra- and intracellular fluid volumes, brain natriuretic peptide and cardiac troponin levels, blood pressure, antihypertensive medication use, patient symptoms and quality of life.
Our study will determine the impact of using BVM biofeedback to prevent IDH and other serious adverse events in susceptible patients.Trial registration: Clinicaltrials.gov NCT01988181 (6 November 2013).
[Show abstract][Hide abstract] ABSTRACT: Uric acid is associated with hypertension and increased renin–angiotensin system activity, although this relationship diminishes after chronic exposure to high levels. Uric acid is more strongly associated with poor outcomes in women compared to men, although whether this is due to a sex-specific uric acid-mediated pathophysiology or reflects sex differences in baseline uric acid levels remains unknown. We examined the association between uric acid and vascular measures at baseline and in response to angiotensin-II challenge in young healthy humans. Fifty-two subjects (17 men, 35 premenopausal women) were studied in high-salt balance. Serum uric acid levels were significantly higher in men compared to women (328 ± 14 μmol/L vs. 248 ± 10 μmol/L, P < 0.001), although all values were within normal sex-specific range. Men demonstrated no association between uric acid and blood pressure, either at baseline or in response to angiotensin-II. In stark contrast, a significant association was observed between uric acid and blood pressure at baseline (systolic blood pressure, P = 0.005; diastolic blood pressure, P = 0.02) and in response to angiotensin-II (systolic blood pressure, P = 0.035; diastolic blood pressure, P = 0.056) in women. However, this sex difference lost significance after adjustment for baseline uric acid. When all subjects were stratified according to high (>300 μmol/L) or low (≤300 μmol/L) uric acid levels, only the low uric acid group showed a positive association between uric acid and measures of vascular tone at baseline and in response to angiotensin-II. Differences in uric acid-mediated outcomes between men and women likely reflect differences in exposure to increased uric acid levels, rather than a sex-specific uric acid-mediated pathophysiology.
[Show abstract][Hide abstract] ABSTRACT: Background:
Arteriovenous fistula is an uncommon complication of central venous catheterization that often requires invasive repair.
We report the case of an arteriovenous fistula that presented as ongoing pain following removal of a tunneled central venous catheter. The fistula resolved spontaneously following a period of compression and observation.
Our study highlights the etiology of this uncommon complication as well as suggesting a role for conservative management.
[Show abstract][Hide abstract] ABSTRACT: Background
Patients with end-stage kidney disease (ESKD) have a high rate of mortality and specifically an increased risk of sudden cardiac death (SCD). Impaired cardiac autonomic tone is associated with elevated risk of SCD. Moreover, patients with ESKD are often vitamin D deficient, which we have shown may be linked to autonomic dysfunction in humans. To date, it is not known whether vitamin D supplementation normalizes cardiac autonomic function in the high-risk ESKD population. The VITamin D supplementation and cardiac Autonomic tone in Hemodialysis (VITAH) randomized trial will determine whether intensive vitamin D supplementation therapies improve cardiac autonomic tone to a greater extent than conventional vitamin D supplementation regimens in ESKD patients requiring chronic hemodialysis.
A total of 60 subjects with ESKD requiring thrice weekly chronic hemodialysis will be enrolled in this 2x2 crossover, blinded, randomized controlled trial. Following a 4-week washout period from any prior vitamin D therapy, subjects are randomized 1:1 to intensive versus standard vitamin D therapy for 6 weeks, followed by a 12-week washout period, and finally the remaining treatment arm for 6 weeks. Intensive vitamin D treatment includes alfacalcidiol (activated vitamin D) 0.25mcg orally with each dialysis session combined with ergocalciferol (nutritional vitamin D) 50 000 IU orally once per week and placebo the remaining two dialysis days for 6 weeks. The standard vitamin D treatment includes alfacalcidiol 0.25mcg orally combined with placebo each dialysis session per week for 6 weeks. Cardiac autonomic tone is measured via 24 h Holter monitor assessments on the first dialysis day of the week every 6 weeks throughout the study period. The primary outcome is change in the low frequency: high frequency heart rate variability (HRV) ratio during the first 12 h of the Holter recording at 6 weeks versus baseline. Secondary outcomes include additional measures of HRV. The safety of intensive versus conventional vitamin D supplementation is also assessed.
VITAH will determine whether an intensive vitamin D supplementation regimen will improve cardiac autonomic tone compared to conventional vitamin D supplementation and will assess the safety of these two supplementation regimens in ESKD patients receiving chronic hemodialysis.
[Show abstract][Hide abstract] ABSTRACT: We previously reported a reduction in central venous catheter (CVC) malfunction when using once-weekly recombinant tissue-plasminogen activator (rt-PA) as a locking solution, compared with thrice-weekly heparin.
To identify risk factors for CVC malfunction to inform a targeted strategy for rt-PA use.
Canadian hemodialysis (HD) units.
Adults with newly placed tunnelled upper venous system CVCs randomized to a locking solution of rt-PA(1 mg/mL) mid-week and heparin (5000 u/ml) on the other HD sessions, or thrice-weekly heparin (5000 u/ml).
CVC malfunction (the primary outcome) was defined as: peak blood flow less than 200 mL/min for thirty minutes during a HD session; mean blood flow less than 250 mL/min for two consecutive HD sessions; inability to initiate HD.
Cox regression was used to determine the association between patient demographics, HD session CVC-related variables and the outcome of CVC malfunction.
Patient age (62.4 vs 65.4 yr), proportion female sex (35.6 vs 48.4%), and proportion with first catheter ever (60.7 vs 61.3%) were similar between patients with and without CVC malfunction. After multivariate analysis, risk factors for CVC malfunction were mean blood processed < 65 L when compared with ≥ 85 L in the prior 6 HD sessions (HR 4.36; 95% CI, 1.59 to 11.95), and mean blood flow < 300 mL/min, or 300 - 324 mL/min in the prior 6 HD sessions (HR 7.65; 95% CI, 2.78 to 21.01, and HR 5.52; 95% CI, 2.00 to 15.23, respectively) when compared to ≥ 350 mL/min.
This pre-specified post-hoc analysis used a definition of CVC malfunction that included blood flow, which may result in an overestimate of the effect size. Generalizability of results to HD units where trisodium citrate locking solution is used may also be limited.
HD session characteristics including mean blood processed and mean blood flow were associated with CVC malfunction, while patient characteristics were not. Whether targeting these patients at greater risk of CVC malfunction with rt-PA as a locking solution improves CVC longevity remains to be determined.
[Show abstract][Hide abstract] ABSTRACT: Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3-4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on 'how to do it'.
We undertook a systematic survey of home hemodialysis programs in Canada to describe current practice patterns.
Development and deployment of a qualitative survey instrument.
Community and academic HHD programs in Canada.
Physicians, nurses and technologists.
Programmatic approaches to patient selection, delivery of dialysis, human resources available, and follow up.
We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group. Multidisciplinary teams at three sites pretested the survey and further suggestions were incorporated. In July 2010 we distributed the survey electronically to all renal programs known to offer HHD according to the Canadian Organ Replacement Registry. We compiled the survey results using qualitative and quantitative methods, as appropriate.
Of the academic and community programs that were invited to participate, 80% and 63%, respectively, completed the survey. We observed wide variation in programmatic approaches to patient recruitment, human resources, equipment, water, vascular access, patient training, dialysis prescription, home requirements, patient follow up, medications, and the approach to non-adherent patients.
Cross-sectional survey, unable to link variation to outcomes. Competition for patients between HHD and home peritoneal dialysis means that case mix for HHD may also vary between centres.
There is wide variation between programs in all domains of HHD delivery in Canada. We plan further study of the extent to which differences in approach are related to outcomes.
[Show abstract][Hide abstract] ABSTRACT: Background
We previously have shown that buttonhole needling is associated with a reduction in hematoma and postulated that buttonhole needling may increase long-term survival of an arteriovenous fistula (AVF). The purpose of this study was to evaluate AVF survival and complications in buttonhole versus standard needling.
Long-term follow up of a randomized controlled trial in which participants were randomly assigned to standard or buttonhole needling and followed up until the AVF was abandoned or the study end date.
Setting & Participants
140 long-term hemodialysis patients in Calgary, Alberta.
Buttonhole needling with median time of exposure to the intervention of 13.2 (IQR, 7.8-19.4) months.
Outcomes & Measurements
Patients were prospectively followed up for study outcomes. Median follow-up times were 17.2 (IQR, 11.9-37.8) and 19.2 (IQR, 12.5-41.0) months for standard and buttonhole needling, respectively (P = 0.2). The primary outcome was median access survival in months. Other outcomes included assisted and unassisted patency rates, rates of surgical and radiologic interventions, and time to abandonment (months) of buttonhole.
Baseline characteristics were similar. The primary outcome, median access survival, was similar in both groups: 16.0 (IQR, 10.6-29.3) and 18.4 (IQR, 10.9-32.7) months for standard and buttonhole needling, respectively (P = 0.2). There were 7 (10.1%) and 6 (8.6%) thromboses with standard and buttonhole needling, respectively (P = 0.6). Median fistulogram rates were similar between techniques (P = 0.2 with intention-to-treat analysis). Most patients (46 of 70) abandoned buttonhole needling by a median of 11.3 (IQR, 4.8-18.2) months. Median time to first infection for buttonhole needling was 11.1 (IQR, 4.9-30.0) months. There were no infections in standard needling of AVFs.
Findings are limited to patients needled by multiple hemodialysis nurses and not applicable to self-needlers.
AVFs with buttonhole needling did not have improved survival. The lack of survival benefit and higher risk of infection should be noted when promoting buttonhole needling.
American Journal of Kidney Diseases 04/2014; 63(4):636–642. DOI:10.1053/j.ajkd.2013.09.015 · 5.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Sex influences the cardiorenal risk associated with body mass index (BMI). The role of the renin-angiotensin-aldosterone system in adiposity-mediated cardiorenal risk profiles in healthy, non-obese men and women was investigated.
Systemic and renal hemodynamic responses to angiotensin-II (AngII) as a function of BMI, waist and hip circumference, waist-hip ratio, as well as fat and lean mass were measured in 18 men and 25 women in high-salt balance, stratified by BMI (<25 kg/m2 (ideal body weight (IBW)) vs. ≥25 kg/m2 overweight)).
In men (n = 7, BMI 23 ± 1 kg/m2) and women (n = 14, BMI 22 ± 2 kg/m2) of IBW, BMI was not associated with the systolic blood pressure (SBP) response to AngII. In contrast, overweight men (n = 11, 29 ± 2 kg/m2) demonstrated a progressively more blunted vasoconstrictor SBP response to AngII challenge as BMI increased (P = 0.007), even after adjustment for covariates. Women maintained the same relationship between BMI and the SBP response to AngII irrespective of weight status (P = 0.2, IBW vs. overweight women). Compared to BMI, other adiposity measures showed similar associations to systemic AngII responsiveness in men but not in women. Increasing BMI was associated with a blunted renovasoconstrictor response to AngII in all subjects, but was more pronounced in men.
Sex influences the effect of adiposity on vascular angiotensin-responsiveness.
[Show abstract][Hide abstract] ABSTRACT: Abstract Vitamin D deficiency is associated with increased arterial stiffness. We sought to clarify the influence of vitamin D in modulating angiotensin II-dependent arterial stiffness. Thirty-six healthy subjects (33 ± 2 years, 67% female, mean 25-hydroxyvitamin D 69 ± 4 nmol/L) were studied in high salt balance. Arterial stiffness, expressed as brachial pulse wave velocity (bPWV) and aortic augmentation index (AIx), was measured by tonometry at baseline and in response to angiotensin II infusion (3 ng/kg/min × 30 min then 6 ng/kg/min × 30 min). The primary outcome was change in bPWV after an angiotensin II challenge. Results were analyzed according to plasma 25-hydroxyvitamin D status: deficient (<50 nmol/L) and sufficient (≥50 nmol/L). There were no differences in baseline arterial stiffness between vitamin D deficient (25-hydroxyvitamin D 40 ± 2 nmol/L) and sufficient (25-hydroxyvitamin D 80 ± 4 nmol/L) groups. Compared with sufficient vitamin D status, vitamin D deficiency was associated with a decreased arterial response to angiotensin II challenge (Δbrachial pulse wave velocity: 0.48 ± 0.44 m/s versus 1.95 ± 0.22 m/s, p = 0.004; Δaortic augmentation index: 9.4 ± 3.4% versus 14.2 ± 2.7%, p = 0.3), which persisted for brachial pulse wave velocity response after adjustment for covariates (p = 0.03). Vitamin D deficiency is associated with increased arterial stiffness in healthy humans, possibly through an angiotensin II-dependent mechanism.
[Show abstract][Hide abstract] ABSTRACT: There has been increased interest in buttonhole cannulation, particularly in the last 5 years, because of the perceived benefit of improved fistula outcomes. The recent randomized trials provide for a timely review regarding the potential benefit and possible harms of the buttonhole technique.
The majority of observational studies report a reduction in pain with buttonhole; however, after reviewing the results from five randomized trials, buttonhole cannulation, when delivered by a nurse, does not appear to be less painful than rope ladder cannulation. Studies consistently report fewer infiltrations, reduced hematoma and a reduction of aneurysm formation with buttonhole. These benefits must be balanced against the increased risk of infection and septic complications seen with buttonhole cannulation.
On the basis of the current studies, buttonhole, when done in an in-center environment with many rotating staff nurses, is a complex and challenging technique. Buttonhole technique might be best utilized for difficult or limited fistula needling sites. An infection prevention education campaign along with regular audits regarding localized infections and bacteremias should be a critical part of any program which uses buttonhole cannulation. A randomized trial comparing buttonhole to rope ladder needling among home hemodialysis or self-needled patients should be the focus for future research.
Current Opinion in Nephrology and Hypertension 09/2013; 22(6). DOI:10.1097/MNH.0b013e328365ae9e · 3.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Vascular access complications are a major cause of morbidity in patients undergoing hemodialysis, and determining how the risks of different complications vary over the life of an access may benefit the design of prevention strategies. We used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to assess the temporal profiles of risks for infectious and noninfectious complications of fistulas, grafts, and tunneled catheters in incident hemodialysis patients. We used longitudinal data to model time from access placement or successful treatment of a previous complication to subsequent complication and considered multiple accesses per patient and repeated access complications using baseline and time-varying covariates to obtain adjusted estimates. Of the 7769 incident patients identified, 7140 received at least one permanent access. During a median follow-up of 14 months (interquartile range, 7-22 months), 10,452 noninfectious and 1131 infectious events (including 551 hospitalizations for sepsis) occurred in 112,085 patient-months. The hazards for both complication types declined over time in all access types: They were 5-10 times greater in the first 3-6 months than in later periods after access placement or a remedial access-related procedure. The hazards declined more quickly with fistulas than with grafts and catheters (P<0.001; Weibull regression). These data indicate that risks for noninfectious and infectious complications of the hemodialysis access decline over time with all access types and suggest that prevention strategies should target the first 6 months after access placement or a remedial access-related procedure.
Journal of the American Society of Nephrology 07/2013; 24(10). DOI:10.1681/ASN.2012121234 · 9.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis.
We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis.
Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]).
We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011).
(1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users.
Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life.
We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices.
Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors.
This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.
American Journal of Kidney Diseases 07/2013; 62(1):112-31. DOI:10.1053/j.ajkd.2013.03.028 · 5.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN: Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION: Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES: We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS: Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES: Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS: 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS: Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS: Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
American Journal of Kidney Diseases 04/2013; 62(1). DOI:10.1053/j.ajkd.2013.02.357 · 5.90 Impact Factor