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Hemodialysis - Science topic

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Greetings,
I have two letters to the editor ready to submit. Do you know a professor who is skilled in the field of quality of life among patients undergoing hemodialysis?
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@sreebhushan raju
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Hello everybody. i have a question about standard ACD-A solution. how much citrate (mmol/L) does ACD-A solution contain? 75 mmol/L ? or 110 mmol/L? i could not understand it.
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The most commonly used citrate formulations in apheresis are Acid-Citrate-Dextrose Formula A (ACD-A) and ACD-B.
ACD-A contains 3% citrate (112 mmol/L of citrate or 21.3 mg/mL) whereas ACD-B has a reduced citrate concentration of 2% citrate (68 mmol/L or 12.8 mg/mL).
References
Lee G, Arepally GM. Anticoagulation techniques in apheresis: from heparin to citrate and beyond. J Clin Apher. 2012;27(3):117-125. doi:10.1002/jca.21222
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considering the blood transfusion reactions , what would be the recommendation for the safe rate to start PRBC transfusion during hemodialysis ? our current practice is to be given in 30 min to 1hour and in first 15 min 50ml /hour.
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Watch for 5 minutes for transfusion adverse effect , than you can transfuse as fast as required for maintained the critical parameters
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A young patient attempted suicide by taking 63 tabs of carbamazepine 200 mg. she was managed with CRRT - CVVH and discharged 10 days later well and couscous.
data supporting the use of hemodialysis in managing carbamazepine poisoning is increasing, so I am not sure if it is worth publishing or not ( if it has a chance to get accepted for publishing)
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you must publish your findings
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If it effect the flow and viscosity then how much it can effect in heart rate and blood pressure
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Effect of hemodialysis on blood viscosity, blood flow rate, heart rate, and blood pressure.
Patients on hemodialysis have increased viscosity, that is multifactorial and can contribute to increased cardiovascular mortality in this group of patients with end stage renal disease (1).
Blood flow rate (BFR) through dialysis machine is one of the parameter of effective hemodialysis, and BFR <250 ml/min compared with >250 ml/min is associated with less effective dialysis, tissue ischemia, particularly the heart, and can lead to increased vascular events (2).
Dialysis is considered one of the strongest antihypertensive in patients who are undergoing hemodialysis. This why in hypertensive patients, antihypertensive drugs on the day of dialysis should not be given before dialysis session, because patients often develop hypotension during dialysis. Associated with hypotension, most of such patients develop tachycardia, but others have no effect, while a few may develop bradycardia(3). Hypotension is particularly more common in patients with ischemic heart disease and patients with diabetic complications (particularly autonomic neuropathy) with renal failure (4)
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Hemodialysis patients are covered by National Health Insurance in most countries. Those are direct costs. However, assessing the comprehensive cost-of-illness (COI) is a challenge for many researchers and practitioners.
Could anyone share the available tool, technique, or method to assess COI in hemodialysis patients?
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To my knowledge, the specific-tools (questionnaires) for assessing COI in hemodialysis patients haven't been published.
So maybe it's better if you focus on COI methods.
In general, COIs will be divided:
- direct healthcare cost
- direct non-healthcare cost
- indirect cost
Of course, they should be combined with a total number of costs. However, they should be used as different methods to calculate.
For examples:
- Informal care (direct non-healthcare cost) can be calculated by Proxy Good Method (most straightforward), Opportunity cost, or contingent valuation method, etc.
- Productivity losses (indirect cost) can be calculated by human capital method or friction cost method, etc. Some questionnaires can be used such as WPAI/iPCQ questionnaires.
Additional, you can find more generic questionnaires via DIRUM (https://www.dirum.org/instruments/all)
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Hepatitis C infection and chronic kidney disease are major health burden worldwide. Hepatitis C infection is associated with a wide range of extra-hepatic manifestations in various organs including the kidneys. A strong association between hepatitis C and chronic kidney disease has come to light. Hemodialysis in supporting the end stage renal disease patients unfortunately carries a risk for hepatitis C infection. Despite much improvement in the care of this group of patients, the prevalence of hepatitis C infection in hemodialysis patients is still higher than the general population. Hepatitis C infection has a negative effect on the survival of hemodialysis and renal transplant patients.
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Hemodialysis
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I am currently working on my Thesis about the maximization of the delivered hemodialysis Dose and stumbled about the BoD and PoD techniques mentioned in "Hemodiafiltration: Technical and Clinical Issues" by Claudio Ronco (DOI: 10.1159/000437403).
Those ideas seem very promising to me but i can hardly find anything about BoD or PoD, unfortunately there are also remarks in the Paper itself.
Do you guys know any paper, clinicaltrial or similar, testing or mentioning those techniques?
Thanks in Advance!
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Okay i so apparently its called Push Pull Dialysis (PPD) e.g. and there are some articles about it. Hope this might help someone someday!
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Can anyone provide papers or links to research conducted on Metabolic Syndrome Status and Dietary Assessment in Hemodialysis Patients?
Thanks
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I have worked on the prevalence of Occult hepatitis B among hemodialysis patient at Th-Qar city south of Iraq (paper in press) and I think this form of the disease represents a serious problem in view of spreading the infection in communities depending on serological methods especially in highly susceptible groups like blood donors or hemodialysis patients. this form of the disease which is serologically silent and can be easily missed can spread to the community. Additionally, the prevalence of occult hepatitis B usually in association with prevalence of overt hepatitis B. \thus now I'm working on review undertake the prevalence of occult hepatitis B infection among Arab countries if anyone like to contribute, please communicate with me
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I suggest large scal study in Arabic countries to estimate the prevalence
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In the case of urgent/emergent hemodialysis, where the patient does not have an AV fistula in place, what is the best site to use for hemodialysis (e.g. internal jugular)?
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Right jugular vein for sure. :)
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which is associated with a lower risk of thrombosis? Which one is associated with less blood stream infection?
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various lock solutions can be based on 3 criteria: (i) risk of catheter-related blood stream infection, (ii) frequency of thrombosis with malfunction and (iii) cost
I had a good practice with alteplase but it's costy then citrate then tarulidine and the last is heparin.When get catheter thrombus in those whom I used heparin I use to give alteplase and wait 2 hours then continue with HD.
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some article said "As other factors besides fluid overload, such as
sympathetic nervous activity, the renin-angiotensin system,
cardiac function and potentially the interdialytic weight
gain, also contribute to the genesis of arterial hypertension
in hemodialysis patients, it appears challenging to associate
the volume status with blood pressure" but the other article was said "Normally, volume overload and elevation of BP result in suppression of RAAS production." and the other said " Angiotensin (Ang) II and aldosterone, both circulating and produced locally in the heart, may contribute to cardiac remodelling in response to cardiac pressure and volume overload or myocardial infarction."
1. Is it the same explanation?
2. whichever occurs first, does the angiotensin level change first? or fluid overload first?
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Angiotensin is a protein hormone that causes blood vessels to become narrower. It helps to maintain blood pressure and fluid balance in the body. Too much angiotensin can cause the body to retain too much fluid or to have elevated blood pressure levels.
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Hello Researchers',
I am working in computational fluid mechanics problems that investigate the effect of dialysate concentration and flow rate.
Q1: what is the maximum net osmotic pressure (MPa) that we can apply on membrane BC as driving force to the mass transfer along the membrane surface or maximum solute mass fraction for the dialysate (k_gsolute/kg_solvent)?
Q2: why the dialysis flow rate limited by 800 ml/min and some publishable journal used 1000 ml/min and not more than this flow rate?
Q3: what is the clearance of urea or uraemic toxin during one session of hemodialysis in (kg/m^2.hour)?
Thanks in advance for you and if you can provide me with a study/studies that have these pieces of information.
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Interesting
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I am going on conducting a study to determine the Prevalence of Metabolic Syndrome (MetS) Among the End-Stage Renal Disease Patients on Hemodialysis in Gaza strip, Palestine, In your opinion; what is the best time to measure the metabolic syndrome criteria (which are: High waist circumference, elevated Fasting Blood Glucose, low high-density lipoprotein cholesterol, elevated triglycerides and elevated blood pressure)?
After my overviewing of many literature reviews; I found that:
1- Few studies measured all MetS criteria randomly.
2- Another one has measured it pre-dialysis.
But I think that I should measure it Pre and post dialysis, because hemodialysis may affect on these criteria (increasing or decreasing), I saw this effects on many studies in the literature which were conducted to evaluate the effect of hemodialysis on many biochemical parameters.
However, I think it will be more accurate if I measure these criteria pre-dialysis and post-dialysis, after that, I will calculate the mean of each parameter for both period, and based on these means I will identify the MetS.
What is your opinion my expert colleagues?
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It will be difficult to measure and diagnose metabolic syndrome in patients with ESRD.The components of MetS are all altered by ESRD. Blood pressure and lipid abnormalities (TG and HDL) are all significantly altered in MetS. The measurement of waist circumference is also variable and not reliable.
A prospective follow up of individuals with MetS to find out how often they develop CKD and ESRD may be a good option.
Thanks Akram.
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instrument to assess knowledge on self care management of chronic kidney disease under hemodialys
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Actually there is no clear question in here.
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We are currently trying to standardise the assessment of haemodialysis extracorporeal blood circuits and filters when evaluating the correct dose of LMWH (fragmin) for haemodialysis patients. I am looking for a standardised assessment tool to score the level of clot formation in the above mentioned circuit and filter when haemodialysis is complete.
Does anyone know of an existing assessment tool?
Many thanks,
Johnny Hooper
Dialysis Unit
Horsens Hospital
Denmark
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Hi Albert,
Many thanks for your very comprehensive answer to my question.
With warm regards,
Johnny Hooper
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Hello, I am trying to set up an in-vitro experiment model for hemodialysis treatment. What is the average concentration of BUN, Crea, and Beta 2- microglobulin concentration observed in chronic renal failure patients?
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"Utilization of haemodialysis services by End Stage Renal Disease patients"
questionairre on above or related topic.
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Is there a study on it?
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This is a condition called "sensorineural hearing loss". The etiology of SNHL associated with hemodialysis is controversial. Possible mechanisms include an antigenicity between the kidney and the labyrinths, but above all the alteration caused by osmotic disequilibrium in the labyrinth due to hemodialysis, and the ototoxic effect of diuretics.
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How to perform it ? 
Once per week, twice per week, once every 2 weeks?
The idea is : patient is already having UOP, of-course with exclusion of totally anuric, oliguric or HF patients.
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Candidates that may benefit from incremental hemodialysis
Good residual renal function with urine output > 0.5 L/d (or KRU>3 ml/min)
Limited fluid retention between two conservative HD treatments with fluid gain < 2.5 kg (or < 5% of ideal dry weight) without HD for 3-4 days
Limited or readily manageable cardiovascular or pulmonary symptoms without clinically significant fluid overload
Suitable body size relative to renal residual kidney function
Hyperphosphatemia (P> 5.5 mEq/L) is infrequent or readily manageable
Good nutrition status
Lack of profound anemia
Infrequent hospitalizations and easily manageable comorbid conditions
Satisfactory health-related quality of life
Use of the criteria on 2x/week HD therapy patients should be re-evaluated once a month.
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SLEDD needs very low dialysate flow ( below 300 cc/min ). which dialysis machine can be adjusted for SLEDD ?
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We did a study back in 2008 that showed using Remifentanyl infusion at 1/10 of the maintenance dose (usually at 0.01mcg/kg/min) till the end of the ENT procedure, patients were noticed to have smooth awakening, less coughing and bucking and better hemodynamics. Does anybody use this technique in his practice ?
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Yes we use, doses of  0,2 - 05 mcg/kg/min with nitrous oxide 66% provide a very good anesthesia.
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is there any documented recommendation for disinfection of HBS+ hemodialysis machine ?
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My opinion is that you shouldn't use a HBs+ hemodialysis machine for a HBS- patient, whenever possible of course
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Hi
I am evaluating renal recovery pattern among non-dialysis dependent AKI patients especially among patients with AKIN-I and AKIN-II stage of AKI. I am bit confuse because my outcome is renal recovery but available literature has vast variation for definition of renal recovery.
Most of the studies have been done on critically ill patients requiring dialysis. But in my case, patients have mild to moderate severity of AKI. There is no patient with dialysis in my study. So definition of dialysis independence will be excluded. On the other hand, as in my study patients are not critically ill and have less severe stage of AKI, so defining AKI as +/-25% of baseline will show that all patients have full recovery. However, most of the patients have elevated levels of Serum creatinine as compared to baseline. and I am confuse to declare them as fully renal recovery patients because I can not ignore the findings of previous studies that "small increase in serum creatinine is associated with high morbidity and mortality"
Please guide me in this regard, with appropriate reference
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Recovery process in patients followed-up due to acute kidney injury
K Magden,1 I Yildirim,1 ME Kutu,2 MC Ozdemir,2 S Peynir,2 A Altas,2 G Yildiz,3 and E Hur1
Abstract
Introduction: Acute kidney injury (AKI) may result in complete recovery in some of the patients and partial recovery in others. AKI episodes may accelerate the progression to chronic kidney disease and end-stage renal failure, while risk for morbidity and mortality is high following AKI. Discharge of patients from the hospital, independently from dialysis is a crucial outcome. Many patients without a need for dialysis, require follow-up for various durations and different treatments. The objective of this study was to compare mean recovery time of the patients followed-up due to prerenal, renal and postrenal AKIs.
Method: In this prospective observational study, a total of 159 patients hospitalized in Bulent Ecevit Hospital, clinic of nephrology or monitored in the other wards and intensive care unit due to AKI, between June 2011 and January 2012, were enrolled. The cases were divided into three groups as prerenal, renal and postrenal, and monitored with the daily visits and renal function testing.
Results: Prerenal AKI was seen by 54%, while renal AKI was observed by 34% and post-renal AKI by 12%. Incidence of chronic kidney disease was 17.6%. Totally 43 patients required hemodialysis (27%). Of these patients, 23 were in the prerenal AKI (53.4%), 15 in the renal AKI (34.8%) and 5 (11.6%) in the postrenal AKI group. Blood urea nitrogen (BUN) and creatinine levels were dropped to the basal values only in the prerenal AKI group, on the seventh day of treatment. These levels remained higher in the postrenal and renal groups on the 7th day of treatment compared to the basal values. BUN levels decreased to the normal values on average 7th day in the postrenal, while remained higher in the renal group.
Conclusion: Prerenal AKI patients recovered in seven days with a proper treatment, although AKI patients due to other reasons should be followed-up for a longer time.
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There is no way for viral particles to pass through the dialyser pores so why we have isolated HBS+ hemodialysis machine ?
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Here is a review of the subject of virus transmission through hemodialysis:
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viral infection (HIV-HBV-HCV) in hemodialysis patients are common now the question is : is there any viral particles passage possibility from the pores of dialyser ?
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Pleas read this article:
The pores in dialysis tubing are too small to allow the passage of virus, unless there were a defect. However, that is not the only way a virus could be passed between dialysis patients.
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Cardiovascular disease is a leading cause of death in patients with end-stage renal disease (ESRD). Hypertension is a major risk factor for cardiovascular complications in these patients. Angiotensin-converting enzyme (ACE) inhibitors are an effective treatment for hypertension in patients with ESRD and are known to improve prognosis in patients with chronic renal failure.
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thank you
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new recommendation please ?
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Urine output continues to be the main issue. 450 ml in 24 hours with no diuretics seems to be a good cut off to indentify those patients that can be quitted from RRT. Urea excretion can be also useful in order to evaluate tubular function.
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I work on a haemodialysis unit in Denmark. We currently use metal needles to access AV fistulas for haemodialysis. I am curious to see if there is any convincing evidence for the use of plastic cannulas over trational metal dialysis needles,  for example reduced trauma, haemotomas and extravasion, increased longlevity of fistula,  reduced percieved pain, reduced incidence of needle-stick injuries in health care workers etc.
Many thanks Johnny Hooper
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An Australian group (Smith and Schoch) published their positive findings in March 2016 issue of Journal of Vascular Access: "Plastic cannula use in hemodialysis access" Abstract available on internet at:http://www.ncbi.nlm.nih.gov/pubmed/26980628.
Also, the U.S. National Kidney Foundation has a current clinical update on this topic at:
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The setting such as QD - QB - Temperature - dialysor ?
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Certainly hemoperfusion. To protect lungs, consider to continue hemoperfusion sessions for 2-4 more days after urine paraquat stops been detected, because the poison bound in tissues keeps releasing.
See: Survival of a paraquat-poisoned patient, despite late (4 days) referral and initiation of conventional haemoperfusion treatment
Nephrol. Dial. Transplant. (1993) 8 (6): 570-571
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Treatment of Thrombosis With Fondaparinux (Arixtra) in a PEDIATRIC Pateint With End-stage Renal Disease Receiving Hemodialysis Therapy
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Fondaparinux (Arixtra) may be given for the prophylaxis of thromboembolism in patients with heparin-induced thrombocytopenia (HIT).  If the patient is not HIT positive one may consider other LMWHs.  Peter is absolutely right that the dose of Fondaparinux or for that matter any LMWH should be carefully titrated based on the CrCl and closely monitored by anti-Xa levels.
Omer
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is there any research in this field ( the ways of correcting PH and Hco3 ) and the advantages and disadvantages ?
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nephrologists have always focused on serum bicarbonate concentration  as marker of metabolic acidosis. HCO3 concentration  has been associated to mortality risk in hemodialysis patients (U-shape curve relationship: see Bommer et al. and Wu et al). Concerns have been raised on changing bicarbonate level in dialysis bath (see, as an example Gennari et al). Please see also Tentori et al.
More recently Yamamoto el al (AJKD 2015)  failed to find relationship between serum HCO3 and mortality risk, however they found high pre-dialysis pH associated with increased risk of death in hemodialysis population.  
at the end of the story there are a lot of under-recognized respiratory disorders in hemodialysis population (see my paper in press on NDT).
In my opinion we should firstly categorize acid-base derangement in our dialysis patients. According to acid-base picture found then we can think how correct the disorder
(If you are interested in the topic, please feel free to ask me  full text of papers I cited above).
hope this is helpfull
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I'm looking for reimbursement information for the Japanese market. I'm also interested in the structure of reimbursement and also of the healthcare system in relation to dialysis - what is the split between private insurance and public funding.
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I can not give answer  I am not include in that
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the normal machine has no QD ( dialysate flow rate ) below 300cc/min . can we use normal machine to do SLEDD while SLEDD needs QD 100 to 200 cc/min ?
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Found this.. might be helpful.. "SLEDD techniques combine the advantages of CRRT and Intermittent Hemodialysis (IHD) by using conventional hemodialysis machines with blood flow rated (BFR) between 50-200 and dialysate flow rates (DSF) of 200-400.  Dialysis time varies anywhere from 6 to 12 hours or can be done continuously. The possible variations and adaptations of blood flow, hemofiltration rate and duration of dialysis time as a function of needs of the patient are practically unlimited, which makes SLEDD applicable to the critically ill patient. "  from  "Slow, Low, Efficient, Daily Dialysis (SLEDD) in the Critically Ill Patient" By Pat Isaacs, MSN, CS, CNN, NP
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I mean who choose the best Ideal mode of RRT ( SLED - CRRT - IHD ) for the patients ? Is there any RRT team in your hospital or nephrologists reply the consultation ? or ICU men ? 
SLED : sustained low efficacy daily dialysis
CRRT : continuous renal replacement therapy
IHD : intermittent hemodialysis
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Renal replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose
INTRODUCTION
The management of patients with acute kidney injury (AKI) is principally supportive, with renal replacement therapy (RRT) indicated in patients with severe kidney injury. Multiple modalities of RRT are available. These include intermittent hemodialysis (IHD); continuous renal replacement therapies (CRRTs); and hybrid therapies, also known as prolonged intermittent renal replacement therapies (PIRRT), such as sustained low-efficiency dialysis (SLED) and extended duration dialysis (EDD). Despite these varied techniques, mortality in patients with AKI remains high, exceeding 40 to 50 percent in severely ill patients. (See "Renal and patient outcomes after acute tubular necrosis".)
The initiation of RRT in patients with AKI prevents uremia and immediate death from the adverse complications of renal failure. It is possible that variations in the timing of initiation, modalities, and/or dosing may affect clinical outcomes, particularly survival. However, there is a paucity of studies in which these issues have been addressed directly.
The optimal timing, type of modality, and dosing strategy for patients with AKI who require RRT will be reviewed here. The different modalities are discussed separately.
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If yes how long can we use isolated UF ?
and in isolated UF can we have reduction of BUN and Creatinine and potasium ?
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I think I could make an argument for doing hemofiltration (HF) at the end of dialysis. In 1977-1980 I worked on building three pool mathematical computer models of fluid and electrolyte shifts in patients undergoing hemodialysis. These days you are probably aware of dialysis disequilibrium but I will describe the fluid shifts here.  
As various chemicals are removed from the blood by diffusion across the dialyzer membrane their concentrations drop. (This doesn't happen with ultrafiltration.) Unless these solutes move across cell membranes very quickly a concentration difference develops between the intracellular compartment (ICF) and extracellular compartment (ECF).
Since the extracellular compartment becomes more dilute it drives osmosis which is really diffusion of water down its own concentration gradient. A lower solute concentration in ECF means a higher water concentration in the ECF. So water diffuses into the cells. The ICF is a big pool, twice the size of ECF so it can soak up a lot of water.  
The ECF can be split into two compartments: intravascular fluid (IVF) and interstitial fluid (ISF), the so called third space. As the volume in the ECF decreases so does the intravascular volume (IVF) as the interface between IVF and ISF is highly permeable and a significant concentration does not develop at that interface. So as ECF volume drops the IVF volume also drops, blood pressure drops and the patient feels sick.
Now what if we carry out ultrafiltration (UF) during dialysis as well. That is what we normally do. It does not directly affect any concentrations significantly but it does decrease ECF volume very quickly. So now we have two competing processes decreasing intravascular volume.
My job (in Newcastle UK) was to try to work out how to use computer control of hemodialysis machines to minimize this effect and we looked at separate UF and hemodialysis (HD) and also haemodiafiltration (in Ulm, Germany). I came to the conclusion that the solute that was most important was not urea but sodium since it is confined to the ECF.
We needed to increase the dialysate sodium concentration which at the time was 134 and use UF to remove sodium.  
Secondly I recommended varying the sodium concentration in the dialysate during dialysis to minimize the peak fluid shifts and derived equations to do that. I was funded in part by Fresenius and they patented the idea and built it into their dialysis machines as sodium modeling.
So now to the question. If we want to do UF separately from dialysis is it better to do it before or after HD? The disequilibrium problem reaches its peak near the beginning of HD and then drops off exponentially with time so it reaches a minimum at the end of HD. So if we minimize ultrafiltration during dialysis and remove volume by UF after completion of HD the competing fluid shifts caused by disequilibrium would be at their minimum and it should be better tolerated.
So that is the long answer to a simple question. I hope it is helpful.
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A large number of admitted patients develop to AKI and need RRT ( renal replacement therapy ) . sometimes we should not move the patient to hemodialysis ward . is there any effective and mobile hemodialysis machine in your medical center ? if yes , what is he mark ?
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In Germany, the Genius therapy method is very popular as mobile HD machine.
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Sever increase in serum iron for example in iron sucrose parenteral consumption for hemodialysis patients occasionally create iron toxicity. In this situation TIBC has false increase in colorimetric method.
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We treat a young boy (13 year old) with severe hypeparatiroidism (PTH 1700) with paricalcitol 6 ug/week. In an adult we would organize parathyroidectomy. We have some doubt about its utility and safety in adolescent boys.
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The patients with chronic renal failure have to undergo hemodialysis. These patients usually have AV fistula. The question is if the blood can be collected from this AV fistula on the beginning, during or after the end of hemodialysis in order to avoid further puncture of vein. I suppose that values like mineralogram or pH will be completely different between these two approaches. But what about drug levels? Does anyone know any study dealing with this issue?
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There is no difference of drug levels known between venous blood and blood from an arteriovenous fistula or av-shunt in hemodialysis patients. However, there can be a difference between the arterial and venous line during hemodialysis because of extracorpororeal drug elimination by hemodialysis or plasmapheresis.
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Oncology ; Nephrology ; Intensive Care ; Hematology
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It depends on indications and clinical conditions (fist of - all hemodynamic stability). What is the cause of renal failure? For example - sepsis - CRRT (hemo- or hemodiafiltration) 12-24 or more hrs. Pre-renal failure after massive blood loss and risk of haemorrhage - short-term dialysis may be better, and so on. Can anybody compare such different patients in a trial?
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can we clear a hemodialysis machine after one cycle use by a HBS+ patient ?
so that we can use the machine for HBS- patients ?
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In 1975 we had shown that sterilizing dialysis machines with acetic acid was effective for avoiding the dissemination of HBs virus from patient to patient.
An electron microscopic study of viral particles showed that acetic acid induced a lysis of the central core.
Of course you can't demonstrate anything on one kidney machine, but if the manufacturer agrees I'd sterilize the contaminated machine with acetic acid.
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I have studied the immunological status in hemodialysis patients , I want to investigate such relation .
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Thanks for you all ... I have benefited very much 
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what is the differences in complications of Isolated UF and Hemodialysis ?
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Hi Jahanzaib
Mainly pass water so solutes concentration increases. 
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We use different concentrations of bicarbonate for each patient . How often should we check ABG (arterial blood gases)?
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serum total CO2 is not enough. In hemodialysis patients mixed acidbase disorders are not so rare as commonly thought (see Yamamotho AJKD few months ago), hence Arterial blood gas analysis are needed. I agree that there are not guidelines. I check BGA every 2 - 3 weeks in the first months, then I feel 2-months checking in chronic patients allows to have the goal
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for age group >60 years old
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Adherence to prescribed oral medication in adult patients undergoing chronic hemodialysis: A critical review of the literature
H Schmid, 1 B Hartmann,2 and H Schiffl1
Abstract
Objective
Poor adherence to complex multimodal therapies is a widely recognized problem in the daily care of dialysis patients, contributing to excess morbidity and mortality of this population. While a few studies have been devoted to understanding patient nonadherence, their results were somewhat controversial. The goals of this review are to quantify nonadherence to certain oral medications, to raise awareness of factors that may cause problems in a patient's adherence to this treatment, and to describe strategies that may be used to improve adherence to prescribed pharmacotherapy.
Methods
A systematic literature review in the MEDLINE and PubMed database (1971-2008) was performed. Quantitative studies, which accurately indicated the total percentages of nonadherence to oral medication in adult patients receiving chronic hemodialysis, were identified.
Results
A total of 19 studies fulfilled the search criteria. Rates of nonadherence to the oral medication ranged from 3 - 80%. More than half of the included studies reported nonadherence rates of ≥ 50% (mean 67%). The use of phosphate binding therapy was the prevalent surveyed oral medication. Self reports, structured interviews, and predialysis serum phosphate levels were the most frequent assessment tools used to record adherence rates. Limitations of the reviewed studies included small patient cohorts, inconsistent definitions of adherence, and a lack of standardized methods for measuring nonadherence.
For more please read at following link.
Regards
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I would like to know is it necessary to  have bacteremia  if patient is diabetic / is there any association between bacteremia and diabetic patients requiring hemodialysis? Can anyone provide me link related to this findings?
Is it possible to have bacteremia in non- diabetic patients more than diabetic patients who are under hemodilaysis course?
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Thank you.
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Hi
Please have a look at following attached link, you'll find answer for your question.
Best wishes
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I am mainly looking at why we are experiencing flow problems with our catheters. Is it the brand of the catheter or is it the technique of inserting them?
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Failure of a permanent (cuffed) CVC can be either immediate (manifested by inability to provide blood flow of at least 300 ml/min during the first postinsertion HD session - see the K/DOQI guidelines) or late. For the latter case, the gradually deteriorating performance of the CVC can be evaluated by measuring pressure/flow characterics of both its arms - see eg. Besarab A, Pandey R: Catheter Management in Hemodialysis Patients: Delivering Adequate Flow. Clin J Am Soc Nephrol, 2011; 6:227-234). With such measurements being done in regular, say one month intervals, it is possible to try some cleaning procedure to remove the fibrin sheet or clots inside the CVC before it gets completely clotted.
F. Lopot, Prague
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Would standardizing coding utilizing accessory modifiers that better describe and discriminate dialysis-related hypotensive episodes improve risk prediction models, result in effective escalation and mitigation strategies, strengthen problem-solving approaches, enhance comparative research, and reduce repeat preventable harm to patients?
Validated research over time may prove that a more stratified hemodialysis hypotension classification will reliably predict impending doom, and effectively crack the code to prevent failure mode.
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capturing and categorizing hypotension episodes during hemodialysis sessions is mandatory in care of patients on hemodialysis.
Analysing that data to dig the causes and practices and setting strategies and guidelines will definitely improve standard of care in any institute.  
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 A 59 yrs old Woman coming to Conventional hemodialysis session, presenting Itching since 2 week, resistant to habitual treat. Please any suggestions.
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If the problem is limited to hemodialysis then our esteemed colleagues have provided useful suggestions. I would suggest to ensure higher kt/v target. This again will be a daunting task as such patients do not tolerate and sign off early. Additional possibilities to consider will be histamine / mast cell disorders. Look for dermatographism and response to H2 receptor blocker in combination with H1 blocker. Wishing you success in managing this difficult case!
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Calcium, Vit.D and phosphate balance is of critical importance in both health and disease. Particularly, patients who are undergoing haemodialysis, are prone to disturbances in calcium and phosphate homeostasis. What are the drugs that should be used with caution / and /or avoided in patients who are undergoing haemodialysis which may further compromise calcium and phosphate metabolism/equilibrium? 
What are the underlying mechanisms by which these drugs affect calcium homeostasis in haemodialysis patients? 
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All the patients undergoing to a dialysis  treatment undergo to medical treatment using variable forms and doses of Vitamin D directed to prevent the  calcium disorders and the consequent bones lesions : and this treatment cold also be the cause of a calcium/phosphate failed balance. Furthermore the treatment based on the inhibitors of the phosphate gut reabsorption could have the same result  
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In one of my researches, I studied anxiety and depression in hemodialysis patients. But I want to know how much stress and depression can affect on CKD progress? What is your opinion or answer about this question?
Regards,
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Dear Nader, 
Some papers on the issue: 
Am J Kidney Dis. 2009 Sep; 54(3): 433–439.
Validation of Depression Screening Scales in Patients With CKD
S. Susan Hedayati, MD, MHSc, Abu T. Minhajuddin, PhD, Robert D. Toto, MD, David W. Morris, PhD, and A. John Rush
Association of frailty and physical function in patients with non-dialysis CKD: a systematic review
Simon R Walker, Kamalpreet Gill, Kerry Macdonald, Paul Komenda, Claudio Rigatto, Manish M Sood, Clara J Bohm, Leroy J Storsley, Navdeep Tangri
BMC Nephrol. 2013; 14: 228.
Social Environmental Stressors, Psychological Factors, and Kidney Disease
Marino A. Bruce, Bettina M. Beech, Mario Sims, Tony N. Brown, Sharon B. Wyatt, Herman A. Taylor, David R. Williams, Errol Crook
 J Investig Med. 2009 April; 57(4): 583–589.
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there are some types of fluid for hemofiltration .can we use ringer lactate as subsitution fluid?
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Many critical care centres in Australia and New Zealand would use the ready-made bicarbonate-buffered large bags (5L) of replacement/substitution fluid for haemofiltration. This may be partly because they have been used in clinical trials in which they have participated, but also because the bicarb’ buffered bags are appropriate for use in patients with reduced lactate metabolism (severe liver failure etc), as well as almost all other critically ill patients with Acute Renal Failure.
Lactate-based solutions can also be used in critical care patients requiring CRRT but in patients with lactic acidosis/severe liver failure they have been shown not to be indicated (HP Kierdorf et al. 1999) hence the preference for bicarb’-based fluids.
Ringer’s lactate has a similar electrolyte content to the ready made large bags, and could potentially be used as substitution fluid, as long as you have in mind the relatively high lactate content depending on patients' electrolyte needs. I have only seen this fluid by the litre in which case it could be inconvenient , compared to the less labour intensive larger bag sizes.
Hope that helps
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Many problems occur in hemodialysis patient life style? Is there any qualitative study about hemodialysis patient life style?
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Kjellstrand et al. and some canadian authors have done quite a few studies on quality of life in dialysis patients comparing conventional and daily dialysis in the years 2000 - 2004. Maybe you will find them under daily dialysis. IWhen i have time I will look them up, too.
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Periodic testing for HDV infection by anti-HDV antibody in HBsAg positive carriers on chronic hemodialysis treatment is recommendable. Reduction of HBV infection in HD patients would be the best solution to control the HDV infection in HD patients. The transmission of HDV infection between HBV infected in HBs Ag positive carriers on chronic hemodialysis is very critical. Is dedication of HDV/HBV machines and infected patients in HD centers a standard strategy or not? It is obvious that the HDV infection in HD patients has been forgotten! There is an apparent lack of attempts to conduct more investigations and create definite protocols to reduce the incidence of HDV infection in HD patients. The global attempt should start soon. Tomorrow is too late!
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No,There is not nessesary
thanks a lot
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is there a risk of transmission of hepatitis B from this patient if he is on negative HBsAG machine?
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If any case with chronic HBV infection (HBs Ag positive more than 6 months) serocovert to HBs Ag negative and anti HBs Ab positive and HBV DNA negative, we can transfer the case from HBV positive devices to HBV negative devices in dialysis setting. However the dialysis patients in all times should vaccinate against HBV infection and follow for ant HBs Ab too.
Yours
Alavian SM
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Raymond vanholder.
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Dear Raymond,
The most cost-effective option perhaps is using a flow regulator, keeping automatically the dialysate flow 1.2 times the bloodflow. (Reference Kult J and Stapf E.: Changing emphasis in modern hemodialysis therapies. Cost-effectiveness of delivering higher doses of dialysis. Int J Artif Organs 2007; 30: 577-582)
With best regards:
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Or any topic near to patient to other patients education in chronic disease?
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Here's a link to an overview, with additional links and contact info.
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for example for a patient with bicarbonate level of 9 mmol and pH 6.80 how many bicarbonate profile can be useful and safe?
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Dear Ramin, I think that your question is not easy to answer without other parameters of ABG and the underlying eatiology of the acidosis.
Usually CKD patients present with high ion gap metabolic acidosis and many experts recommend to treat the cause of acidosis rather than using alcalinisation. In any case rising rapidly the patient's bicarb level during the first dialysis hour can be deleterous.
In one paper by US Noh et al (Electrolyte and Blood Pressure, 2007) they reduced safely the dialysate bicarbonate level up to 25 mEq/L in hemodialysis patients with severe metabolic acidosis.
I would just advice (in case of any other dialysis indication) to raise your patient's pH progressively using other classical methods and to go for hemodialysis once you are near 20 mmol/l of serum bicarbonate.
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I check VBG and change the bicarbonate concentration for hemodialysis patients . How often should i check VBG . and how often should i change the bicarbonate concentration in dialysate fluid ?
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We control hypokaliemia , that is the principal cause of sudden cardiac dead , using 3 mmol /l K+ and 1.25 mmol/l Ca++ in dialysate . Vascular calcifications depend on many factors and alkalosis is not the main  factor . My experience  began many years ago and vascular calcifications are the minor problem with respect to malnutrition linked to prolonged acidosis .
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I mean is it necessary to prescribe HBIG to other HBs Ag- patients? Or should inside of dialysis machine which has been used for HBs Ag+ patient be opened and washed?
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Yes, I will also recommend to use standard disinfection protocols for all machines.
Using separate rooms will probably reduce the risk of patient-to-patient  contamination through medical staff. Isolating machines for Ag HBs patients is still controversial.
However, I use to say that continuous training of caregivers to respect standard aseptia rules during the whole care process is the easiest and most effective way to prevent all these nosocomial infections
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In Nephrovit (the multivit tablet for dialysis patients ) there is only 500 micro gr to 800 micro gr folic acid but in some paper they recommend 5 to 15 mg folic acid per day . is there any need to add tab folic acid 5 mg to nephrovit or the folic acid in nephrovit is enough ?
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5 and up to 10 mg/day should be sufficient to treat the deficiency.
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Is there any differences between Isolated UF in hemodialysis  and SCUF and CVVH without subsittution in CRRT ?
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Dear Ramin,
In brief,
SCUF is process of removing fluid but does not allow for significant solute clearance. It is typically used for volume overloaded patients with or without renal failure, such as congestive heart failure patients refractory to diuretics.
In CVVH the solutes are removed by convection; no dialysate is used.  Typically ultrafiltration rates of 1 to 2 L/hour are used. 
IN CVVH, you have much higher ultrafiltration rate, therefore you will have more convection and receive clearance of solute.
IN SCUF, you have only small amount of ultrafiltration, therefore, you do not have significant solute clearance, just only volume removal.
Another point is CVVH, you also correct electorlytes and acid-base by replacement fluid.
Best regards,
Wisit
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if they need ZINC , how much ?
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Dear Ramin,
Administration of zinc improved appetite loss, dry mouth, nausea, and hypogeusia,
while incidence of these symptoms increased in control group.
As shown in this following study:
The dose that was used is 100 mg.
Hope this helps!
Best regards,
Wisit
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Can we relay on HIV Ab and HCV Ab result , to diagnose HIV and HCV while we know ESRD patients are immune compromised?
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Sorry for late answering. May be the below paper can help you for the prevalence of HCV in immunocompromised patients. Wafaa M. El-Emshaty, Douaa Raafat, Doaa M. Elghannam, Niveen Saudy, Ehab E. Eltoraby, Abd Elhameed A. Metwalli. DIAGNOSTIC PERFORMANCE OF AN IMMUNOASSAY FOR SIMULTANEOUS DETECTION OF HCV CORE ANTIGEN AND ANTIBODIES AMONG HAEMODIALYSIS PATIENTS. Brazilian Journal of Microbiology (2011) 42: 303-309
For HIV  you must use PCR.
Best regard.
Nouhoum Bouaré
PH PhD, CNAM Bamako
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dialyzer size - pump speed - dialysate speed - max Ultrafiltration and the relation with sex - age - BMI and cardiac health 
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There are some individual parameters which must be set for each particular patient (dialysis time, blood flow, heparin dose, sodium and bicarbonate concentration, substitution volume if you use HDF) or even for each dialysis session (volume to be ultrafiltered). There are a few "rules of thumb" with which you can start and later adjust according to the results:
Dialysis session time should not be less then 4 hours
Blood flow should be high enough to give total processed blood volume equal or higher than body weight
Sodium concentration about 3 mmol/l higher than patient predialysis plasma value
Bicarbonate concentration i dialysate - start with 30 mmol/l is safe.
UF rate should not generally exceed 10 ml/hour/kg of body weight
If you use unfractionated heparin you can start with bolus of 50 iu per kg of body weight and then 300 iu/hour as an infusion. This will certainly need adjustment - you have to look to bleeding time after removal of needles and to the dialyzer appearance (how many fibres are clotted) after rinse back.
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Is there equal negative pressure ?
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CVVHDF = Continuous veno-venous hemodiafiltration
CVVHFD = Continuous veno-venous high flux dialysis
Basically, CVVHDF uses both replacement fluid and dialysate, but CVVHFD uses dialysate only (no replacement fluid).
Hope this helps!
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I have a patient with active ankylosing spondylitis(AS) and second (2007;2012) kidney transplantation (due to chronic glomerulonephritis). Ankylosing spondylitis is active with BASDAI . 5,5 -  6,0 during last 3 years, CRO changes from 11 - 25 mg/l (normal value 0 - 5 mg/l), spine ligament calcification has found in 3 cervical and lumbar spine ligaments  on X- ray. Due to kidney transplantation the patient use MMF and prednisolone. 
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I am unaware of any published reports on the concomitant use of a TNF inhibitor and mycophenolate mofetil in AS. It would seem reasonable to try this combination while monitoring closely for any potential adverse events in your patient. Before attempting this treatment regimen, I advise consulting with your local renal transplant colleagues.
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How much weight gain is acceptable between hemodialysis cycles for ESRD patients?
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EDTNA/ERCA guidelines say that by consensus the IDWG should be no more than 4% of patients dry weight or between 1.5-2.0kg. In life threatening fluid overload the safest way to remove large volumes of fluid is using iso uf as above but no more than 1000ml over half an hour with very close monitoring.
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lower and upper limit of BP for starting hemodialysis?
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Dear marano 
thanks alot
usually we have drop in BP but sometimes due to excess renin excretion we have increase in BP . 
But I want to know is there any cutoff in high BP that we have to use IV nitroglycerine or other antihypertensive drugs before starting hemodialysis ?
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Thanks for all the great replies from great Professors , I would like to give more information about that real life challenging case. 63 years old lady suffering of DM,HTN and ESRD on regular hemodialysis. She had a coronary stent(DES) 7 months before hospital admission.She presented to ER suffering of heamatemsis and melena and upper endoscopy done revealed reflux esophagitis.During hospital stay ECG showed depressed ST segment on v1-v3 leads and her serial troponin I showed rising levels but there was no chest pain. She was receiving aspirin , clopidogrel, statin , ACEi , B blocker and insulin. Upon examination she was HD stable , in sinus rhythm, with no evidence of heart failure or murmurs.
After stoppage of bleeding GRACE /Crusade scores were measured to assess risk of bleeding and that of cardiovascular events.She has 30% risk of death in 6 months on GRACE score and and risk of 30% of in hospital major bleeding. Conservative medical or early invasive therapy?
1)What do you think is the best management in this patient...keeping in mind that under treatment increases risk of death and cardiac complications with a probably stenosed coronary stent while aggressive treatment is associated with risk of death from significant bleeding.
2)Are there any guidelines or a consensus regarding management of such challenging cases ?
3)If you choose the medical therapy when can we start anticoagulants and platelets after stoppage of bleeding?
Waiting to hear  valuable inputs from my professors and colleagues....Thank you
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99% agree with my colleagues. First endoscopic study to filiate origin of the bleeding, then is mandatory to do a programmed coronary angiography. Once you know the etiology of the bleeding and its possible  solution you can decide an antiagregation therapy (if possible, perhaps only LMWH?). Regards
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The use of pre-blood fluid in the reduction of filter clotting in dialysis is well known, but it is also known to reduce the efficiency of the dialysis abilities.
Could you please explain how your unit overcomes the drawback of the use of pre-blood fluid, and how the use of Filtration Fraction determines the use of pre-blood fluid? Some units determine that pre-blood fluid is not needed if the Filtration Fraction is below 30%. 
Does this not then save the unit money if pre-blood fluid is not used? Also, it has been stated that in the use of Heparin in Dialysis, the APTT is irrelevant in the ability to stop the filter clotting off. What APTT therapeutic range does your unit run at?
Any information provided would be appreciated.
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Thank you Ali for your input on this subject, I will read them with interest.
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What is the real risk of central vein stenosis after short term renal replacement therapy in a critical care unit?
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Just say hello and attach an article source for you to browse
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For the past two or three weeks, we've noted a number of cases of vascular access bleeding after dialysis. The dose of the anticoagulant used not changed.
What are the possible and common reasons for this?
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The two main reasons for access vascular bleeding at the end of dialysis session are either excessive anticoagulation of the session or a stenosis on the venous site of the fistula
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We have a middle aged male on dialysis who is now transfusion dependant for pure red cell aplasia (PRCA), most likely antibody mediated due to Aranesp. Would anyone undertake renal transplantation and if so what are the caveats? NB the literature is variable on this topic-some successes, some failures.
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Hi Vicky
Yes you have read it correctly, the patient concerned has antibodies to the ESA.
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Primary methods of hemodialysis took more than 12 hours time.
Progress in dialysis led to shorter  time, about 4 hours.
Because I know already some complications associated with hemodialysis is a result of rapid change in blood chemistry, and on the other side the long time of dialysis is one of the major problems of dialysis patients. How new methods in future would be possible to compensate this rapid fluid removal and rapid electrolyte disequilibrium? I think restrictions from this point of view hinder decreasing in length of time and frequency of dialysis in future.
Any ideas would be greatly appreciated
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I think that by now we should not keep dialysis time under 4 hours
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Is one protein for each activity enough?
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Thanks Vivekanand for your reply. 
I am looking markers for both formation and resoprtion and also for chondrogenic phenotype only. I understand that Bone Specific ALP is for bone formation. Any markers that will be expressed in in vitro cultured cells such Runx-2/cbfa-1, smad, BMPs etc will be great that could be detected with western blotting or Elisa.
Thanks Again. 
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What are the mechanisms by which the fistula closes spontaneously post kidney transplant?
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Improvement in coagulation system
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Our results showed that high prevelence among haemodialysis patients
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Yes, principally in some countries
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More often, the veins are deep and in order to make them easily accessible requires big surgical wounds with the associated morbidity of wound infections and breakdown. Using a prosthetic graft makes the conduit accessible, often through small wounds.
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Keep it simple and break the access project into two staged procedures whenever possible and your life will be much easier, I promise. Stage 1: create the fistula. Stage 2: superficialize it. Today I usually do a simple elevation, creating a 10 cm cannulation segment.
  I tell you this having done 13 fistula liposuctions, 20 lipectomies, A hundred or two  transpositions with new tunnels or big flaps, and 6 venous window needle guides
Keep it simple!
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