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WOS: 000398117600023, PubMed ID: 28025382, Background. From an individual participant data (IPD) meta-analysis from four randomized controlled trials comparing haemodialysis (HD) with post-dilution online-haemodiafiltration (ol-HDF), previously it appeared that HDF decreases all-cause mortality by 14% (95% confidence interval 25; 1) and fatal cardiovascular disease (CVD) by 23% (39; 3). Significant differences were not found for fatal infections and sudden death. So far, it is unclear, however, whether the reduced mortality risk of HDF is only due to a decrease in CVD events and if so, which CVD in particular is prevented, if compared with HD. Methods. The IPD base was used for the present study. Hazard ratios and 95% confidence intervals for cause-specific mortality overall and in thirds of the convection volume were calculated using the Cox proportional hazard regression models. Annualized mortality and numbers needed to treat (NNT) were calculated as well. Results. Besides 554 patients dying from CVD, fatal infections and sudden death, 215 participants died from 'other causes', such as withdrawal from treatment and malignancies. In this group, the mortality risk was comparable between HD and ol-HDF patients, both overall and in thirds of the convection volume. Subdivision of CVD mortality in fatal cardiac, non-cardiac and unclassified CVD showed that ol-HDF was only associated with a lower risk of cardiac casualties [0.64 (0.61; 0.90)]. Annual mortality rates also suggest that the reduction in CVD death is mainly due to a decrease in cardiac fatalities, including both ischaemic heart disease and congestion. Overall, 32 and 75 patients, respectively, need to be treated by high-volume HDF (HV-HDF) to prevent one all-cause and one CVD death, respectively, per year. Conclusion. The beneficial effect of ol-HDF on all-cause and CVD mortality appears to be mainly due to a reduction in fatal cardiac events, including ischaemic heart disease as well as congestion. In HV-HDF, the NNT to prevent one CVD death is 75 per year., EuDial working group; European Nephrology and Dialysis Institute; Catalan Society of Nephrology; Fresenius Medical Care; Dutch Kidney Foundation [C02.2019]; Fresenius Medical Care, Netherlands; Gambro Lundia AB, Sweden; Dr E.E. Twiss Fund; International Society of Nephrology/Baxter Extramural Grant Program; Netherlands Organization for Health Research and DevelopmentNetherlands Organization for Health Research and Development [170882802]; national grant from the Health Ministry (Programme Hospitalier de Recherche Clinique, PHRC); Gambro through the Catalan Society of Nephrology; Roche Netherlands, The HDF Pooling project was designed, conducted and analysed independently of the financial contributors of the individual studies as listed below. Study data were collected and retained by the investigators and were not available for the financial contributors of the individual studies. S.A.E.P. and the meetings of the representatives of the combined authors of the four studies were financially supported by the EuDial working group. EuDial is an official working group of the European Renal Association-European Dialysis Transplant Association (ERA-EDTA, http://era-edta.org/eudial/European_Dialysis_Working_Group.html). No industry funding was received for any part of or activity related to the present analysis.; The Turkish HDF study was supported by European Nephrology and Dialysis Institute with an unrestricted grant. The study was performed in Fresenius Medical Care haemodialysis clinics in Turkey. ESHOL was supported by The Catalan Society of Nephrology and by grants from Fresenius Medical Care and Gambro through the Catalan Society of Nephrology. The CONTRAST study was supported by a grant from the Dutch Kidney Foundation (Nierstichting Nederland Grant C02.2019), and unrestricted grants from Fresenius Medical Care, Netherlands, and Gambro Lundia AB, Sweden. Additional support was received from the Dr E.E. Twiss Fund, Roche Netherlands, the International Society of Nephrology/Baxter Extramural Grant Program, and the Netherlands Organization for Health Research and Development (ZONMw Grant 170882802). The French HDF study was supported by a national grant from the Health Ministry (Programme Hospitalier de Recherche Clinique, PHRC) as a means to improve care and outcome of elderly chronic disease patients.

Background. From an individual participant data (IPD) meta-analysis from four randomized controlled trials comparing haemodialysis (HD) with post-dilution online-haemodiafiltration (ol-HDF), previously it appeared that HDF decreases all-cause mortality by 14% (95% confidence interval 25; 1) and fatal cardiovascular disease (CVD) by 23% (39; 3). Significant differences were not found for fatal infections and sudden death. So far, it is unclear, however, whether the reduced mortality risk of HDF is only due to a decrease in CVD events and if so, which CVD in particular is prevented, if compared with HD. Methods. The IPD base was used for the present study. Hazard ratios and 95% confidence intervals for cause-specific mortality overall and in thirds of the convection volume were calculated using the Cox proportional hazard regression models. Annualized mortality and numbers needed to treat (NNT) were calculated as well. Results. Besides 554 patients dying from CVD, fatal infections and sudden death, 215 participants died from 'other causes', such as withdrawal from treatment and malignancies. In this group, the mortality risk was comparable between HD and ol-HDF patients, both overall and in thirds of the convection volume. Subdivision of CVD mortality in fatal cardiac, non-cardiac and unclassified CVD showed that ol-HDF was only associated with a lower risk of cardiac casualties [0.64 (0.61; 0.90)]. Annual mortality rates also suggest that the reduction in CVD death is mainly due to a decrease in cardiac fatalities, including both ischaemic heart disease and congestion. Overall, 32 and 75 patients, respectively, need to be treated by high-volume HDF (HV-HDF) to prevent one all-cause and one CVD death, respectively, per year. Conclusion. The beneficial effect of ol-HDF on all-cause and CVD mortality appears to be mainly due to a reduction in fatal cardiac events, including ischaemic heart disease as well as congestion. In HV-HDF, the NNT to prevent one CVD death is 75 per year.

La implantación del proceso de planificación anticipada de cuidados y del documento de voluntades anticipadas (DVA) es escasa en España. Por este motivo, el Grupo de Ética y Nefrología de la Sociedad Española de Nefrología (S.E.N.) elaboró una encuesta para conocer la opinión de los pacientes en programa de diálisis sobre el DVA y otras situaciones relacionadas con el fin de la vida. Los pacientes recibieron documentación explicativa sobre la naturaleza y significado del DVA y un cuestionario sobre su conocimiento y aceptación. Se recogió su punto de vista sobre diversos aspectos relacionados con el fin de la vida. La encuesta se realizó en siete unidades de diálisis hospitalarias con un total de 416 pacientes en diálisis en activo. El cuestionario se entregó a 265 pacientes, 154 contestaron la encuesta, el 69,2% respondió sin ayuda. El grado de implantación del DVA era muy bajo (7,9%) y también la designación de representante (6,6%). Los pacientes tenían una idea muy clara sobre sus deseos ante situaciones como coma irresoluble, estado vegetativo, demencia irreversible y enfermedad grave no tratable y más de un 65% no deseaban que se les aplicaran ventilación mecánica, alimentación por sonda, diálisis o maniobras de resucitación en caso de parada cardiorrespiratoria. Muchos opinaron que el DVA podría hacerse antes de comenzar el tratamiento de diálisis, pero la mayoría consideró que sólo debería ofrecerse a aquellas personas que lo pidieran (el 65 frente al 34%). En conclusión, los pacientes en diálisis tienen una postura bastante definida ante diversas situaciones asociadas con el fin de la vida, sin embargo esta voluntad no está reflejada documentalmente debido a la escasa implantación de los DVA. Advance care planning (ACP) and the subsequent advance directive document (ADD), previously known as "living wills", have not been widely used in Spain. The Ethics Group from the Spanish Society of Nephrology has developed a survey in order to investigate the opinion of dialysis patients regarding the ADD and end-of-life care. Patients received documentation explaining ACP and filled out a survey about their familiarity with and approval of the ADD. Seven hospital dialysis centres participated in the study for a total of 416 active dialysis patients. Questionnaires were distributed to 263 patients, 154 of which answered (69.2% completed them without assistance). The rates for ADD implementation (7.9%) and designation of a representative person (6.6%) were very low. Most of the patients clearly expressed their wishes about irreversible coma, vegetative state, dementia and untreatable disease. More than 65% did not want mechanical ventilation, chronic dialysis, tube feeding or resuscitation if cardiorespiratory arrest occurred. They reported that an ADD could be done before starting dialysis but most thought that it should be offered only to those who requested it (65% vs 34%). In conclusion, patients have clear wishes about end-of-life care, although these desires had not been documented due to the very low implementation of the ADD.

La implantación del proceso de planificación anticipada de cuidados y del documento de voluntades anticipadas (DVA) es escasa en España. Por este motivo, el Grupo de Ética y Nefrología de la Sociedad Española de Nefrología (S.E.N.) elaboró una encuesta para conocer la opinión de los pacientes en programa de diálisis sobre el DVA y otras situaciones relacionadas con el fin de la vida. Los pacientes recibieron documentación explicativa sobre la naturaleza y significado del DVA y un cuestionario sobre su conocimiento y aceptación. Se recogió su punto de vista sobre diversos aspectos relacionados con el fin de la vida. La encuesta se realizó en siete unidades de diálisis hospitalarias con un total de 416 pacientes en diálisis en activo. El cuestionario se entregó a 265 pacientes, 154 contestaron la encuesta, el 69,2% respondió sin ayuda. El grado de implantación del DVA era muy bajo (7,9%) y también la designación de representante (6,6%). Los pacientes tenían una idea muy clara sobre sus deseos ante situaciones como coma irresoluble, estado vegetativo, demencia irreversible y enfermedad grave no tratable y más de un 65% no deseaban que se les aplicaran ventilación mecánica, alimentación por sonda, diálisis o maniobras de resucitación en caso de parada cardiorrespiratoria. Muchos opinaron que el DVA podría hacerse antes de comenzar el tratamiento de diálisis, pero la mayoría consideró que sólo debería ofrecerse a aquellas personas que lo pidieran (el 65 frente al 34%). En conclusión, los pacientes en diálisis tienen una postura bastante definida ante diversas situaciones asociadas con el fin de la vida, sin embargo esta voluntad no está reflejada documentalmente debido a la escasa implantación de los DVA.

The atheroembolic disease is an entity characterized by obstruction of multiple small arteries by cholesterol crystals. The incidence rises steeply with advancing age and following an invasive procedure involving arteries in patients with atherosclerosis. Actually it has a growing interest due to the increased frequency and to the lack of appropriate therapy. In this paper we report a clinical case of multiple system disease secondary to anticoagulant therapy in a 69 years old patient. We review the pathogenesis, clinical features, laboratory dates and pathology of the disease

To ensure our patients are receiving an adequate dose in every dialysis session there must be a target to achieve this in the short or medium term. The incorporation during the last years of the ionic dialysance (ID) in the monitors, has provided monitoring of the dialysis dose in real time and in every dialysis session. Lowrie y cols., recommend monitoring the dose with Kt, recommending at least 40 L in women and 45 L in men or individualizing the dose according to the body surface area. The target of this study was to monitor the dose with Kt in every dialysis session for 3 months, and to compare it with the monthly blood test. 51 patients (58% of our hemodialysis unit), 32 men and 19 women, 60.7+/-14 years old, in the hemodialysis programme for 37.7+/-52 months, were dialysed with a monitor with IC. The etiology of their chronic renal failure was: 3 tubulo-interstitial nephropathy, 9 glomerulonephritis, 12 vascular disease, 7 polycystic kidney disease, 7 diabetic nephropathy and 13 unknown. 1,606 sessions were analysed during a 3 month period. Every patient was treated with the usual parameters of dialysis with 2.1 m2 cellulose diacetate (33.3%), 1.9 m2 polisulfone (33.3%) or 1.8 m2 helixone, dialysis time of 263+/-32 minutes, blood flow of 405+/-66, with dialysate flow of 712+/-138 and body weight of 66.7+/-14 kg. Initial ID, final ID and Kt were measured in each session. URR and Kt/V were obtained by means of a monthly blood test. The initial ID was 232+/-41 ml/min, the final ID was 197+/-44 ml/min, the mean of Kt determinations was 56.6+/-14 L, the mean of Kt/V was 1.98+/-0.5 and the mean of URR was 79.2+/-7%. Although all patients were treated with a minimum recommended dose of Kt/V and URR when we used the Kt according to gender, we observed that 31% of patients do not get the minimum dose prescribed (48.1+/-2.4 L), 34.4% of the men and 26.3% of the women. If we use the Kt individualized for the body surface area, we observe that 43.1% of the patients do not get the minimum dose prescribed with 4.6+/-3.4 L less than the dose prescribed. We conclude that the monitoring of dialysis dose with the Kt provides a better discrimination detecting that between 30 and 40% of the patients perhaps do not get an adequate dose for their gender or body surface area.

The use of central catheters in hemodialysis patients as a permanent vascular access has increased during the last years, reaching numbers of around 7% of prevalent patients and between 25% of incident patients. Although the current catheters allow higher sanguineous flows with smaller incidence of infectious complications and dysfunction, the dose of dialysis that is reached is still inferior to that obtained with native arterio-venous fistula (AVF) and grafts. The aim of the present study was to evaluate the possible additional time supposed by dialysis using central venous catheters with respect to habitual vascular access as a consequence of the lesser blood flow (Qb) and the irregularity of its function (frequent lowering of the Qb and necessity of inverting the lines on many occasions). A total of 48 patients (31 men/17 women) with an average age of 61,6 +/- 14 years old (rank: 28-83), 20 with tunnelled catheter and the remaining with AVF, were included in the study. All the patients were dialyzed in the modality of high flux hemodialysis with a polisulphone of 1,9 m2 dialyzer, dialysis time of 240 minutes, dialysate flow 500 ml/min and monitors equipped with ionic dialysance (ID) with the objective of obtaining a Kt of 45 litres with each one of the different vascular accesses. The patients with AVF received 3 sessions, with variations of Qb to 300, 350 and 400 ml/min. The patients with tunnelled catheter received two sessions, to the maximum Qb, one with normal connection and other with inverted one. In the results obtained it is possible to emphasize that only the patients with AVF and 400 ml/min reached the objective of 45 L of Kt. The patients with AVF needed to increase 12 minutes of hemodialysis with a Qb of 350 ml/min and 28 minutes with a Qb of 300 ml/min; the catheters on normal position needed to increase 24 minutes and finally in the inverted catheters an increase of 59 minutes was necessary to reach the same Kt objective. We concluded that the patients dialyzed with central catheters on average needed to increase by 30 minutes the time of dialysis if the catheter worked in a normal position but 60 minutes if the arterio-venous lines were inverted so as to reach the minimum dose of dialysis.

Amyloidosis is a syndrome characterized by intercellular deposition of a predominantly proteic substance in any organ and tissue. The kidney is one of the most affected organs and very important in as much as its involvements might produce the initial manifestations of the syndrome and could be the one responsible to establish the prognosis in many cases. In this paper, the most relevant features of the different types of renal amyloidosis (glomerular, vascular and tubulo-interstitial), and one special type of amyloidosis in patients on chronic hemodialysis and likewise other interesting aspects in the evolution of amyloidosis of kidney transplanted patients were reviewed. Emphasis was placed on renal vascular amyloidosis and on amyloidosis among patients on hemodialysis as these might deserve special clinical and etiopathogenic considerations according to our own experience.

Hypertension is a very frequent complication in patients in hemodialysis. A high percentage of the patients on standard hemodialysis remain hypertense in spite of intensive pharmacologic treatment. We presented the case of a hypertense patient with difficult control in spite of antihypertensive treatment with five drugs and several secondary complications. The change to a short daily hemodialysis was successful to hypertension control and allowed a gradual suspension of drugs.