Yassir Zajjari

A model to predict optimal dialysate flow.

Diffusive clearance depends on blood (Qb) and dialysate flow (Qd) rates and the overall mass transfer area coefficient (KoA) of the dialyzer. In this article we describe a model to predict an appropriated AutoFlow (AF) factor (AF factor = Ratio Qd/Qb), that is able to provide adequate Kt/V for hemodialysis patients (HDP), while consuming lower amounts of dialysate, water and energy during the treatment. We studied in vivo the effects of three various Qd on the delivered dose of dialysis in 33 stable HDP. Hemodialysis was performed at Qd of 700 mL/mn, 500 mL/mn, and with AF, whereas specific dialysis prescriptions (treatment time, blood flow rate [Qb], and type and size of dialyzer) were kept constant. The results showed that increasing the dialysate flow rate more than the model of AF predicted had a small effect on the delivered dose of dialysis. The Kt/V (mean ± SD) was 1.52 ± 0.16 at Qd 700, 1.50 ± 0.16 at Qd 500, and 1.49 ± 0.15 with AF. The use of the AF function leads to a significant saving of dialysate fluid. The model predicts the appropriate AF factor that automatically adjusts the dialysate flow rate according to the effective blood flow rate of the patient to achieve an appreciable increase in dialysis dose at the lowest additional cost.

La néphropathie non diabétique chez les patients diabétiques de type 2 à l'hôpital militaire Mohammed V de Rabat (Maroc)

: The distinction between diabetic nephropathy lesions and non-diabetic renal lesions is not always obvious and is often based on renal biopsy. This study evaluated the prevalence and predictors of nondiabetic renal disease in people with type 2 diabetes. The study was conducted between January 2008 and October 2010 in the nephrology department of the military hospital in Rabat. The study included 16 patients with type 2 diabetes in whom renal biopsy was indicated. Non-diabetic renal disease was found in 6 of the patients (37.5%); IgA nephropathy was the most frequent non-diabetic renal disease (half of non-diabetic renal diseases). Hypertension was significantly less frequent in the non-diabetic renal disease group than the diabetic nephropathy group (16.7% versus 80.0%, P = 0024), duration of diabetes was a shorter (4.5 versus 15.5 years, P = 0.022) and diabetic retinopathy was absent (100% versus 40%, P = 0.026). There were no statistically significant differences between the 2 groups in relation to age, sex, creatinine level, 24-hour proteinuria, nephrotic syndrome and microscopic haematuria.

Quantification of hemodialysis dose: what Kt/V to choose?

Background Quantification of hemodialysis became more accurate and easier after the advent of ionic dialysance and the use of methods for estimating urea distribution volume (V). The aim of this study was to compare different methods of hemodialysis dose assessment: Kt/VDau (Daugirdas 2nd generation), Kt/VOCM (Kt by OCM (Online Clearance Monitor) and V by Watson), and Kt/VBCM (Kt by OCM and V by bio-impedance); and to assess the dialysis adequacy, defined by a Kt/V≥1.4. Design Prospective, observational study. Methods 35 hemodialysis sessions were evaluated in 35 chronic hemodialysis patients. During each session, we measured simultaneously, Kt/VOCM, Kt/VBCM and calculated Kt/VDau by performing blood samples before and after each session. Results 35 patients, gender (M/F: 19/16), mean age of 50.49 years, were evaluated. We noted a difference between the three methods of evaluating Kt/V index: Kt/VDau, Kt/VOCM and Kt/VBCM (1.82 ± 0.29; 1.45 ± 0.23; 1.8 ± 0.33, p<0.001). Comparison of Kt/VOCM with Kt/VDau and Kt/VBCM leads to a significant systematic underestimate of Kt/V by 22% and 20.5% respectively. Better agreement between Kt/VDau and Kt/VBCM was observed. The adequate hemodialysis was achieved, according to three methods: Kt/VDau, Kt/VOCM and Kt/VBCM respectively in 100%, 57,1% and 88.6% of the cases. Conclusions The Kt/V index is different depending on the method used for its evaluation. The three methods can be used for quantification of hemodialysis with a better agreement between Kt/VDau and Kt/VBCM. In this study, Kt/VOCM results underestimate hemodialysis efficiency. This difference has to be considered when applying quantification of hemodialysis to clinical practice.

The Kt/V by ionic dialysance: Interpretation limits.

The availability of hemodialysis machines equipped with online clearance monitoring (OCM) allows frequent assessment of dialysis efficiency and adequacy without the need for blood samples. Accurate estimation of the urea distribution volume (V) is required for Kt/V calculated from OCM to be consistent with conventional blood sample-based methods. A total of 35 patients were studied. Ionic dialysance was measured by conductivity monitoring. The second-generation Daugirdas formula was used to calculate the Kt/V single-pool (Kt/VD). Values of V to allow comparison between OCM and blood-based Kt/V were determined using Watson formula (VWa), bioimpedance spectroscopy (Vimp), and blood-based kinetic data (Vukm). Comparison of Kt/Vw ocm calculated by the ionic dialysance and Vw (Kt/Vw ocm) with Kt/VD shows that using VW leads to significant systematic underestimation of dialysis dose by 24%. Better agreement between Kt/V ocm and Kt/VD was observed when using Vimp and Vukm. Bio-impedancemetry and the indirect method using the second-generation Daugirdas equation are two methods of clinical interest for estimating V to ensure greater agreement between OCM and blood-based Kt/V.

Gastrointestinal bleeding due to angiodysplasia in patients on hemodialysis: A single-center study.

Gastrointestinal (GI) bleeding due to angiodysplastic lesions is a common problem among patients receiving hemodialysis (HD). We studied 22 HD patients (5 females and 17 males) who had GI bleeding due to angiodysplasia; the mean age of whom was 54 ± 10 years. All patients had upper and lower GI endoscopy. The most common site for the lesion was the right colon in seven cases (31.8%), followed by stomach in 4 cases (18.1%). In eight (36.3%) patients, there were multiple lesions located in the stomach, duodenum, and the right colon. All patients were treated with coagulation; with argon plasma in 14 (63.6%) patients, bipolar coagulation in five (22.7%) patients, and hot clip in three (13.6%) patients. One patient who presented with persistent bleeding despite endoscopic therapy was well-benefited of a complementary treatment, thalidomide. Hemostasis was obtained in all patients after an average of 6.8 sessions of endoscopic coagulation procedure. We conclude that angiodysplasia is a frequent cause of hemorrhage in chronic renal failure that can be managed in most patients by argon plasma and bipolar coagulation.

Serum tumor markers in hemodialysis patients

Aims The main objective of this work was to evaluate the influence of end-stage renal disease (ESRD) on concentrations of five tumor markers (TMs): carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9 (CA19-9), CA15-3, CA125, and prostate specific antigen (PSA) in a group of chronic hemodialysis patients (CHPs); and to study the influence of hemodialysis (HD) sessions on concentrations of the same TMs. Methods We compared TMs levels in CHP before HD sessions to a control group of 50 healthy volunteers, the dosages were determined before and immediately after the HD session Comparisons were made before and after correction for dialysis-induced hemoconcentrations. Results We enrolled 74 CHPs, all TM concentrations were higher in this group compared to control group, but this increase was significant for CEA (4.25 ± 2.89 vs 2.41 ± 1.81ng/ml; p<0.0001), CA125 (27.84 ± 92.27 vs 13.30 ± 9.85 ng/ml; p = 0.048) and CA19-9 (19.65 ± 25.02 vs 10.23 ± 11.00 U/ml; p = 0.011). Post-dialysis levels were significantly higher than those in pre-dialysis. CEA (3.35 [2,46-5.51] vs 4,06 [2.60-6.78] ng/ml; p<0.0001), CA125 (13.24 [9.66-18.63] vs 16.01 [11.33-22.53] ng/ml; p<0.0001), CA19-9 (12.29 [5.59-21.97] vs 16.29 [7.18-24.7] U/ml; p<0.0001), CA15-3 (13.06 [10.05-17.48] vs 14.58 [11.72-19.35] ng/ml; p<0.0001 and PSA (0.83 [0.5-1.24] vs 1.06 [0.62-1.43] ng/ml; p<0.0001). Conclusions Our work confirms that HD increases concentrations of the five TMs evaluated and suggests that the use of CA15-3 and PSA remains valid in CHPs since their concentrations were not altered by ESRD, unlike CEA, CA125, and CA19-9.

Insuffisance rénale aiguë révélant une hypothyroïdie auto-immune

Although the clinic picture is often indicative of muscle manifestations in patients with hypothyroidism, signs and symptoms of this condition are variable from simple elevation of serum muscle enzymes with myalgia, muscle weakness, cramps to rhabdomyolysis with acute renal failure which remains a rare event. Thyroid hormones affect the function of almost every body organ, and thyroid dysfunction produces a wide range of metabolic disturbances. Hypothyroidism is associated with significant effects on the kidney which the pathophysiology seems to be multifactorial, but the exact mechanisms remain poorly understood. Hypothyroidism as a cause of renal impairment is usually overlooked, leading to unnecessary diagnostic procedures. The main objective of our observation is to report a case of acute renal failure revealing an autoimmune hypothyroidism in which thyroid hormone substitution led to a significant improvement in muscular, thyroid and renal disorders.

Diagnostic value of NT-ProBNP for left ventricular hypertrophy in hemodialysis patients

We measured NT-proBNP levels in 30 stable patients on maintenance haemodialysis, before and after hemodialysis session with low-flux polysulfone dialyzers, all mesures were done by a third-generation assay (Elecsys Analyzer, Roche Diagnostics, Mannheim, Germany). We hypothesized that serum NT-proBNP cut-off value could serve as a biochemical marker to detect LVH in patients on haemodialysis treatment, regardless of chronic fluid overload. We assessed LV masse using trans-thoracic echocardiography, LVH was defined as an indexed left ventricular mass> 134 g/m2 in man and 110 g/m2 in woman. NT-proBNP levels increased significantly after hemodialysis sessions (5575,93 ± 5509,53 versus 4114,3856,37 ± pg/ml p<0,0001). A significant positive correlation was found between NT-proBNP level and left ventricular mass (r = 0.75, P<0.0001). NT-proBNP was significantly higher in patients with LVH: (5270,35 ± 3410,23 versus 2477,27 ± 1421,91 pg/ml P = 0,045). In the multivariate regression analysis NT-proBNP was the only independent predictor of LVH (r = 0.75, P<0.0001 Our results suggests that NT-proBNP could be a potential marker of LVH in chronic renal failure patients on hemodialysis.

Bisalbuminemia during remission of nephrotic syndrome.

The bisalbuminemia acquired outside of the long-term antibiotic treatment is an exceptional event. It is a rare condition characterised by the presence of two distinct fractions of serum albumin on electrophoresis. This anomaly reflects the presence, at the same time, of a normal albumin and a modified albumin. These changes of albumin may be related to various causes. Their association with nephrotic syndrome is exceptional. We report a case of bisalbuminemia during a period of remission of nephrotic syndrome.

Assessment of dialysis adequacy guidelines implementation in a developing country.

Dialysis adequacy has been shown to have a significant impact on patient survival, but there are few data concerning the adequacy of the delivered hemodialysis dose in developing countries. To describe the level of implementation of dialysis practice guidelines in a dialysis center in Morocco, we retrospectively reviewed our 1-year experience of managing chronic hemodialysis patients (CHP), from May 2009 to May 2010. Demographic and biochemical data were collected, and the percentage of patients achieving targets recommended by the NKF-KDOQI guidelines were calculated. Our data suggests that dialysis units in a developing country can achieve current guidelines targets for dialysis adequacy, however, our results are not generalizable to all dialysis centers in Morocco.