Effects of in-center daily hemodialysis upon mineral metabolism and bone disease in end-stage renal disease patients
Keywords:
Daily hemodialysis, Renal osteodystrophy, Bone diseaseAbstract
CONTEXT: Alternative hemodialysis schedules have been proposed to improve the quality of the dialysis. Nonetheless, their influence upon mineral and bone disorders is unknown. OBJECTIVE: To report the impact of a daily hemodialysis schedule upon the lesions of renal osteodystrophy. TYPE OF STUDY: Prospective non-controlled study. SETTING: Public University Hospital. PARTICIPANTS: Five patients treated by daily hemodialysis for at least 24 months. INTERVENTION: Daily dialysis sessions were accomplished with non-proportional dialysis machines without an ultrafiltration control device, with blood flow of 300 ml/min, bicarbonate dialysate ([Ca]=3.5 mEq/L) at 500 ml/min, and low-flux membrane dialyzers. Sessions were started at 6:00 p.m. (except Sundays) and lasted 2 hours. MAIN MEASUREMENTS: Serum levels of Ca and P from the last 6 months on conventional hemodialysis for the same patients were used for comparison with each semester of daily hemodialysis. Bone biopsies and PTH levels were obtained at the end of the conventional hemodialysis period and then again after 2 years of daily hemodialysis. RESULTS: Mean serum calcium was significantly higher during the second and third semesters of daily dialysis [10.0 mg% (SD 0.6), and 10.0 mg% (SD 0.8), respectively] compared to standard dialysis [9.4 mg% (SD 0.8)], p < 0.05. Mean values for phosphorus were significantly lower during every semester of daily hemodialysis [6.3 mg% (SD 1.8), 5.8 mg% (SD 1.7), 6.0 mg% (SD 1.7), and 6.0 mg% (SD 1.8)] compared to standard dialysis [7.2 mg% (SD 2.7)], P < 0.05. Variations in mean Ca x P product followed the same pattern as for phosphorus [59.5 (SD 16.0), 57.1 (SD 16.3), 59.8 (SD 17.7), and 58.31 (SD 20.9) vs. 68.6 (SD 27.3), P < 0.05]. After 2 years on daily hemodialysis, 2 patients who had aplastic lesion were found to have mild bone disorder. In addition, one patient with mixed bone lesion and moderate bone aluminum accumulation had osteitis fibrosa with no aluminum. Intact PTH values at the beginning of study and after 2 years on daily hemodialysis did not differ [134 pg/ml (SD 66) vs. 109 pg/ml (SD 26), P = 0.60, respectively]. CONCLUSIONS: Patients treated using daily hemodialysis had better control of serum phosphorus and perhaps a lower risk of metastatic calcifications. Daily hemodialysis also seemed to be beneficial to low turnover bone disease and bone aluminum deposition.
Downloads
References
Malluche H, Faugere MC: Renal bone disease 1990: an unmet challenge for the nephrologist. Kidney Int 1990;38:193-211.
Sherrard DJ, Hercz G, Pei Y, et al. The spectrum of bone dis- ease in end-stage renal failure: an evolving disorder. Kidney Int 1993;43:436-42.
Hruska KA, Teitelbaum SL. Renal osteodystrophy. N Engl J Med 1995;333:166-74.
Miller JH, Von Albertini B, Gardner PW, Shinaberg JH. Tech- nical aspects of high-flux hemodiafiltration for adequate short (under 2 hours) treatment. Trans Am Soc Artif Intern Organs 1984;30:377-81.
Fabris A, La Graça G, Chiaramonte S, et al. Total solute ex- cretion versus clearance on the evaluation of standard and short hemodialysis. Trans Am Soc Artif Intern Organs 1988;34:627-9.
Ronco C, Fabris A, Chiaramonte S, et al. Comparison of four different short dialysis techniques. Int J Artif Organs 1988;11:169-74.
Shimizu AG, Taylor DW, Sackett DL, et al. Reducing pa- tient morbidity from high-efficiency hemodialysis: a dou- ble-blind crossover trial. Trans Am Soc Artif Intern Organs 1983;29:666-8.
Marangoni R, Savino R, Colombo R, Cimino R, Civardi F. Short time treatment with high-efficiency paired filtration di- alysis for chronic renal failure. Artif Organs 1992;16:547-52.
Charra B, Calemard M, Ruffet M, Chazot C, Terrat JC, Laurent G. Survival as an index of adequacy of dialysis. Kidney Int 1992;41:1286-91.
Charra B, Calemard M, Laurent G. Importance of treatment time and blood pressure control in achieving long-term sur- vival on dialysis. Am J Nephrol 1996;16:35-44.
Buoncristiani U, Quintaliani G, Cozzari M, Giombini L, Ragaiolo M. Daily dialysis: Long-term clinical metabolic re- sults. Kidney Int 1988;33(suppl 24):S137-S40.
Kenley RS. Will daily home hemodialysis be an important fu- ture therapy for end-stage renal disease? Seminars in Dialysis 1995;8:261-3.
Buoncristiani U, Fagugli RM, Pinciaroli MR, Kulurianu H, Ceravolo G, Bova C. Reversal of left-ventricular hypertrophy in uremic patients by treatment with daily hemodialysis. Contrib Nephrol 1996;119:152-6.
Lugon JR, Rembold SM, Pereira CM, et al. Improvements in dialysis adequacy and quality of life by in-center daily hemodialysis.(abstract) J Am Soc Nephrol 1997;8:165A.
Villanueva AR, Mehr LA: Modifications of the Goldner and Gomori one-step trichrome stains for plastic-embedded thin sections of bone. Am J Med Technol 1977;43:536-8.
Maloney NA, Ott AS, Alfrey AC, Miller NL, Coburn JW, Sherrard DJ. Histological quantification of aluminum in iliac bone from patients with renal failure. J Lab Clin Med 1982;99:206-16.
Andress DL, Maloney NA, Coburn JW, Endress DB, Sherrard DJ. Osteomalacia and aplastic bone disease in aluminum-related osteodystrophy. J Clin Endocrinol Metabol 1987;65:11-6.
Goodman WG, Coburn JW, Ramirez JA, Slatopolsky E, Salusky IB. Renal osteodystrophy in adults and children. In: Favus MJ, editor. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 3rd ed. New York: Raven Press; 1996:341-60.
Parfitt AM, Drezner MK, Glorieux FH, et al. Bone histomorphometry: Standardization and nomenclature, sym- bols and units. J Bone Miner Res 1987;2:595-610.
Lazarus JM, Denker BM, Owen WF Jr. Hemodialysis. In Bren- ner BM, ed. The Kidney (Vol. 2), 5th ed. Philadelphia: WB Saunders; 1996:2424-506.
Pierratos A, Ouwendyk M, Francouer R et al. Nocturnal hemodialysis: three-year experience. J Am Soc Nephrol 1998;9:859-869.
Massry SG, Coburn JN, Lee DBN, Jowsey J, Kleeman CR. Skeletal resistance to parathyroid hormone in renal failure. Ann Intern Med 1973;78:357-64.
Hsu CH, Patel SR, Young EW, Vanholder R. The biological ac- tion of calcitriol in renal failure. Kidney Int 1994;46:605-12.
Splendiani G, Tancredi M, Buoncristiani U, Cozzari M, Oratore A, Amicosante G. Extraction of middle molecules with daily short dialysis. Progr Artif Organs; 1983:452-5.
Salusky IB, Goodman WG. Renal bone disease in pediatric pa- tients receiving treatment with maintenance peritoneal dialy- sis. Child Nephrol Urol 1991;11:165-8.
Hernandez D, Concepcion MT, Lorenzo V, et al. Adynamic bone disease with negative aluminum staining in pre-dialysis patients: prevalence and evolution after maintenance dialysis. Nephrol dial Transplant 1994;9:517-23.
