Blood purification
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In recent years, a number of techniques have been studied and developed in the field of renal replacement therapy in the septic patient. Manipulation of ultrafiltrate dose, membrane porosity, mode of clearance, and combinations of techniques have yielded promising findings. ⋯ An ultrafiltration rate between 35 and 45 ml/kg/h, with adjustment for predilution and down time, can be recommended for the septic patient until other data are available. The results of further dose outcome studies with higher ultrafiltration rates will likely be the stepping stone to further improvements in daily clinical practice.
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In the last years, publications have questioned the classical dose of 35 ml/kg, but are those studies strong enough in terms of scientific power in order to change our practice? We will try to settle some recommendations for clinicians. Manipulation of dose, porosity, and combinations have yielded promising findings. However, conclusive evidence based on randomized trials remains scarce, limiting the practical implementation in daily practice. ⋯ An ultrafiltration rate of around 35 ml/kg/h, with adjustment for predilution, can be recommended for the septic patient. Recent studies do not have enough power to change this recommendation in view of its shortcomings. Finally the recommendation is to keep going with a continuous technique, a pure continuous veno-venous hemofiltration mode, and at a dose of 35 ml/kg/h while waiting for other studies to be published.
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Infection constitutes a leading cause of morbidity and mortality in hemodialysis (HD) patients. The type of vascular access is an important determinant of the risk of infection. Therefore, identification of risk factors leading to catheter-related bacteremia (CRB) is strongly required. The aim of this prospective large cohort study of HD patients using only catheters as vascular access was to isolate risk factors for CRB. ⋯ Reducing CRB is still a challenge for nephrologists to reduce patient morbidity and mortality. Our study could demonstrate that diabetes, previous history of CRB, site of catheter implantation and duration of catheter use were the most important risk factors for bacteremia. Therefore, to prevent CRB, particular attention should be paid to patients with diabetes and a previous history of bacteremia following strict hygienic and aseptic rules for catheter handling associated with the regular use of antiseptic lock solutions.
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Achieving normohydration remains a non-trivial issue in haemodialysis therapy. Preventing the deleterious effects of fluid overload and dehydration is difficult to achieve. Objective and clinically applicable methods for the determination of a target representing normohydration are needed. ⋯ Whole-body bioimpedance spectroscopy in combination with a physiologic tissue model provides for the first time an objective and relevant target for clinical dry weight assessment.
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In contrast to the general population, in maintenance hemodialysis (MHD) patients, small body size is correlated with reduced survival. The reasons for this association are unclear but may be related to a lower uremic toxin load relative to body weight and a higher distribution volume for uremic toxins in large patients. Since anemia is a salient feature in dialysis patients, this study aimed to explore the relationship between body composition and anemia control. ⋯ Anemia control is related to body composition in Black dialysis patients. EPO requirements and EPO resistance are reduced in patients with high TAT, SAT and MM (the latter in females only). A lower uremic load in large dialysis patients may contribute to these findings.