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Article Review/Hyperlink
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Yang CS, Chen SW, Chiang CH, Wang M, Peng SJ, Kan YT
Effect of increasing dialysis dose on serum albumin and
mortality in hemodialysis
Am J Kidney Dis
(Mar) 27:380-386 1996

During a 6-year period the authors noted that Kt/V increased in their
hemodialyzed patients from 1.3 in 1987 to 1.5 in 1990 to 1.7/dialysis in
1993. During the same period, mortality declined from 16.1 to 13.2 to 8.0
%/year and serum albumin concentrations increased from 3.8 to 4.0 to 4.3
g/dl. Since both low albumin concentrations and low Kt/V values are
associated with increased mortality, the authors suggested that the
improvement they observed in both albumin and mortality were caused by the
increase in Kt/V.
Their study was observational, so cause-and-effect cannot
be discerned and their study cannot be used as a basis for treatment.
However, the data are important because they serves as a stimulus for more
definitive interventional studies to determine the beneficial effect, if
any, from further increases in Kt/V. Such a study is currently under way in
the United States: the NIH-sponsored multi centered HEMO study. A previous
NIH-sponsored interventional study in the late 1979's (NCDS) failed to show
improvement in albumin or morbidity as Kt/V increased above 1.0/dialysis
thrice weekly. Several more recent observational studies have suggested
continued improvement in outcome as Kt/V is increased above 1.2/dialysis but
others have not.
The authors of this report acknowledge that during the
period of observation several other changes occurred in their dialysis
center such as the introduction of EPO, reduction in number of transfusions,
control of hepatitis, elimination of acetate and cellulose-based dialyzers,
volume control of ultrafiltration, and improved water treatment, that could
have contributed to the improvements in albumin and mortality. The absence
of contemporary controls leaves open the possibility of an unidentified
factor that may have influenced either the mix of patients admitted to the
dialysis center or their risk of death. For example, patients dialyzed in
more recent years may have been started sooner, thereby shortening their
exposure to uremic toxins and preserving native kidney clearance. The
increase in Kt/V itself could have resulted from acceptance of healthier
patients who were able to tolerate more prolonged dialysis with higher blood
flows. The authors acknowledge that "due to patient noncompliance,"
increasing the dose of dialysis (Kt/V) "was difficult before that time
(1988)."
Comment: Because of the many alternative interpretations of their
data, a statement
made in the abstract that "increasing the dose of dialysis improves serum
albumin levels" is too strong. The concept, however, is intriguing and
deserves further study. (Thomas A. Depner, M.D., University of California
Davis)
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