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S 12 Parallel Session
Programme of the Session
Title: Technical-Dialysis Adequacy
GS: Jasper Boomker (The Netherlands)
NeoKidney – a renewed approach to mobile haemodialysis
O 13
Inversion of branches in dysfunctional central venous catheters – impact on haemodialysis efficacy
Osvaldo Albuquerque (Portugal)
O 14
Hypoxia-inducible factor prolyl hydroxylase inhibitors: The future of anaemia management in chronic kidney disease?
Danilo Villafuerte Nebres (UK)
O 15
Rheopheresis: a treatment for peripheral arterial disease
Jean Marc Lagarde (France)
O 16
Individualised heparinisation profile implementation for the extracorporeal blood circuit of haemodialysis patients
Helena Caldeira (Portugal)
Abstracts
GUEST SPEAKER
NeoKidney – a renewed approach to mobile haemodialysis
J.M. Boomker1, 2, J.P. Stooker2, F.P. Wieringa2, 3, 4, T.A.J. Oostrom1
1Nierstichting Nederland, Bussum, Netherlands; 2NeoKidney Development BV, Bussum, Netherlands; 3TNO Science & Industry, Delft, Netherlands; 4Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
Background
Dialysis treatment sustains the lives of millions of patients. Still many patients feel restricted by their treatment regimen and also suffer from the dismal effects of the “dialysis unphysiology”. Home dialysis offers more scheduling flexibility and the opportunity for frequent dialysis, but demands costly structural modifications to the home, is relatively complicated and therefore only an option for a restricted number of patients.
Patient organizations demands plus the apparent innovation gap within dialysis industry, triggered the Dutch Kidney Foundation to start developing a small, mobile and easy-to-handle haemodialysis device that can be used virtually everywhere. Portablity/wearability is enabled by a dialysate recycling sorbent system.
We took a renewed approach by commissioning two medical device companies to combine several of their state-of the-art technologies. Good progress is ongoing towards a portable artificial kidney (PAK) weighing 5-10 kg and using only a few litres of dialysate. The renewed approach involves patient feedback sessions to discuss the concept and design of the PAK.
This program – which has been assigned to Neokidney Development BV - is predominately funded by the Dutch Kidney Foundation (via earmarked donations from major donors) and Dutch health care insurance companies. For large scale production and distribution, we seek partnerships with companies with access to many patient clinics and patient homes.
We aim for continuous innovation: For the next generation devices several research projects already have started focusing on new sorbent filters, membranes and sensors to further decrease the size and better fine-tune dialsyate composition and efficacy of treatment.
BIOGRAPHY OF THE GUEST SPEAKER
O 13
Inversion of branches in dysfunctional central venous catheters - impact on haemodialysis efficacy
O. Albuquerque1, A. Seabra1, J. Fazendeiro Matos2, M.T. Parisotto3
1NephroCare Coimbra, Fresenius Medical Care, Coimbra, Portugal; 2NephroCare Portugal, Fresenius Medical Care, Porto, Portugal; 3Care Value Management EMEA, Fresenius Medical Care, Bad Homburg, Germany
Background
In haemodialysis when the nurse finds an arterial branch of a dysfunctional catheter, the inversion of branches is often used, despite the known increase of recirculation. This is often done as a last resort, before implementing more expensive methods (e.g. fibrinolytic agents or even catheter replacement).
Objectives
• To assess whether the inversion of branches of dysfunctional catheters improves dialysis effectiveness.
• To compare the results obtained with functional catheters (without an inversion of branches).
Methods
28 patients with permanent tunnelled central venous catheters (CVC) were divided into 2 groups:
• group 1: 14 patients with dysfunctional CVC
• group 2: 14 patients with functional CVC
We compared the dialysis effectiveness (urea reduction ratio (URR), Kt/V) of patients dialysed
• with normal branches of group 1 with those dialysed with inverted branches of group 1.
• with normal branches of group 2 with patients dialysed with inverted branches of group 1.
Results
5 of dysfunctional CVC worked only in an inverted position of branches. In the remaining 9, the inversion of branches resulted in a decrease of Kt/V from 1.63 to 1.47 and of URR from 74.2% to 72.9%, despite the increase of Qb from 286 to 303.3ml/min. Functional catheters with normal branches had a Kt/V of 1.54 and a URR of 75%.
Conclusion/Application to practice
Despite the small population analysed, our priority is to keep the catheter on normal branches, as in our study this was associated with a better dialysis efficacy. The inversion of branches is a valid alternative in case of reduced blood flow. If this alternative is necessary, dialysis efficacy must be imperatively supervised.
O 14
Hypoxia-inducible factor prolyl hydroxylase inhibitors: The future of anaemia management in chronic kidney disease?
D .V. Nebres1, L. Goldstein1, C. Adan1, I.C. Macdougall1
1Renal Research Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
Background
The current standard-of-care for treating anaemia in CKD patients is ESA therapy, with or without iron supplementation. There are, however, some limitations with this treatment, notably the need for frequent injections. A new class of drugs, called HIF prolyl hydroxylase inhibitors, are in clinical trials; the evidence to date suggests that they also improve CKD anaemia, and their major advantage is that they are orally-active.
Methods
In our renal unit, we have performed phase 1, 2, and 3 clinical trials of two of these new agents, roxadustat and molidustat. Both drugs are given in tablet form. To date, 10 patients in our unit have been enrolled to the roxadustat study (longest on treatment 92 weeks), and 24 patients to molidustat (6-month study with extension phase).
Results
All patients in these trials had baseline haemoglobins of around 8 to 9 g/dl, and all have responded to treatment. Anecdotally, this has been associated with them feeling stronger, with less fatigue. The drugs seem well-tolerated, and no significant adverse effects have been noted. Administering the treatment as tablets would seem to be the main advantage of this class of drugs over current ESAs.
Conclusion/Application to practice
Clearly, the full analysis of the phase 2/3 clinical trials of these agents is required before any definitive conclusions can be made about their efficacy and safety, but the preliminary experience in our unit is very positive. If successful, HIF prolyl hydroxylase inhibitors would be particularly useful in CKD patients not receiving haemodialysis, preventing the need for frequent lifelong injections.
O 15
Rheopheresis: a treatment for peripheral arterial disease
M. Hermelin1, J.M. Lagarde1
1DNTO, Haemodialysis, Toulouse, France
Background
Many patients suffer from peripheral occlusive arterial disease caused by arterial narrowing, especially at the lower extremities due to atherosclerosis. Age, chronic kidney failure, and diabetes are the main risk factors for peripheral arterial disease. Traditional treatments rely on trophic care, surgery, and medicines that improve blood perfusion and reduce blood viscosity.
Objectives
A novel apheresis technique called rheopheresis has been recently developed. It reduces blood viscosity by decreasing plasma concentrations of fibrinogen, alpha 2 macroglobulin, and lipoproteins.
Methods
Rheopheresis was implemented in our department in April 2015 using the Rheofilter ER4000®. This innovative treatment was decided upon by the vascular-surgery, vascular-medicine, and nephrology teams
Results
To date, six patients have been treated using this technique. Therapy has been scheduled as follows: three sessions during the first two weeks, two sessions during the next two weeks, and then one session per week for a month. The number of sessions was adapted according to the patient's health status. Tolerance to this therapy was excellent. Although the use of analgesics could be decreased for some patients (n=x), the criteria to evaluate the efficacy of this therapy are yet to be determined.
Conclusion/Application to practice
In conclusion, rheopheresis is a promising therapy for peripheral arterial disease. However, further studies are required to assess its efficacy.
O 16
Individualised heparinisation profile implementation for the extracorporeal blood circuit of haemodialysis patients
H. Caldeira1, S. Lima1, M. Silva1, B. Pinto2, R. Peralta2, J. Fazendeiro Matos2
1NephroCare Vila Nova Gaia, Fresenius Medical Care, Vila Nova Gaia, Portugal; 2NephroCare Portugal, Fresenius Medical Care, Porto, Portugal
Background
Anticoagulation monitoring of the extracorporeal blood circuit (EBC) during the haemodialysis session is a pre-requisite for its efficiency. Therefore, individualised anticoagulation profiles are necessary to maintain EBCs' performance and to reduce blood loss, nurses' workload, additional disposable consumption and consequentially the treatment costs.
Objectives
• Optimise EBC anticoagulation profiles by implementing a systematic record of EBC status.
Methods
The first term of the study was from May 2013-May 2014, the second from June 2014-June 2015. During May 2014, the aspect of dialyzer and blood lines was rated. Reinfusion volume was recorded at the end of each haemodialysis session. Data inclusive EBC observations were collected for both studied periods. In the second term of the study, the heparin prescription was revised, individualised heparin profiles and reinfusion volumes were developed according to EBC observations and database records.
Results
Of the 109 patients studied, 67 were males.
8 patients did anti-aggregation medication and 7 had no associated anticoagulant. All patients participated in the two terms of the study. The average age was 69 years.
Comparing the first studied year versus the second year revealed:
• 18,881 treatments versus 18,712 treatments,
• 64 versus 56 clotted EBCs,
• a heparin consumption of 183 versus 191 vials,
• an average reinfusion volume of 334ml versus 355ml.
Conclusion/Application to practice
Individualised EBC anticoagulation under standard blood heparinization for haemodialysis seems to contribute to a reduction in EBC clotting, as well as a cost optimisation.