Aula 2018 Sessio 1 1

* Novetats en Diàlisi
-Dra. Raquel Ojeda López

(Adjunt Servei de Nefrologia, Hospital Clínic de Barcelona)
R. Ojeda. HCP. 15 de febrero de 2018

Guión. Novedades en diálisis
• Técnica y adecuación de diálisis
• Complicaciones HD
• Anemia
• Acceso Vascular
• En el tratamiento de VHC
• Metabolismo óseo y mineral

• Anemia
• Acceso Vascular

Novedades. Técnica y Adecuación de HD
• n=3.075 incident dialysis patients

• 64 Spanish FMC clinics
• January 2009-December 2012
• < 3 m en TRS
• HD vs OL-HDF
• Primary outcome: to investigate the
impact of the type of renal replace-
ment on all-cause mortality in
incident ERSD patients
• All subjects were risk-exposed at
least 4 years
Am J Nephrol 2017;46:288–297
Am J Nephrol 2017;46:288–297
*** p < 0.001

** p < 0.01
* p < 0.05
Association between the convective volume and all-cause mortality
Am J Nephrol 2017;46:288–297
**RRF is important:
• reduces inter-dialytic weight gains
• increases middle molecule and protein
bound toxin clearances
• is associated with better quality of life
*The 24-hour urine collection for urea

and creatinine clearance remains the
mainstay for RRF assessment.
Semin Dial, 2017;30:270-276

• What Is Incremental HD?:
• Incremental dialysis approach to initiating HD is to consider RRF and aim to

achieve a composite total urea clearance target
• Not only apply to initiating HD, also includes the management of prevalent
patients who have lost their RRF or have extracellular water excess,
thereby increasing dialysis frequency, duration and considering HDF
• Dialysis regime should be adjusted to the needs of the individual patient:
– Yes RRF: a less frequent, shorter session, smaller surface area dialyzer,
slower blood or dialysate pump speeds and smaller needle size.
– No RRF: higher convective volume with online HDF, using a superflux
dialyzer, or adding an adsorptive membrana
Blood Purif 2017;44:217–226

Blood Purif 2017;44:217–226

** Clinical trials have not shown that prescribing dialysis

treatment to achieve higher dialyzer urea clearance targets
improves patient survival or quality of life.
** More frequent dialysis schedules appear to be associated with

more rapid loss of RRF. As such an incremental approach to
initiating dialysis may well preserve RRF.
**However, to be successful, this approach requires regular

monitoring of RRF so that timely changes in dialysis session
time and/or frequency or modality can be considered according
to individual patient comorbidities.
Semin Dial, 2017;30:270-276

• The aim of the study was to design a user-friendly tool for IHD prescription.
• Daugirdas published a very useful paper endorsed by the last KDOQI clinical
practice guidelines for HD adequacy. The software (‘Solute-solver’), is freely
available at www.ureakinetics.org; it is of great help for nephrologists who
are skilled in information technology, but could represent a difficult task for
less experienced clinicians.
• They designed a user-friendly tool for IHD prescription, consisting of only a
few rows of a common spreadsheet.
• “SPEEDY”: Spreadsheet for the Prescription of incrEmental haEmoDalYsis.
• SPEEDY consists of five sections, corresponding to five sheets, namely,
KRUn&eKt/V, Kd&Td, Kd&QB, KoA_vitro and PCRn (where QB is the blood
flow rate; KoA in vitro the haemodialyzer mass transfer-area coefficient for
urea; PCRn the normalized protein catabolic rate).
Nephrol Dial Transplant 2018 Jan 5. doi: 10.1093/ndt/gfx343

• In conclusion, SPEEDY is able to provide clinically acceptable results; thus,

any interested reader/clinician could be encouraged to copy the few lines of
the spreadsheet and get a personal tool for an easy and fast prescription
of IHD.
• Two immediate consequences of the extensive utilization of SPEEDY could
derive:
(i) a larger dissemination of IHD might occur, potentially leading to
advantages to patients, nephrologists, caregivers and financial
resources
(ii) SPEEDY could represent a useful tool to set an ineludibly needed

full-fledged clinical trial, comparing IHD with standard thrice-weekly
HD as far as some hard outcomes, such as survival and quality of life
Nephrol Dial Transplant 2018 Jan 5. doi: 10.1093/ndt/gfx343

Kidney Int Rep, 2017; 2: 933–942

• n= 16 pacientes
• Una sesión con cada
filtro en HD y HDF
• Mismas condiciones
Nefrologia 2017 Nov 29. pii: S0211-6995(17)30069-3



• Anemia
• Acceso Vascular

Novedades. Complicaciones en HD
Complicaciones durante HD
Las complicaciones más frecuentes durante
las sesiones de hemodiálisis son:
hipotensión (20%-30%)
calambres (5%-20%)
náuseas y vómitos (5%-15%)
cefalea (5%)
dolor torácico (2%- 5%)
dolor de espalda (2%-5%)
picores (5%)
fiebre y escalofríos (< 1%)
John T. Daugirdas MD. Manual de Diálisis, 5ª Edición
Complicaciones durante HD
Las complicaciones más frecuentes durante
las sesiones de hemodiálisis son:
hipotensión (20%-50%)
calambres (5%-20%)
náuseas y vómitos (5%-15%)
cefalea (5%)
dolor torácico (2%- 5%)
dolor de espalda (2%-5%)
picores (5%)
fiebre y escalofríos (< 1%)
John T. Daugirdas MD. Manual de Diálisis, 5ª Edición
Nephrol Dial Transplant 2018;33:149-159

Nephrol Dial Transplant 2018;33:149-159

Blood Purif 2018;45:320–326

Blood Purif 2018;45:320–326

Blood Purif 2018;45:320–326

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

• Anemia
• Acceso Vascular

Novedades. Anemia
Am J Kidney Dis.,69:815-826, 2017

Novedades. Anemia
Funciones de HIF
1.- Aumenta DMT1 (divalente metal
transporter) y DcytB (duodenal
cytochrome)
2.- Aumenta el trasporte de Fe a
trasferrina y el número de R-transf
en m.o.
3.- Libera el hierro de la transf en
m.o.
4.- Aumenta EPO-R y producción
endógena de EPO
5.- Aumenta el R-trasferrina en pro-
eritrocitos
6.- Promueve la formación de
eritrocitos maduros
7.- Favorece liberación de hierro del
eritrocito maduro, para su reuso
Am J Kidney Dis, 69:815-826, 2017
Novedades. Anemia
Cifras de hemoglobina (g/L)
Cifras de Hepcidina (ng/mL)
Brigandi RA et al. Am J Kidney Dis. 67:861-871, 2016

Novedades. Anemia
Semergen. 2017 Dec 8. pii: S1138-3593(17)30325-8

Novedades. Anemia
Aten Primaria. 2018 Jan;50(1):60-64

Novedades. Anemia
Aten Primaria. 2018 Jan;50(1):60-64

• Anemia
• Acceso Vascular

Novedades. Acceso Vascular
Am J Kidney Dis. 70(4):486-497, 2017

Am J Kidney Dis. 70(4):486-497, 2017

Am J Kidney Dis. 70(4):486-497, 2017

Am J Kidney Dis. 70(4):486-497, 2017

Kidney Int. 2017 Sep 7. pii: S0085-2538(17)30495-7



Ibeas J et als. Nefrologia. 2017 Nov;37 Suppl 1:1-191

• Anemia
• Acceso Vascular

Novedades. Tratamiento de VHC

J Clin Gastroenterol. 2017 Nov 3. doi: 10.1097/MCG.0000000000000941



Nephrol Dial Transplant. 2017;32(12):2065-2071



Gane e et als. N Engl J Med 2017;377:1448-55.

o N =104

o N =104

o N =104

• Anemia
• Acceso Vascular

Novedades. Metabolismo Óseo-Mineral
Nutrients 2017, 9, 328




 45 pacientes prevalentes HD
 Déficit de 25-OH vitamina D
(< 20 ng/ml)
 Calcifediol (Hidroferol®) 0,266
mcg/vo/15 ds/durante 3 meses
 Se determinaron pre y post-tto:
 Parámetros de MOM
 Anemia
 Inflamación
 Se recogieron fármacos y dosis
Nefrología, 2018; 38(1): 41–47

• Mejor control del HPTS
Nefrología, 2018; 38(1): 41–47

Nefrología, 2018; 38(1): 41–47

Nefrología, 2018; 38(1): 41–47

Nefrología, 2018; 38(1): 41–47

o TENAPANOR:
• Minimally absorbed small
molecule
• Inhibitor of the sodium/
Hydrogen exchanger isoform
3
• Functions in the gut to
reduce sodium and phosphate
absorption
J Am Soc Nephrol 28: 1933–1942, 2017

• Randomizaron//n=162
• Completaron//n=115
(71%)
• 6 regímenes Tenapanor
– 3 mg/24 hs
– 30mg/24 hs
– 1 mg/12 hs
– 3 mg/12 hs
– 10 mg/12 hs
– 30mg/12 hs
– placebo
• T= 4 sem.
J Am Soc Nephrol 28: 1933–1942, 2017

J Am Soc Nephrol 28: 1933–1942, 2017

J Am Soc Nephrol 28: 1933–1942, 2017

Block G et als. JAMA. 2017;317(2):146-155.





Block GA et als. JAMA. 2017;317(2):156-164.



Novedades en diálisis…Mensajes
• HDF-OL vs HD-HF: Mejora la supervivencia en pacientes
incidentes
• HD Incremental,…es posible! Es una buena opción de TRS
• HipoTA ID aumenta la mortalidad en pacientes incidentes y
prevalentes en HD
• Estabilizadores de HIF (Inhibidores de HIF-Prolil
hidroxilasa),…parece una buena alternativa para el
tratamiento de la anemia en ERC
• Nefrología intervencionista…FAV sin cirugía
• La curación de la hepatopatía por VHC en HD es posible!
• Etelcalcetide,…Mejor control del HPTS!!
Gracias

Aula 2018 Sessio 1 1

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* Novetats en Diàlisi

-Dra. Raquel Ojeda López

R. Ojeda. HCP. 15 de febrero de 2018

• Metabolismo óseo y mineral

R. Ojeda. HCP. 15 de febrero de 2018

• Metabolismo óseo y mineral

R. Ojeda. HCP. 15 de febrero de 2018

• n=3.075 incident dialysis patients

*** p < 0.001

Association between the convective volume and all-cause mortality

*The 24-hour urine collection for urea

Semin Dial, 2017;30:270-276

• What Is Incremental HD?:

• Incremental dialysis approach to initiating HD is to consider RRF and aim to

Blood Purif 2017;44:217–226

Blood Purif 2017;44:217–226

** Clinical trials have not shown that prescribing dialysis

** More frequent dialysis schedules appear to be associated with

**However, to be successful, this approach requires regular

Semin Dial, 2017;30:270-276

Nephrol Dial Transplant 2018 Jan 5. doi: 10.1093/ndt/gfx343

• In conclusion, SPEEDY is able to provide clinically acceptable results; thus,

(ii) SPEEDY could represent a useful tool to set an ineludibly needed

Nephrol Dial Transplant 2018 Jan 5. doi: 10.1093/ndt/gfx343

Kidney Int Rep, 2017; 2: 933–942

Nefrologia 2017 Nov 29. pii: S0211-6995(17)30069-3

Nefrologia 2017 Nov 29. pii: S0211-6995(17)30069-3

Nefrologia 2017 Nov 29. pii: S0211-6995(17)30069-3

• Metabolismo óseo y mineral

R. Ojeda. HCP. 15 de febrero de 2018

Nephrol Dial Transplant 2018;33:149-159

Nephrol Dial Transplant 2018;33:149-159

Blood Purif 2018;45:320–326

Blood Purif 2018;45:320–326

Blood Purif 2018;45:320–326

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

Semin Dial, 2017;30:492-500

• Metabolismo óseo y mineral

R. Ojeda. HCP. 15 de febrero de 2018

Am J Kidney Dis.,69:815-826, 2017

Cifras de hemoglobina (g/L)

Cifras de Hepcidina (ng/mL)

Brigandi RA et al. Am J Kidney Dis. 67:861-871, 2016

Semergen. 2017 Dec 8. pii: S1138-3593(17)30325-8

Semergen. 2017 Dec 8. pii: S1138-3593(17)30325-8

Aten Primaria. 2018 Jan;50(1):60-64

Semergen. 2017 Dec 8. pii: S1138-3593(17)30325-8

Aten Primaria. 2018 Jan;50(1):60-64

• Metabolismo óseo y mineral

R. Ojeda. HCP. 15 de febrero de 2018

Am J Kidney Dis. 70(4):486-497, 2017

Am J Kidney Dis. 70(4):486-497, 2017

Am J Kidney Dis. 70(4):486-497, 2017

Am J Kidney Dis. 70(4):486-497, 2017

Kidney Int. 2017 Sep 7. pii: S0085-2538(17)30495-7

Kidney Int. 2017 Sep 7. pii: S0085-2538(17)30495-7

Kidney Int. 2017 Sep 7. pii: S0085-2538(17)30495-7

Ibeas J et als. Nefrologia. 2017 Nov;37 Suppl 1:1-191

• Metabolismo óseo y mineral

R. Ojeda. HCP. 15 de febrero de 2018