Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Podcasts
    • Subject Collections
    • Archives
    • ASN Meeting Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
    • Reprint Information
  • Trainees
    • Peer Review Program
    • Prize Competition
  • About CJASN
    • About CJASN
    • Editorial Team
    • CJASN Impact
    • CJASN Recognitions
  • More
    • Alerts
    • Advertising
    • Reprint Information
    • Subscriptions
    • Feedback
  • ASN Kidney News
  • Other
    • JASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology

User menu

  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • JASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology
  • Subscribe
  • My alerts
  • Log in
  • My Cart
Advertisement
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Podcasts
    • Subject Collections
    • Archives
    • ASN Meeting Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
    • Reprint Information
  • Trainees
    • Peer Review Program
    • Prize Competition
  • About CJASN
    • About CJASN
    • Editorial Team
    • CJASN Impact
    • CJASN Recognitions
  • More
    • Alerts
    • Advertising
    • Reprint Information
    • Subscriptions
    • Feedback
  • ASN Kidney News
  • Visit ASN on Facebook
  • Follow CJASN on Twitter
  • CJASN RSS
  • Community Forum
Special Features
You have accessRestricted Access

Nephrology Quiz and Questionnaire: Renal Replacement Therapy

Thomas A. Golper, Discussant, Richard J. Glassock and Anthony J. Bleyer
CJASN August 2012, 7 (8) 1347-1352; DOI: https://doi.org/10.2215/CJN.01740212
Thomas A. Golper
*Vanderbilt Medical School, Vanderbilt University, Nashville, Tennessee;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
*Vanderbilt Medical School, Vanderbilt University, Nashville, Tennessee;
Richard J. Glassock
†David Geffen School of Medicine, University of California, Los Angeles, California; and
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Anthony J. Bleyer
‡Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data Supps
  • Info & Metrics
  • View PDF
Loading

Summary

Presentation of the Nephrology Quiz and Questionnaire has become an annual “tradition” at the meetings of the American Society of Nephrology. It is a very popular session judged by consistently large attendance. Members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They can also compare their answers in real time, using audience response devices, with those of program directors of nephrology training programs in the United States, acquired through an Internet-based questionnaire. Topics presented here include fluid and electrolyte disorders, transplantation, and ESRD and dialysis. Cases representing each of these categories along with single best answer questions were prepared by a panel of experts (Drs. Palmer, Hricik, and Golper, respectively). After the audience responses, the “correct” and “incorrect” answers then were briefly discussed and the results of the questionnaire were displayed. This article aims to recapitulate the session and reproduce its educational value for a larger audience—readers of the Clinical Journal of the American Society of Nephrology. Have fun.

Case 1

A 50-year-old male municipal manager on automated peritoneal dialysis (APD) for 2 years underwent semi-elective coronary artery bypass surgery. He was doing well before this event and had 500–1000 ml/d of urine output, which provided a weekly Kt/V of 0.3 to go along with his peritoneal dialysis (PD) Kt/V of 1.5 for a total weekly Kt/V of 1.8. He was a low-average transporter who spent 9 hours nightly on the cycler performing three exchanges of 2500 ml, a last bag fill of 2000 ml and a mid-day exchange also of 2000 ml. His body surface area was 1.9 m2. Most of his solution utilization was 1.5% dextrose, and he was usually clinically euvolemic but required antihypertensive medications and diuretics.

After the bypass surgery, he was hypotensive with apparently compromised cardiac output. Residual kidney function (RKF) deteriorated. He did not thrive upon hospital discharge and rehabilitation, and he lost muscle mass. It was decided to increase the delivered dose of dialysis to see if that could help improve his overall failure to thrive. He preferred to continue APD.

Renal Replacement Therapy Question 1

Given the patient’s circumstances and lifestyle choices, how could his dose of PD BEST be increased in a most cost-efficient manner (Figure 1)?

  1. Increase the number of exchanges per day.

  2. Increase the fill volume per cycler exchange.

  3. Increase his ultrafiltration per day.

  4. Increase dwell time on the cycler and thus his time on the cycler.

  5. Increase his transport status.

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Question 1: Which is the best option for increasing the dialysis dose in this patient? The correct answer is A.

Discussion of Case 1

The best choice is B: Increase the fill volume per cycler exchange. It would be ideal if the patient were to regain the lost RKF. In fact, this did occur over the next 3 months; however, because this could not be predicted, it was necessary to increase the delivered dose of PD. His ultrafiltration had always been good, as expected from his low-average transport status. Fortunately, this situation persisted after the bypass.

Using a cycler is a lifestyle decision for PD patients, allowing them to perform the majority of their therapy during sleep. Over time, as RKF is lost, there may be a need to alter the PD regimen. After his heart surgery, our patient was considered underdialyzed but he desired to remain on APD.

Sterile peritoneal dialysate is the limiting resource in PD, because the solution is provided in bags and increasing the amount of fluid used increases cost. Clearance is the product of the effluent volume times the ratio of the dialysate solute concentration over the plasma solute concentration (D/P). To increase the product, one must increase either or both components. In other words, to increase PD dose, one must increase effluent volume per week and/or have more solute per unit volume. Therefore, the limited resource must be increased because there is no feasible way to increase D/P (see below).

For the effluent to have a concentration of solute approaching that of plasma, the solute must move faster across the peritoneal membrane, or it must have longer time to dwell within the peritoneal cavity to reach equilibrium with the plasma concentration. Transmembrane solute transport status is characterized by the speed of this equilibration, ranging from low (or slow) to high (or rapid) with two average positions between those extremes (1). There are chemicals such as vasodilators that have been used to temporarily increase this transport speed (2), but this strategy has not been clinically practical. Peritoneal inflammation is an example of vasodilation and is most often caused by microorganism contamination of the dialysate, causing peritonitis. In active peritonitis, and for several weeks of the recovery phase, peritoneal transport is accelerated. Severe infections as well as recurrent infections may lead to a permanent conversion to a higher transport state (3). There is concern that this contributes to loss of peritoneal membrane function over time, and is not a desirable method to increasing solute clearance. Furthermore, increasing the solute transport status may have other more immediate detrimental effects. Not only would uremic solutes move faster from plasma to dialysate, but so would proteins, leading to significant protein losses and potential malnutrition as seen in nephrotic syndrome. High transporters also transport glucose rapidly from dialysate to plasma, leading to excessive glucose absorption, which may exacerbate malnutrition by impairing appetite. In addition, the rapid absorption of the dialysate glucose dissipates the osmotic gradient driving force for ultrafiltration. Thus, high transporters lose more protein, absorb more glucose, and ultrafilter more poorly than do patients with lower transport status. Consequently, it is no surprise that observational studies suggest that outcomes are worse in higher transport states (4). Choice E is not correct.

The option to increase dialysate solute concentration by keeping the fluid in the peritoneal cavity longer is attractive. Our patient was already leaving fluid in as he left the cycler in the morning and already performed a manual exchange during the day. Option A, increasing the number of exchanges per day, has two undesirable aspects. First is the intrusion on his lifestyle to perform another 30-minute exchange during the day. Second, peritonitis rates are increased with more frequent exchanges (5–7). Although a second day exchange (option A) would increase the dialysis dose, it is a less attractive alternative in this setting.

To keep fresh fluid in longer to equilibrate better, the patient must spend more time on the cycler. Option D, increasing overall cycler time by increasing exchange duration, would increase dialysis dose but affects lifestyle. For this approach to significantly increase the dialysis dose, the cycler time would likely need to increase by 2 hours. This would be a good strategy if this alteration fit into the patient’s lifestyle. However, many patients, including ours, do not want to be “tethered” (his word) to their cycler for an additional 2 hours. The patient was already spending 9 hours “tethered,” and he did not want to increase this further. In fact, PD patients in the United States have recently increased their time on the cycler (8) up to levels seen in our patient. In summary, the option of leaving the fluid in longer by increasing the cycler time commitment is feasible if it fits into the patient’s lifestyle; in our case, it was not preferred.

Another option, but intentionally not offered as an answer, is to increase the number of exchanges performed during the 9 hours of cycling. This strategy would almost certainly increase small solute clearance (9). As fresh dialysate enters the peritoneal cavity, the rate of solute transfer is at its fastest at the start, slowing down as equilibrium is approached. The constant inflow of fresh dialysate will maximize solute removal into the dialysate and is the basis behind an experimental therapy called continuous flow PD (10). Because this requires either two catheters or a special two-directional flow catheter (11), PD is not yet performed in this manner.

The current approach is rapid exchanges on the cycler with infusion of fresh dialysate at short intervals. This maximizes the concentration gradient from blood to dialysate and increases the rate of small solute (e.g., urea and creatinine) removal (9). This may not be true for slower-moving solutes because surface area is not being utilized during inflow and drainage. For each cycle, a conservative estimate is that 25 minutes is used to fill and drain. Thus, for a cycle length of 60 minutes, 25 minutes are spent with a less than full peritoneal cavity in what is marginal or insignificant therapy and only 35 minutes are devoted to maximal surface area utilization where there is effective therapy. If the cycle length is 2 hours and 35 minutes are used to fill and drain, there are 85 minutes of fully effective therapy. Therefore, speeding up exchanges on a cycler may not always increase solute clearance due to the proportion of the cycle being inefficient during fill and drain (12). This may not matter for urea but it will for larger solutes, especially in the low and low-average transporters. In addition, rapid cycling stimulates aquaporin channels due to the increased osmotic activity of the dialysate; this results in more solute-free water movement into the peritoneal cavity. This sodium-free water movement dilutes the sodium concentration in the dialysate, and is called “sodium sieving.” If the aquaporin-derived water is not allowed to dwell in the peritoneal cavity long enough for sodium to diffuse from plasma into the dialysate through the (nonaquaporin) intercellular pores, then the drained effluent will remain sodium poor relative to the sodium concentration in the plasma. Essentially, more free water then leaves the body relative to interstitial water. When this occurs, the patient becomes hypernatremic, which stimulates thirst. Thus, rapid cycling results in the use of large volumes of dialysis, poorer large solute removal, and potentially inadequate sodium removal (13).

Option C is to increase solute removal by convection, which translates to increasing ultrafiltration per day. Convective transport removes larger molecules better than diffusion and would be attractive for our patient’s uremia. However, to really improve his uremic symptoms, his convective transport would likely need to increase by at least a liter per day. Achieving this would require an increased use of hypertonic exchanges (2.5% and 4.25% dextrose solutions) and perhaps the replacement of one of his day exchanges with icodextrin. We discourage the use of hypertonic exchanges in our program because of the long-term adverse effects of glucose exposure on the peritoneal membrane (14,15). Hypertonic exchanges are reserved for higher transporters or emergencies. Icodextrin is an alternative, unattractive only because of its extra expense. Increasing the number of exchanges on the cycler would increase ultrafiltration and small solute clearance but would decrease diffusion time for larger solutes. This might be compensated by increased convective transport of these larger molecules. As discussed above, increasing exchanges on the cycler increases dialysate inflow volume and costs but was not offered as an answer.

In our opinion, increasing fill volume per cycler exchange (option B) is the best answer. The number of connections is not changed so contamination risk is not increased. Surface area is maximized, and lifestyle is not altered. When we increase fill volumes in an APD patient in our program, we start with increasing only the fills from the cycler and we increase in increments of 100 ml per exchange every 1 or 2 weeks so that the patient is essentially unaware of the sensation of the increased volumes. A blinded study has shown that patients infrequently complain of either mild or moderate discomfort with larger fill volumes in the sitting position (16) and patients are even more tolerant of such volumes when supine on the cycler. The benefit of incrementally increasing cycler fill volumes on peritoneal Kt/V is exemplified in Figure 2. Dialysate for cyclers comes in large volume bags and increasing fill volume in this way rarely leads to increased dialysate cost. Thus, from the aspect of ease of operation and cost benefit, option B to increase fill volumes is the best of the offered choices.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

Increments in fill volumes of 100–200 ml have minimal effect on sensation of fullness, intra-abdominal pressure, and clearance. However, if fill volumes are nudged up by these amounts every few weeks the clearance benefits add up and symptoms are avoided. Ave, average. (Courtesy of Dr. Salim Mujais.)

Case 2

A 55-year-old male farmer, weighing 120 kg, being treated by in-center hemodialysis requested transfer to home dialysis. He already placed his own needles into a well functioning fistula, and his wife participated actively in his care. He had always taken in very large quantities of fluids daily even before ESRD, and this behavior continued on in-center hemodialysis. He preferred to perform home hemodialysis 3–4 times per week, needing to remove 2–6 L at each session. He tolerated this well but eventually developed both rhythm disturbances and left ventricular dysfunction. His fluid gains persisted despite his increasing intolerance of the ultrafiltration demands. He was offered more frequent home hemodialysis. For ease of set-up and take-down, he switched from his Fresenius K machine to NxStage “short” daily home hemodialysis, with his medical condition mandating at least six dialysis sessions per week. Despite his low BP, his fistula performance remained outstanding and he routinely achieved a blood flow rate (Qb) of 450 ml/min.

His interdialytic fluid gains remained at 3 L/d, mandating 3000 ml of ultrafiltration at each dialysis session. Because his dry weight body size yielded a urea volume of distribution of 72 L (75 L when wet), each dialysis session required 30 L of dialysate. The 30 L of dialysate required 3 hours and 20 minutes of dialysis time (200 total minutes) to process.

Renal Replacement Therapy Question 2

How much extra time per treatment session would be required to remove the 3 L of fluid by ultrafiltration under several different operating conditions (Qb and flow fraction) described below (Figure 3)?

  1. Blood flow rate (Qb) 400 ml/min, flow fraction 25%, would require 25 minutes more.

  2. Blood flow rate (Qb) 400 ml/min, flow fraction 25%, would require 20 minutes more.

  3. Blood flow rate (Qb) 450 ml/min, flow fraction 33.33%, would require 25 minutes more.

  4. Blood flow rate (Qb) 450 ml/min, flow fraction 33.33%, would require 20 minutes more.

  5. None of the above.

Figure 3.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 3.

Question 2: How much extra time would be required at varying flow fractions? The correct answer is D.

Discussion of Case 2

Answer D is the most correct choice. In 2011, the Centers for Medicare and Medicaid services implemented a prospective payment system for dialysis services in the United States. One feature of this new policy was to provide a financial incentive for the use of home dialysis. Furthermore, the Frequent Hemodialysis Network Trial demonstrated a cardiovascular benefit to more frequent hemodialysis (17). This was followed by several reports from the Following Rehabilitation, Economics, and Everyday-Dialysis Outcome Measurements (FREEDOM) study, suggesting that restless leg syndrome, sleep disturbances, postdialysis recovery time, and depression were also improved with short daily hemodialysis (18,19). This constellation of events contributed to the growth of home hemodialysis.

The simplicity of the NxStage system has made it the most popular current version of home hemodialysis. Some of the benefits of this system are that it generally only requires 3 weeks for training, it does not require home plumbing modifications, and the equipment is small and portable.

Gotch popularized the concept of standard weekly Kt/V to help equate in terms of urea clearance intermittent versus continuous kidney replacement therapies and the frequency of the applied intermittent treatments (20). This is one of several mathematical models that allow the comparison of different kidney replacement therapies with the clearance of urea over a week’s duration. Although they are not clinically validated, many clinicians have found them useful and they certainly are helpful in quantitative comparison of urea clearance by differing dialytic modalities. Figure 4 shows where the currently prescribed therapies relate relative to each other on a standardized weekly Kt/V scale.

Figure 4.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 4.

The weekly standardized Kt/V is a useful method to compare the dose equivalency of various dialysis modalities. Shown here are different modalities, all delivering a standardized weekly dose approaching 2.0 but requiring continuous or frequent applications to do so. HD, hemodialysis. Modified with permission from reference 20.

In the NxStage system, dialysate fluid is provided. As with PD, the dialysate is a scarce commodity because it must be ultrapure. Also as in PD, to maximize clearance in the setting of scarce dialysate, the dialysate must be highly saturated with solute. To do this efficiently requires increased contact time between blood and dialysate. The practical application is to operate with a low ratio of dialysate flow rate (Qd) to blood flow rate (Qb). A large surface area for such contact also facilitates saturation of dialysate. These are features of the NxStage system. Conventional hemodialysis operates with high Qd (thus huge water requirements) and high Qb, whereas NxStage uses low Qd but high Qb. Conventional hemodialysis is not concerned with saving dialysate, so dialysate saturation is unimportant.

NxStage developed the term flow fraction, which is the ratio of effluent flow (spent dialysate + ultrafiltration) divided by Qb. Fully saturated dialysate would mean that clearance is equal to effluent flow rate. For a small solute which moves rapidly across dialyzer membranes, using urea as the example and in-house data from NxStage, a flow fraction of 25% would yield a saturation of about 95%, which then equates to a clearance that is approximately 95% of effluent flow rate. Increasing the flow fraction to 33% would drop the saturation to about 92%. Preferable (cost-effective) flow fractions are in this range. This generally requires accesses to deliver a Qb of ≥400 ml/min. If the Qb is not this high, then the flow fraction will be greater than preferred, and consequently dialysate will be less saturated and essentially wasted. This would increase treatment time and require more dialysate to deliver the same dialytic dose. For this reason, NxStage requires a well functioning access for frequent short-duration treatments.

Answers A and B stipulate a Qb of 400 ml/min and a flow fraction of 25%. Because the flow fraction is the ratio of effluent flow (spent dialysate + ultrafiltration) divided by Qb, this means that the effluent flow (Qd) will be 100 ml/min (100/400=0.25, or 25%). With a Qd of 100 ml/min, this means that it will require for 30 L of dialysate for 300 minutes (5 hours). For the 3000 ml that needs to be ultrafiltered, this will then require (at 100 ml/min) an additional 30 minutes of treatment. This means that Qd is 100 ml/min and 3000 extra ml must be removed at this rate; 3000 ml at 100 ml/min requires 30 additional minutes. Thus, answers A and B are incorrect.

Answers C and D stipulate a Qb of 450 ml/min with a flow fraction of 33.33%. This means that Qd is 150 ml/min and 3000 extra ml must be removed at this rate; 3000 ml at 150 ml/min requires 20 additional minutes. Thus, answer C is incorrect, whereas answer D is correct.

Another simple solution is that without any ultrafiltration and a Qd of 150 ml/min, our patient requires 3 hours and 20 minutes (200 minutes) to process 30 L of dialysate. He has an additional 3 L of ultrafiltrate to process. If 30 L requires 200 minutes, then an additional 3 L would require 20 additional minutes. The lesson to learn with this case is that ultrafiltration extends treatment time with NxStage therapy.

The prescription for this patient with a urea volume of distribution of 72 L was 30 L of dialysate with 92% saturation yielding a Kt/V of 0.38 per treatment. Without any convective urea removal, his six treatments per week with a Kt/V of 0.38 per dialysis would yield a standardized Kt/V approaching our 2.0 target (Figure 4). However, with 3 L of ultrafiltration 100% saturated with urea, there is an increase in treatment time but an increase in Kt/V of approximately 4% (3/75) to 0.395 per treatment.

Disclosures

None.

Acknowledgment

This work was presented at the 2011 Annual Meeting of the American Society of Nephrology, November 8–13, 2011, Philadelphia, Pennsylvania.

Footnotes

  • Published online ahead of print. Publication date available at www.cjasn.org.

  • Copyright © 2012 by the American Society of Nephrology

References

  1. ↵
    1. Twardowski ZJ,
    2. Nolph KD,
    3. Khanna R,
    4. Prowant BF,
    5. Ryan LP,
    6. Moore HL,
    7. Nielson MP
    : Peritoneal equilibration test. Perit Dial Bull 7: 138–147, 1987
    OpenUrl
  2. ↵
    Maher JF: Blood flow to the peritoneum: physiological and pharmacological influences. In: CAPD Update, edited by Moncrief JW, Popovich RP, New York, Masson Publishing USA Inc, 1980, pp 53–62
  3. ↵
    1. del Peso G,
    2. Fernández-Reyes MJ,
    3. Hevia C,
    4. Bajo MA,
    5. Castro MJ,
    6. Cirugeda A,
    7. Sánchez-Tomero JA,
    8. Selgas R
    : Factors influencing peritoneal transport parameters during the first year on peritoneal dialysis: Peritonitis is the main factor. Nephrol Dial Transplant 20: 1201–1206, 2005pmid:15827050
    OpenUrlCrossRefPubMed
  4. ↵
    1. Brimble KS,
    2. Walker M,
    3. Margetts PJ,
    4. Kundhal KK,
    5. Rabbat CG
    : Meta-analysis: Peritoneal membrane transport, mortality, and technique failure in peritoneal dialysis. J Am Soc Nephrol 17: 2591–2598, 2006pmid:16885406
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Holley JL,
    2. Bernardini J,
    3. Piraino B
    : Continuous cycling peritoneal dialysis is associated with lower rates of catheter infections than continuous ambulatory peritoneal dialysis. Am J Kidney Dis 16: 133–136, 1990pmid:2382649
    OpenUrlPubMed
    1. Korbet SM,
    2. Vonesh EF,
    3. Firanek CA
    : Peritonitis in an urban peritoneal dialysis program: An analysis of infecting pathogens. Am J Kidney Dis 26: 47–53, 1995pmid:7611267
    OpenUrlCrossRefPubMed
  6. ↵
    1. Rodríguez-Carmona A,
    2. Pérez Fontán M,
    3. García Falcón T,
    4. Fernández Rivera C,
    5. Valdés F
    : A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis. Perit Dial Int 19: 253–258, 1999pmid:10433162
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Mujais S,
    2. Childers RW
    : Profiles of automated peritoneal dialysis prescriptions in the US 1997-2003. Kidney Int Suppl 70[103]: S84–S90, 2006pmid:17080117
    OpenUrlCrossRefPubMed
  8. ↵
    1. Perez RA,
    2. Blake PG,
    3. McMurray S,
    4. Mupas L,
    5. Oreopoulos DG
    : What is the optimal frequency of cycling in automated peritoneal dialysis? Perit Dial Int 20: 548–556, 2000pmid:11117246
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Amerling R,
    2. Ronco C,
    3. Levin NW
    : Continuous flow peritoneal dialysis. Perit Dial Int 20[Suppl 2]: S172–S177, 2000
  10. ↵
    1. Ronco C,
    2. Gloukhoff A,
    3. Dell’Aquila R,
    4. Levin NW
    : Catheter design for continuous flow peritoneal dialysis. Blood Purif 20: 40–44, 2002pmid:11803158
    OpenUrlCrossRefPubMed
  11. ↵
    1. Baczynski D,
    2. Antosiewicz S,
    3. Waniewski J,
    4. Nowak Z,
    5. Wankowicz Z
    : Efficacy of peritoneal dialysis during infusion and drainage procedures. Perit Dial Int 30: 633–637, 2010
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Demetriou D,
    2. Habicht A,
    3. Schillinger M,
    4. Hörl WH,
    5. Vychytil A
    : Adequacy of automated peritoneal dialysis with and without manual daytime exchanges: A randomized controlled trial. Kidney Int 70: 1649–1655, 2006
    OpenUrlCrossRefPubMed
  13. ↵
    1. Davies SJ,
    2. Phillips L,
    3. Naish PF,
    4. Russell GI
    : Peritoneal glucose exposure and changes in membrane solute transport with time on peritoneal dialysis. J Am Soc Nephrol 12: 1046–1051, 2001
  14. ↵
    1. Schwenger V,
    2. Morath C,
    3. Salava A,
    4. Amann K,
    5. Seregin Y,
    6. Deppisch R,
    7. Ritz E,
    8. Bierhaus A,
    9. Nawroth PP,
    10. Zeier M
    : Damage to the peritoneal membrane by glucose degradation products is mediated by the receptor for advanced glycation end-products. J Am Soc Nephrol 17: 199–207, 2006pmid:16319192
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Sarkar S,
    2. Bernardini J,
    3. Fried L,
    4. Johnston JR,
    5. Piraino B
    : Tolerance of large exchange volumes by peritoneal dialysis patients. Am J Kidney Dis 33: 1136–1141, 1999pmid:10352203
    OpenUrlCrossRefPubMed
  16. ↵
    1. Chertow GM,
    2. Levin NW,
    3. Beck GJ,
    4. Depner TA,
    5. Eggers PW,
    6. Gassman JJ,
    7. Gorodetskaya I,
    8. Greene T,
    9. James S,
    10. Larive B,
    11. Lindsay RM,
    12. Mehta RL,
    13. Miller B,
    14. Ornt DB,
    15. Rajagopalan S,
    16. Rastogi A,
    17. Rocco MV,
    18. Schiller B,
    19. Sergeyeva O,
    20. Schulman G,
    21. Ting GO,
    22. Unruh ML,
    23. Star RA,
    24. Kliger AS,
    25. FHN Trial Group
    : In-center hemodialysis six times per week versus three times per week. N Engl J Med 363: 2287–2300, 2010pmid:21091062
    OpenUrlCrossRefPubMed
  17. ↵
    1. Jaber BL,
    2. Lee Y,
    3. Collins AJ,
    4. Hull AR,
    5. Kraus MA,
    6. McCarthy J,
    7. Miller BW,
    8. Spry L,
    9. Finkelstein FO,
    10. FREEDOM Study Group
    : Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. Am J Kidney Dis 56: 531–539, 2010pmid:20673601
    OpenUrlCrossRefPubMed
  18. ↵
    1. Jaber BL,
    2. Schiller B,
    3. Burkhart JM,
    4. Daoui R,
    5. Kraus MA,
    6. Lee Y,
    7. Miller BW,
    8. Teitelbaum I,
    9. Williams AW
    Finkelstein FO; FREEDOM Study Group: Impact of short daily hemodialysis on restless leg symptoms and sleep disturbances. Clin J Am Soc Nephrol 6: 1049–1056, 2011
    OpenUrlAbstract/FREE Full Text
  19. ↵
    1. Gotch FA
    : The current place of urea kinetic modelling with respect to different dialysis modalities. Nephrol Dial Transplant 13[Suppl 6]: 10–14, 1998pmid:9719197
    OpenUrlCrossRefPubMed
View Abstract
PreviousNext
Back to top

In this issue

Clinical Journal of the American Society of Nephrology: 7 (8)
Clinical Journal of the American Society of Nephrology
Vol. 7, Issue 8
August 07, 2012
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
View Selected Citations (0)
Print
Download PDF
Sign up for Alerts
Email Article
Thank you for your help in sharing the high-quality science in CJASN.
Enter multiple addresses on separate lines or separate them with commas.
Nephrology Quiz and Questionnaire: Renal Replacement Therapy
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Nephrology Quiz and Questionnaire: Renal Replacement Therapy
Thomas A. Golper, Discussant, Richard J. Glassock, Anthony J. Bleyer
CJASN Aug 2012, 7 (8) 1347-1352; DOI: 10.2215/CJN.01740212

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Nephrology Quiz and Questionnaire: Renal Replacement Therapy
Thomas A. Golper, Discussant, Richard J. Glassock, Anthony J. Bleyer
CJASN Aug 2012, 7 (8) 1347-1352; DOI: 10.2215/CJN.01740212
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Summary
    • Case 1
    • Case 2
    • Disclosures
    • Acknowledgment
    • Footnotes
    • References
  • Figures & Data Supps
  • Info & Metrics
  • View PDF

More in this TOC Section

  • Patient and Other Stakeholder Engagement in Patient-Centered Outcomes Research Institute Funded Studies of Patients with Kidney Diseases
  • Alport Syndrome in Women and Girls
  • Urinary Stone Disease: Advancing Knowledge, Patient Care, and Population Health
Show more Special Features

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Articles

  • Current Issue
  • Early Access
  • Subject Collections
  • Article Archive
  • ASN Meeting Abstracts

Information for Authors

  • Submit a Manuscript
  • Trainee of the Year
  • Author Resources
  • ASN Journal Policies
  • Reuse/Reprint Policy

About

  • CJASN
  • ASN
  • ASN Journals
  • ASN Kidney News

Journal Information

  • About CJASN
  • CJASN Email Alerts
  • CJASN Key Impact Information
  • CJASN Podcasts
  • CJASN RSS Feeds
  • Editorial Board

More Information

  • Advertise
  • ASN Podcasts
  • ASN Publications
  • Become an ASN Member
  • Feedback
  • Follow on Twitter
  • Password/Email Address Changes
  • Subscribe

© 2021 American Society of Nephrology

Print ISSN - 1555-9041 Online ISSN - 1555-905X

Powered by HighWire