Factors that Affect Postdialysis Rebound in Serum Urea Concentration, Including the Rate of Dialysis

Abstract

Abstract. Previous studies have suggested that postdialysis urea rebound is related to K/V, the rate of dialysis, but a systematic analysis of factors that affect rebound has not been reported. With the use of 30-min and, in a subset, 60-min postdialysis samples, postdialysis urea rebound was measured to (1) determine how well previously proposed equations based on the rate of dialysis (K/V) predict rebound in a large sample of patients with varying characteristics, (2) determine whether other factors besides K/V affect rebound, and (3) estimate more precise values for coefficients in prediction equations for rebound. Rebound was calculated relative to both immediate and 20-s postdialysis samples to study early components of rebound unrelated to access recirculation. The equilibrated Kt/V (eKt/V) computed by fitting the two-pool variable volume model to the 30-min postdialysis sample agreed well with eKt/V based on the 60-min postdialysis sample. Using the pre-, post-, and 30-min postdialysis samples for 1245 patients with arteriovenous (AV) accesses, the median intercompartmental mass transfer coefficient (Kc) was 797 ml/min for rebound computed relative to the 20-s postdialysis samples and 592 ml/min relative to the immediate postdialysis samples. K/V was the strongest predictor of rebound among 22 factors considered. Other factors associated with greater rebound for 1331 patients using AV accesses or venous catheters included access type, black race, male gender, absence of congestive heart failure, greater age, ultrafiltration rate, and low predialysis or intradialysis systolic BP. Equations of the form eKt/V ϭ single-pool Kt/V Ϫ B ϫ (K/V) were fit to the data. With AV access, the optimum values for the slope term (B) were 0.39 and 0.46 (in h Ϫ1 ) for single-pool Kt/V calculated based on 20-s postdialysis or immediate postdialysis samples, respectively. For patients using venous catheters, the respective values for B were 0.22 and 0.29. Postdialysis urea rebound can be predicted with acceptable accuracy from a postdialysis sample using a zero-intercept, K/V-based rate equation. Several patient or treatment-specific factors predict enhanced or reduced rebound. Rate equation slope coefficients for K/V of 0.39 (AV access) and 0.22 (venous access) are proposed when a 15-to 20-s slow-flow method is used to draw the postdialysis blood. Slightly higher K/V slope coefficients (0.46 and 0.29, respectively) should be used if a shorter (e.g

Association of Achieved Dialysis Dose with Mortality in the Hemodialysis Study

“…On the basis of data obtained during the trial, the original rate equation was modified to eKt/V ϭ spKt/V Ϫ 0.40 K/V (ϩ 0.01 for patients in the high dose group) for reporting the trial results (31). The modified equation gives eKt/V values approximately 0.06 Kt/V units higher than the original rate equation.…”

Modeled Urea Distribution Volume and Mortality in the HEMO Study

“…We restricted analyses of V m to modeled sessions with Ͻ15 minutes of interruption time and no obvious blood urea nitrogen (BUN) measurement errors (7,10).…”

Kinetic Modeling and Adequacy of Dialysis

“…3. When dialysis is completed, the flow from intracellular to extracellular compartment causes a fast increase of postdialysis urea concentration in plasma, i.e., urea rebound (Daugirdas et al, 2001;Daugirdas et al, 2004), Fig. 3.…”

“…or the formula derived from observations during the HEMO Study (Depner et al, 1999;Eknoyan et al, 2002;Daugirdas et al, 2004):…”

“…Single-pool KT/V overestimates the removed amount of urea because of the postdialysis urea rebound, i.e., a fast postdialysis increase in urea concentration in plasma, which is a compartmental effect; therefore, the equilibrated KT/V (eqKT/V), estimated by the Daugirdas formula, was introduced to clinical practice (Daugirdas et al, 2001). Equilibrated KT/V values can be also calculated using an alternative equation by Daugirdas and Schneditz (Daugirdas & Schneditz, 1995), or the formula derived from observations during the HEMO Study (Depner et al, 1999;Eknoyan et al, 2002;Daugirdas et al, 2004), or that introduced by Tattersall et al (Tattersall et al, 1996). The usage of the KT/V index as a sole and optimal measure of dialysis dose is questioned by many authors.…”