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This chapter on the technical and theoretical aspects of intermittent renal replacement therapy is divided into three parts. First we present the equations and theory relating to mass and fluid transfer for the principle forms of... more
This chapter on the technical and theoretical aspects of intermittent renal replacement therapy is divided into three parts. First we present the equations and theory relating to mass and fluid transfer for the principle forms of intermittent therapy: hemodialysis, hemodiafiltration and hemofiltration. This is followed by a discussion of urea kinetics, treatment quantification as Kt/V, and urea generation rate determination in acute renal failure. In the final section, we develop a quantitative framework to guide prescription of intermittent therapy for the acute renal failure patient.
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Urea kinetic modeling (UKM) has been originally proposed by F. Gotch and J. Sargent as a guide to optimize and individualize the dialysis prescription in uremic patients. In a recent report, the US National Cooperative Dialysis Study... more
Urea kinetic modeling (UKM) has been originally proposed by F. Gotch and J. Sargent as a guide to optimize and individualize the dialysis prescription in uremic patients. In a recent report, the US National Cooperative Dialysis Study group, showed the power of this approach compared to conventional methods. It was also concluded that dialysis adequacy could be predicted with a high success rate by determining three parameters; uremia represented by the Urea Time Averaged Concentration, dialysis dose defined as KT/V ratio, and dietary protein intake calculated from the urea generation rate. In spite of its potential usefulness, UKM has not gained clinical acceptance among nephrologists since it appeared always complicated due to its mathematical formulation or cumbersome to be used routinely in dialyzed patients. In this paper the authors will bring the reader from basic concepts to practical use of UKM to guide dialysis strategy. Limits of validity and difficulty in using this approach are also discussed. It is concluded that UKM by using very simple and basic parameters is a practical, and very powerful tool for assessing the dialysis adequacy and nutritional status of dialyzed patients. Direct quantification from dialysate (or ultrafiltrate) collection appeared a simple and precise method which should avoided multiple blood sampling.
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Predilutional [1] and postdilutional hemofiltration (HF) [2] and hemodiafiltration (HDF) [3] have been proposed as alternatives to conventional hemodialysis (HD) for more than a decade, and yet by December 31, 1984, their utilization... more
Predilutional [1] and postdilutional hemofiltration (HF) [2] and hemodiafiltration (HDF) [3] have been proposed as alternatives to conventional hemodialysis (HD) for more than a decade, and yet by December 31, 1984, their utilization remained limited to less than 5% of end-stage renal disease (ESRD) patient population receiving some form of maintenance dialysis in Europe [4]. The restricted application of both HF and HDF contrasts with the claims insisting on marked improvement in dialysis tolerance obtained with convective solute removal, characterized by a reduction in the incidence of symptomatic hypotension and postdialytic fatigue [5–7]. This situation can, at least partly, be explained by the higher cost of HF/HDF induced by the use of commercially prepared sterile apyrogenic electrolyte solutions required to compensate for the large amounts of body fluids removed by convection during each HF/HDF session.
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Choosing a treatment modality for an acute renal failure (ARF) patient is always a challenging problem for the physician [1]. The principal objective is to provide an adequate or even an optimal treatment without adversely affecting... more
Choosing a treatment modality for an acute renal failure (ARF) patient is always a challenging problem for the physician [1]. The principal objective is to provide an adequate or even an optimal treatment without adversely affecting patient outcome, while not further compromising renal functional recovery [2, 3]. One has to match the dialysis dose to the particular patient needs while providing adequate protein and caloric intake. One must also try to prevent further hemodynamic compromise and consequently additional renal injury [2, 3, 4].
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Background Ischaemic end-organ damage during haemodialysis (HD) is a significant problem that may be ameliorated by intradialytic cooling. A randomised trial was performed to compare standard HD (SHD; dialysate temperature 37°C) and... more
Background Ischaemic end-organ damage during haemodialysis (HD) is a significant problem that may be ameliorated by intradialytic cooling. A randomised trial was performed to compare standard HD (SHD; dialysate temperature 37°C) and programmed cooling of the dialysate [thermocontrolled HD (TCHD)] using multiparametric magnetic resonance imaging (MRI) to assess structural, functional and blood flow changes in the heart, brain and kidneys. Methods Prevalent HD patients were randomly allocated to receive either SHD or TCHD for 2 weeks before undergoing serial MRI at four time points: pre-, during (30 min and 180 min) and post-dialysis. MRI measures include cardiac index, myocardial strain, longitudinal relaxation time (T1), myocardial perfusion, internal carotid and basilar artery flow, grey matter perfusion and total kidney volume. Participants then crossed to the other modality to repeat the study protocol. Results Eleven participants completed the study. Separation in blood temperat...
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Despite the significant medical and technical improvements in the field of dialytic renal replacement modalities, morbidity and mortality are excessively high among patients with end-stage kidney disease, and most interventional studies... more
Despite the significant medical and technical improvements in the field of dialytic renal replacement modalities, morbidity and mortality are excessively high among patients with end-stage kidney disease, and most interventional studies yielded disappointing results. Hemodiafiltration, a dialysis method that was implemented in clinics many years ago and that combines the two main principles of hemodialysis and hemofiltration—diffusion and convection—has had a positive impact on mortality rates, especially when delivered in a high-volume mode as a surrogate for a high convective dose. The achievement of high substitution volumes during dialysis treatments does not only depend on patient characteristics but also on the dialyzer (membrane) and the adequately equipped hemodiafiltration machine. The present review article summarizes the technical aspects of online hemodiafiltration and discusses present and ongoing clinical studies with regards to hard clinical and patient-reported outco...
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Background Previous studies suggest that haemodiafiltration reduces mortality compared with haemodialysis in patients with end-stage kidney disease (ESKD), but the controversy surrounding its benefits remains and it is unclear to what... more
Background Previous studies suggest that haemodiafiltration reduces mortality compared with haemodialysis in patients with end-stage kidney disease (ESKD), but the controversy surrounding its benefits remains and it is unclear to what extent individual patients benefit from haemodiafiltration. This study is aimed to develop and validate a treatment effect prediction model to determine which patients would benefit most from haemodiafiltration compared with haemodialysis in terms of all-cause mortality. Methods Individual participant data from four randomized controlled trials comparing haemodiafiltration with haemodialysis on mortality were used to derive a Royston-Parmar model for the prediction of absolute treatment effect of haemodiafiltration based on pre-specified patient and disease characteristics. Validation of the model was performed using internal-external cross validation. Results The median predicted survival benefit was 44 (Q1–Q3: 44–46) days for every year of treatment ...
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Lower dialysate calcium (dCa) concentration and dialysate citric-acidification may positively affect calcification propensity in serum of haemodialysis (HD) patients. However, the accompanying lower ionized blood calcium concentration may... more
Lower dialysate calcium (dCa) concentration and dialysate citric-acidification may positively affect calcification propensity in serum of haemodialysis (HD) patients. However, the accompanying lower ionized blood calcium concentration may lead to a prolonged cardiac action potential, which is possibly pro-arrhythmic. The aim of this study is to investigate the influence of citric-acid dialysate on the QT-interval corrected for heart rate (QTc) compared to conventional dialysate with different dCa concentrations. We conducted a four-week multicentre, randomized cross-over trial. In week one and three patients received acetic-acid dialysate with a dCa of 1.50 mmol/l (A1.5), in week two and four acetic-acid dialysate with a dCa of 1.25 mmol/l (A1.25) or citric-acid dialysate (1.0 mmol/l) with a dCa of 1.50 mmol/l (C1.5) depending on randomization. Patients had continuous ECG monitoring during one session in week one, two and four. The data of 13 patients were available for analysis. Re...
Research Interests: Risk, Calcium, Medicine, Sudden Death, Hemodialysis, and 4 moreFormulas, Citric Acid, QT interval, and hemodiafiltration
Chronic volume overload is pervasive in patients on chronic haemodialysis and substantially increases the risk of cardiovascular death. The rediscovery of the three-compartment model in sodium metabolism revolutionizes our understanding... more
Chronic volume overload is pervasive in patients on chronic haemodialysis and substantially increases the risk of cardiovascular death. The rediscovery of the three-compartment model in sodium metabolism revolutionizes our understanding of sodium (patho-)physiology and is an effect modifier that still needs to be understood in the context of hypertension and end-stage kidney disease. Assessment of fluid overload in haemodialysis patients is central yet difficult to achieve, because traditional clinical signs of volume overload lack sensitivity and specificity. The highest all-cause mortality risk may be found in haemodialysis patients presenting with high fluid overload but low blood pressure before haemodialysis treatment. The second highest risk may be found in patients with both high blood pressure and fluid overload, while high blood pressure but normal fluid overload may only relate to moderate risk. Optimization of fluid overload in haemodialysis patients should be guided by c...
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Background Citric acid–based bicarbonate haemodialysis (CIT-HD) has gained more clinical acceptance over the last few years in France and is a substitute for other acidifiers [e.g. acetic acid (CH3COOH) and hydrochloric acid (HCl)]. This... more
Background Citric acid–based bicarbonate haemodialysis (CIT-HD) has gained more clinical acceptance over the last few years in France and is a substitute for other acidifiers [e.g. acetic acid (CH3COOH) and hydrochloric acid (HCl)]. This trend was justified by several clinical benefits compared with CH3COOH as well as the desire to avoid the consequences of the corrosive action of HCl, but a nationwide clinical report raised concerns about the long-term safety of CIT-HD. The aim of this study was to assess the long-term effects of CIT-HD exposure on patient outcomes in western France. Methods This is a population-based retrospective multicentre observational study performed in 1132 incident end-stage kidney disease patients in five sanitary territories in western France who started their renal replacement therapy after 1 January 2008 and followed up through 15 October 2018. Relevant data, collected prospectively with the same medical software, were anonymously aggregated for the pur...
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Background Fluid overload is frequent among hemodialysis (HD) patients. Dialysis therapy itself may favor sodium imbalance from sodium dialysate prescription. As on-line hemodiafiltration (OL-HDF) requires large amounts of dialysate... more
Background Fluid overload is frequent among hemodialysis (HD) patients. Dialysis therapy itself may favor sodium imbalance from sodium dialysate prescription. As on-line hemodiafiltration (OL-HDF) requires large amounts of dialysate infusion, this technique can expose to fluid accumulation in case of a positive sodium gradient between dialysate and plasma. To evaluate this risk, we have analyzed and compared the fluid status of patients treated with HD or OL-HDF in French NephroCare centers. Method This is a cross-sectional and retrospective analysis of prevalent dialysis patients. Data were extracted from the EUCLID5 data base. Patients were split in 2 groups (HD and OL-HDF) and compared as whole group or matched patients for fluid status criteria including predialysis relative fluid overload (RelFO%) status from the BCM®. Results 2242 patients (age 71 years; female: 39%; vintage: 38 months; Charlson index: 6) were studied. 58% of the cohort were prescribed post-dilution OL-HDF. Co...
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Chronic renal failure and the uremic state lead to accumulation of various endogenous inhibitors of nitric oxide synthase. Previous studies on end-stage uremic patients nitric oxide synthase activity in murine vascular endothelium and... more
Chronic renal failure and the uremic state lead to accumulation of various endogenous inhibitors of nitric oxide synthase. Previous studies on end-stage uremic patients nitric oxide synthase activity in murine vascular endothelium and cytokine-induced macrophage cell lines was shown to be modulated during treatment (Nephrol Dial Transplant 1995; 10: 1386-96). Paired filtration dialysis, a modified hemodiafiltration technique, physically separates convection from diffusion. Plasmas, ultrafiltrates and dialysates from seven uremic patients undergoing paired filtration dialysis performed using ultrapure apyrogen substitution fluid in the absence (first 120 min) or presence (last 120 min) of extracellular fluid reduction were tested for their inhibitory/stimulatory effect on ecNOS, constitutively expressed on t. End 1 cell line, a murine vascular endothelium, or for their inducing effect on iNOS, inducible on J774 cells, a macrophage cell line. On ecNOS, Group 1 (stimulatory, 3/7 patien...
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Stroke prevention in dialysis-dependent patients with atrial fibrillation (AF) is an unresolved clinical dilemma. Indeed, no randomized controlled trial evaluating the efficacy and safety of oral anticoagulants in this population, has... more
Stroke prevention in dialysis-dependent patients with atrial fibrillation (AF) is an unresolved clinical dilemma. Indeed, no randomized controlled trial evaluating the efficacy and safety of oral anticoagulants in this population, has been conducted so far. Observational research on the use of warfarin in patients on dialysis has shown conflicting results. This uncertainty is mirrored by the wide variations in warfarin prescription patterns across centers. We sought to evaluate the association between the use of vitamin K antagonists (VKAs) and mortality among hemodialysis patient with AF and to assess potential factors affecting the risk-benefit profile of warfarin in this population. A total of 91,987 patients registered in the European Clinical Dialysis Database® system from January 2004 to January 2015. Of which, 9,238 patients were identified with a diagnosis of AF. After excluding ineligible patients, a 1:1 propensity score matched cohort of 1,324 warfarin users and non-users ...
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Background: The number of circulating endothelial progenitor cells (EPCs) decreases on account of chronic kidney disease (CKD). Methods: Twenty patients were enrolled in this prospective and randomised study in two parallel arms:... more
Background: The number of circulating endothelial progenitor cells (EPCs) decreases on account of chronic kidney disease (CKD). Methods: Twenty patients were enrolled in this prospective and randomised study in two parallel arms: conventional haemodialysis versus online haemodiafiltration. EPCs number and T-cell activation were analysed at baseline and monthly during a 4-month period of follow-up. Results: CD38bright and HLA-DR+ expression among CD8 memory T cells were negatively associated with both CD34+ (r = -0.70, p = 0.0006) and CD34+ CD133+ (r = -0.62, p = 0.004) cell numbers. Conversely, a positive correlation was observed between CD34+ and CD34+ CD133+ cells with transferrin (r = 0.75, p = 0.0001 and r = 0.47, p = 0.04, respectively), and CD34+ CD133+ cells with transthyretin (r = 0.51, p = 0.02). No significant association was observed between dialysis modality and the evolution of the EPC number. Conclusions: Chronic T-cell activation may be a component of the malnutrition...
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Abstract INTRODUCTION AND AIMS: There is currently no consensus about the indications for therapeutic apheresis, also due to the lack of large clinical trials. A registry where all the data can be organized and analyzed therefore becomes... more
Abstract INTRODUCTION AND AIMS: There is currently no consensus about the indications for therapeutic apheresis, also due to the lack of large clinical trials. A registry where all the data can be organized and analyzed therefore becomes a priority for all professionals ...
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Cardiovascular disease (CVD) is a major burden in dialysis-dependent chronic kidney disease (CKD5D) patients. Several factors contribute to this vulnerability including traditional risk factors such as age, gender, life style and... more
Cardiovascular disease (CVD) is a major burden in dialysis-dependent chronic kidney disease (CKD5D) patients. Several factors contribute to this vulnerability including traditional risk factors such as age, gender, life style and comorbidities, and non-traditional ones as part of dialysis-induced systemic stress. In this context, it appears of utmost importance to bring a closer attention to CVD monitoring in caring for CKD5D patients to ensure early and appropriate intervention for improving their outcomes. Interestingly, new home-used, self-operated, connected medical devices offer convenient and new tools for monitoring in a fully automated and ambulatory mode CKD5D patients during the interdialytic period. Sensoring devices are installed with WiFi or Bluetooth. Some devices are also available in a cellular version such as the Withings Remote Patient Monitoring (RPM) solution. These devices analyze the data and upload the results to Withings HDS (Hybrid data security) platform se...
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ABSTRACTHemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure... more
ABSTRACTHemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure simultaneously induces persistent physiological changes that adversely affect several organs. Dialysis patients experience this systemic stress condition usually thrice weekly and sometimes more frequently depending on the treatment schedule. Dialysis-induced systemic stress results from multifactorial components that include treatment schedule (i.e. modality, treatment time), hemodynamic management (i.e. ultrafiltration, weight loss), intensity of solute fluxes, osmotic and electrolytic shifts and interaction of blood with components of the extracorporeal circuit. Intradialytic morbidity (i.e. hypovolemia, intradialytic hypotension, hypoxia) is the clinical expression of this systemic stress that may act as a disease modifier, resulting in multiorga...
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Online haemodiafiltration (HDF) represents today the most advanced and innovative form of renal replacement therapy (RRT). Recent controlled trials tend to prove its superiority over conventional haemodialysis on hard clinical end points... more
Online haemodiafiltration (HDF) represents today the most advanced and innovative form of renal replacement therapy (RRT). Recent controlled trials tend to prove its superiority over conventional haemodialysis on hard clinical end points provided that the right convective dose was delivered. In this article we report on present prevalent use and epidemiologic trends of HDF worldwide as well as on practice patterns in HDF prescription. In addition we analyze factors that may affect HDF clinical acceptance and more widely its implementation. National and international renal registries provide valuable demographic and epidemiologic information on end stage kidney disease patients on RRT. However, the updating and maintenance of such information system is particularly challenging at a country level and even more so on an international basis. Lag time, incompleteness and/or imprecision of data collection may further hamper precision and validity of data reporting. Fresenius Medical Care ...
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Background: A growing body of scientific evidence indicates that clinical outcomes of hemodialysis patients can be improved with short daily dialysis treatment. Current in-center hemodialysis machines do not fulfill the requirements... more
Background: A growing body of scientific evidence indicates that clinical outcomes of hemodialysis patients can be improved with short daily dialysis treatment. Current in-center hemodialysis machines do not fulfill the requirements needed for self-care home hemodialysis (HHD) treatment. In line with the reviviscence of home therapy, several hemodialysis devices have been developed and deployed for treatment. Physidia S3 is one of these new dialysis delivery systems featuring an appealing design and functionalities intended for daily HHD treatment. Methods: In this French multicenter proof-of-concept study enrolling 13 training centers, we report our preliminary experience with a special focus on quantifying clinical performances in short daily HHD treatment performed during the training period of the patients. Results: Among the 80 patients included in this study, a total of 249 sessions could be analyzed. Dialysis dose, estimated from weekly standardized Kt/V, was maintained at 2....
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The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for... more
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Protein energy malnutrition is recognized as a leading cause of morbidity and mortality in dialysis patients. Protein–energy-wasting process is observed in about 45% of the dialysis population using common biomarkers worldwide. Although... more
Protein energy malnutrition is recognized as a leading cause of morbidity and mortality in dialysis patients. Protein–energy-wasting process is observed in about 45% of the dialysis population using common biomarkers worldwide. Although several factors are implicated in protein energy wasting, inflammation and oxidative stress mechanisms play a central role in this pathogenic process. In this in-depth review, we analyzed the implication of sodium and water accumulation, as well as the role of fluid overload and fluid management, as major contributors to protein–energy-wasting process. Fluid overload and fluid depletion mimic a tide up and down phenomenon that contributes to inducing hypercatabolism and stimulates oxidation phosphorylation mechanisms at the cellular level in particular muscles. This endogenous metabolic water production may contribute to hyponatremia. In addition, salt tissue accumulation likely contributes to hypercatabolic state through locally inflammatory and imm...
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Background: The aim was to compare the effects of high-flux hemodialysis (HF-HD) versus high-volume post-dilution hemodiafiltration (HV-HDF) on mortality risk. Methods: Retrospective observational study of prevalent patients on... more
Background: The aim was to compare the effects of high-flux hemodialysis (HF-HD) versus high-volume post-dilution hemodiafiltration (HV-HDF) on mortality risk. Methods: Retrospective observational study of prevalent patients on hemodialysis who were followed for two years and treated in 28 kidney centers in Colombia. In this study, we included all adult patients who had been on dialysis for at least 90 days treated with an arteriovenous fistula. They were classified as HF-HD if they underwent this treatment exclusively (100% of time). For HV-HDF, if they received this treatment in more than 90% of the observation period. The primary outcome variable was mortality, and the type of hemodialysis therapy was considered as the exposure variable. Propensity score matching (PSM) and Cox regression models were used to evaluate the effect of dialysis modality on the mortality risk. Results: A total of 2933 patients were analyzed, 2361 patients with HF-HD and 572 with HV-HDF. After PSM, 1010 ...
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New physiologic findings related to sodium homeostasis and pathophysiologic associations require a new vision for sodium, fluid and blood pressure management in dialysis-dependent chronic kidney disease patients. The traditional dry... more
New physiologic findings related to sodium homeostasis and pathophysiologic associations require a new vision for sodium, fluid and blood pressure management in dialysis-dependent chronic kidney disease patients. The traditional dry weight probing approach that has prevailed for many years must be reviewed in light of these findings and enriched by availability of new tools for monitoring and handling sodium and water imbalances. A comprehensive and integrated approach is needed to improve further cardiac health in hemodialysis (HD) patients. Adequate management of sodium, water, volume and hemodynamic control of HD patients relies on a stepwise approach: the first entails assessment and monitoring of fluid status and relies on clinical judgement supported by specific tools that are online embedded in the HD machine or devices used offline; the second consists of acting on correcting fluid imbalance mainly through dialysis prescription (treatment time, active tools embedded on HD ma...
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Background: Due to their immunocompromised conditions, hemodialysis (HD) patients are at high risk of being infected with SARS-CoV-2 with poor clinical outcomes. We explored safety, efficacy and variability factors associated with vaccine... more
Background: Due to their immunocompromised conditions, hemodialysis (HD) patients are at high risk of being infected with SARS-CoV-2 with poor clinical outcomes. We explored safety, efficacy and variability factors associated with vaccine immune response in these patients. Methods: From 18 January to 30 April 2021, 87 HD patients were enrolled in this study and subdivided in two sub-groups: SARS-CoV-2 positive prior to vaccination and naïve patients. The vaccination protocol included two intramuscular shots of the mRNA vaccine at a 28-day interval. The vaccine response was evaluated one month after the first and second shots by measuring anti-S antibody titers. Findings: 44% of the patients studied, were women; median age was 58 years. One month after the first shot, 64.3% of patients had anti-S antibody titers < 50 U/mL while 96.5% had anti-S antibody titers > 250 U/mL one month after the second shot. We show that the anti-SARS-CoV-2 spike mRNA vaccine elicits a great tolerab...
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The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of ‘flux’ of membranes as well toxicity... more
The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of ‘flux’ of membranes as well toxicity of compounds that need to be targeted for removal remain unresolved issues, the relative role, efficiency and utilization of solute removal principles to optimize HD treatment are better delineated. Through the combination and intensity of diffusive and convective removal forces, levels of concentrations of a broad spectrum of uremic toxins can be lowered significantly and successfully. Extended clinical experience as well as data from several clinical trials attest to the benefits of convection-based HD treatment modalities. However, the mode of delivery of HD can further enhance the effectiveness of therapies. Other than treatment time, frequency and location that offer clinical benefits and increase patient well-being, treatment- and patient-speci...
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Jüdische Kinder in Erez Israel was the last overtly Jewish-themed photobook published in Germany before the Holocaust. Although it consists only of a six-page introduction by the scholar-activist Bertha Badt-Strauß, one page of captions,... more
Jüdische Kinder in Erez Israel was the last overtly Jewish-themed photobook published in Germany before the Holocaust. Although it consists only of a six-page introduction by the scholar-activist Bertha Badt-Strauß, one page of captions, and twenty-one photographs by photographer Nachum ‘Tim’ Gidal of adorable young children in Mandatory Palestine, its propaganda mission transcends its diminutive size and surface superficiality. This article interprets this photobook as an example of the photo essay, a modernist form that emerged from Weimar Germany’s unique media environment, in which photographs assumed rhetorical and argumentative functions generally associated with written language. To encourage German Jews and particularly German-Jewish women to emigrate, Jüdische Kinder in Erez Israel creates an allegory of the children’s vulnerability by eliciting responses associated with the minor aesthetic category of ‘cuteness’. To this end, it draws on two important photo essay genres of...
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Conventional urea kinetic modelling (UKM) has several drawbacks, in particular the complexity of the required calculations and the need for accurate values of parameters which are difficult to measure, such as dialyzer clearance and blood... more
Conventional urea kinetic modelling (UKM) has several drawbacks, in particular the complexity of the required calculations and the need for accurate values of parameters which are difficult to measure, such as dialyzer clearance and blood flow. An alternative method of UKM is proposed based on collecting a small fraction of spent dialysate flow for 3 consecutive dialyses. Application of a urea mass balance to the 7 day period permits neglecting changes in body urea stores. Thus no blood sampling is required for most patients. The required calculations are simple and straightforward. The partial dialysate collection (PDC) method was compared to conventional UKM in a 3 patient, 15 week study. Protein catabolic rate (PCR) from PDC was a smooth curve and consistent with dietary estimation for each patient. Conventional UKM gave variable PCR results which were 17–27% higher on average. This discrepancy was attributed to overestimation of dialyzer clearance. PDC was concluded to be more c...