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Current Controversies in Hemodialysis Therapy The series of commentaries in this issue of Semi- nars in Dialysis relates to controversies over the therapy of patients on hemodialysis. There are many such potential topics; however, I focused on those issues over which there is a continuing debate and where patient outcome is a consideration. The sce- nario was designed such that two noted authorities would discuss opposing points of view in each of the selected topics. Generally, nephrologists and vascular surgeons are neither shy, retiring, nor unopinion- ated, and it was my hope that we would have hearty debates over each of the topics. However, as each of the guest contributors approached the point of ex- pressing written opinion, much more concordance and an interest in avoiding flagrant disagreement was noted. Nonetheless, the differing points of view offered on each of these topics will be rewarding to the reader. Adequacy of dialytic therapy is considered in the discussion of the need for formal urea kinetic mod- eling by Drs. Gotch and Barth, while the appropri- ateness of short-time dialysis, which clearly is guided by the former topic, is discussed by Drs. Parker and Bosch. The need for treatment of hypertriglyceride- mia in dialysis patients to prevent accelerated cardi- ovascular disease is discussed by Drs. Brunzell, Davis, and Rostand. One of the newer vascular diagnostic tests being implemented in the dialysis units is the duplex Doppler. Drs. Martin and Kirk- man debate the need for angiograms, duplex Doppler studies, and early surgery in marginally functioning dialysis accesses. Malnutrition is a well-documented contributor to mortality in dialysis patients and Drs. Wolfson and Bilbrey discuss the pros and cons of intradialytic hyperalimentation. &Microglobulin/ amyloid arthropathy is the new “black plague” of dialysis patients. Drs. Diraimondo, Pollak, and Van- holder discuss the role of dialysis membrane bioin- compatability in this disorder. Many physicians are concerned about a potential increase in access thrombosis with the advent of erythropoietin ther- apy. Drs. Muirhead and Eschbach discuss whether this new drug has indeed affected the incidence of access thrombosis. Newer treatment regimens utiliz- ing vitamin D for hyperparathyroid bone disease include oral pulse and the intravenous route. Drs. Slatopolsky, Delmez, and Malluche discuss current appropriate approaches to the use of 1,25-dihydrox- ycholecalciferol. Finally, Drs. Paganini and Henrich debate the appropriateness of arteriovenous or ven- ovenous continuous therapies as opposed to standard dialysis in unstable patients with acute renal failure. The reader will recognize the above participants as knowledgeable experts, each of whom has made numerous contributions to the literature. We limited the length of discussions to present pertinent infor- mation in a concise fashion. I believe this has been accomplished. The debate on each of the questions may not have been resolved; however, discussion of the issues is nonetheless enlightening. J. Michael Lazarus Director, Clinical Services Nephrology Division Brigham and Women’s Hospital Harvard Medical School Boston, MA 153

Current Controversies in Hemodialysis Therapy

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Current Controversies in Hemodialysis Therapy

The series of commentaries in this issue of Semi- nars in Dialysis relates to controversies over the therapy of patients on hemodialysis. There are many such potential topics; however, I focused on those issues over which there is a continuing debate and where patient outcome is a consideration. The sce- nario was designed such that two noted authorities would discuss opposing points of view in each of the selected topics. Generally, nephrologists and vascular surgeons are neither shy, retiring, nor unopinion- ated, and it was my hope that we would have hearty debates over each of the topics. However, as each of the guest contributors approached the point of ex- pressing written opinion, much more concordance and an interest in avoiding flagrant disagreement was noted. Nonetheless, the differing points of view offered on each of these topics will be rewarding to the reader.

Adequacy of dialytic therapy is considered in the discussion of the need for formal urea kinetic mod- eling by Drs. Gotch and Barth, while the appropri- ateness of short-time dialysis, which clearly is guided by the former topic, is discussed by Drs. Parker and Bosch. The need for treatment of hypertriglyceride- mia in dialysis patients to prevent accelerated cardi- ovascular disease is discussed by Drs. Brunzell, Davis, and Rostand. One of the newer vascular diagnostic tests being implemented in the dialysis units is the duplex Doppler. Drs. Martin and Kirk- man debate the need for angiograms, duplex Doppler studies, and early surgery in marginally functioning dialysis accesses. Malnutrition is a well-documented contributor to mortality in dialysis patients and Drs. Wolfson and Bilbrey discuss the pros and cons of

intradialytic hyperalimentation. &Microglobulin/ amyloid arthropathy is the new “black plague” of dialysis patients. Drs. Diraimondo, Pollak, and Van- holder discuss the role of dialysis membrane bioin- compatability in this disorder. Many physicians are concerned about a potential increase in access thrombosis with the advent of erythropoietin ther- apy. Drs. Muirhead and Eschbach discuss whether this new drug has indeed affected the incidence of access thrombosis. Newer treatment regimens utiliz- ing vitamin D for hyperparathyroid bone disease include oral pulse and the intravenous route. Drs. Slatopolsky, Delmez, and Malluche discuss current appropriate approaches to the use of 1,25-dihydrox- ycholecalciferol. Finally, Drs. Paganini and Henrich debate the appropriateness of arteriovenous or ven- ovenous continuous therapies as opposed to standard dialysis in unstable patients with acute renal failure.

The reader will recognize the above participants as knowledgeable experts, each of whom has made numerous contributions to the literature. We limited the length of discussions to present pertinent infor- mation in a concise fashion. I believe this has been accomplished. The debate on each of the questions may not have been resolved; however, discussion of the issues is nonetheless enlightening.

J. Michael Lazarus Director, Clinical Services Nephrology Division Brigham and Women’s Hospital Harvard Medical School Boston, MA

153