Relationship between effective ionic dialysance and in vivo urea clearance during hemodialysis

Effective ionic dialysance (EID) can be measured from dialyzer inlet and outlet conductivity changes following two steps of dialysate conductivity. Relationships between EID and in vivo urea clearances were studied four times per hemodialysis treatment in eight patients, each undergoing six hemodialysis treatments (192 data sets). Dialyzer blood flow was varied from 190 to 500 mL/min. Dialysate flow was constant (751 to 771 mL/min), and a standard dialyzer (700 HG; Cobe, Lakewood, CO) was used. Double samples were drawn for arterial, venous, and dialysate urea measurements. Two laboratory values were missing. Twelve unreliable laboratory values indicated by divergent results were excluded. Urea clearances were calculated by formulae converting whole-blood to blood-water urea clearances. EID was measured using Diascan (Gambro-Dasco, Medolla, Italy). Mass balance was checked by comparison of dialysate and blood-water urea clearances. Divergent results between dialysate and blood-water urea clearance values led to the exclusion of an additional three laboratory values. A small error (4.2%) in urea mass balance was found (dialysate greater than blood-water urea clearances). A total of 175 data sets were compared. EID showed excellent correlation with blood-water urea clearances (r = 0.92) over the line of identity, with a mean difference of -3.5 mL/min (-1%), and similarly with dialysate urea clearances (r = 0.92; mean difference, -13.4 mL/min; -5%). For both blood- and dialysate-side comparisons, differences increased with greater clearances. Because EID is an effective clearance and urea clearance is a measure of dialyzer clearance, the curves were corrected for cardiopulmonary recirculation; access recirculation was zero (Transonic monitor; Transonic Systems Inc, Ithaca, NY). For cardiopulmonary recirculation correction, cardiac output and access flows were assumed to be 6.4 L and 1.46 L/min. Corrected data show EID correlates with blood-side urea clearance (r = 0.92), with a mean difference of +7.3 mL/min (3.3%), and is constant over the range of clearances. EID correlated with dialysate urea clearance (r = 0.92) with virtually no difference. The difference on the blood side is consistent with the urea mass balance error found. These data indicate that EID using Diascan can provide an accurate indication of effective urea clearances obtained during hemodialysis and is of value in monitoring dialysis adequacy.