***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Protein requirements in stable , adequately dialysed haemodialysis patients are not known and recommendations vary . It is not known whether increasing the dialysis dose above the accepted adequate level has a favourable effect on nutrition . The aim of this study was to determine whether prescribing a high protein diet and increasing the dose of dialysis would have a favourable effect on dietary protein intake and nutritional status in stable , adequately dialysed haemodialysis patients . Effects on hyperphosphataemia and acidosis were also studied . METHODS Patients were r and omized to a high dialysis dose ( HDD ) group ( target Kt/V(eq ) of 1.4 ) or a regular dialysis dose ( RDD ) group ( target Kt/V(eq ) of 1.0 ) . All patients were prescribed a high protein ( HP ) diet [ 1.3 g/kg of ideal body weight (IBW)/day ] and a regular protein ( RP ) diet ( 0.9 g/kg/day ) , each during 40 weeks in a crossover design . In 50 patients , 23 in the HDD and 27 in the RDD group follow-up was > or = 10 weeks . These patients , aged 56+/-15 years , were included in the analysis . Nutritional status was assessed by anthropometry , plasma albumin and a nutritional index . RESULTS Delivered Kt/V(eq ) in the HDD group ( 1.26+/-0.14 ) was significantly higher than in the RDD group ( 1.02+/-0.08 ) . Protein intake estimated from total nitrogen appearance ( PNA ) measurements and food records ( DPI ) was significantly higher during the HP diet ( PNA(IBW ) , 1.01+/-0.18 g/kg/day ; DPI(IBW ) , 1.15+/-0.18 g/kg/day ) than during the RP diet ( PNA(IBW ) , 0.90+/-0.14 g/kg/day ; DPI(IBW ) , 0.94+/-0.11 g/kg/day ) . Increasing the dialysis dose did not increase protein intake either during the HP or RP diet . Plasma albumin ( 41.9+/-3.0 g/l ) lean body mass ( 107+/-15 % of normal values ) and the nutritional index did not differ between the dialysis dose groups or protein diets and remained stable overtime . Dry body weight ( 97+/-14 % ) and total fat mass increased over time in the HDD group , but remained stable in the RDD group suggesting an effect of dialysis dose on energy balance . There was no effect of the protein diets on dry body weight or total fat mass . Plasma phosphate levels and oral bicarbonate supplements were lower in the HDD group , but were comparable between the protein diets . CONCLUSIONS Prescribing a HP diet result ed in a modest increase in actual protein intake , but increasing dialysis dose did not have a contributing effect . A HP diet or increasing the dialysis dose did not have a favourable effect on the nutritional status . A dietary protein intake of at least 0.9 g/kg IBW/day appears to be sufficient for adequately dialysed haemodialysis patients without overt malnutrition BACKGROUND Dialysis adequacy targets frequently are difficult to achieve in large hemodialysis patients .  Dual dialyzers can be used to improve clearance . It is unknown whether series or parallel configurations are superior . METHODS Eighteen large hemodialysis patients ( mean weight , 92.4 kg ) were enrolled in a r and omized , crossover trial to directly compare dual dialyzers in parallel and series configurations .  Treatment times , blood flow rates , and dialysate flow rates were kept constant . RESULTS Compared with a single dialyzer , parallel dual dialyzers increased the single-pool Kt/V ( spKt/V ) from 1.25 + /- 0.22 to 1.43 + /- 0.29 ( P < 0.003 ) . Series dual dialyzers improved urea clearance measured by spKt/V ( spKt/V(urea ) ) to 1.46 + /- 0.26 ( P < 0.0003 compared with a single dialyzer ) . Kt/V and urea reduction ratio of dual dialyzers in parallel were not significantly different from those of dual dialyzers in series . Half the subjects failed to meet the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative recommended adequacy target for spKt/V(urea ) of 1.2 or less using a single dialyzer . With the use of dual dialyzers , 83 % of subjects achieved this adequacy target . Serum levels of a middle molecule , beta2-microglobulin , were reduced 34 % after 2 months of dual-dialyzer therapy . Cost analysis estimates annual net savings of 1,260 dollars with dual-dialyzer therapy , primarily from projected savings in inpatient expenses . CONCLUSION In large hemodialysis patients , our study shows that dual dialyzers in parallel and series are equally effective at improving urea clearance without prolonging dialysis treatment times BACKGROUND Half of the dialysis population suffers from hyperphosphataemia , which is now recognized as a major factor of haemodialysis ( HD ) morbidity and mortality . Current control is focussed on reducing dietary phosphate intake and diminishing absorption using phosphate binders , whereas control and quantification of phosphate removal by HD is undervalued . The aim of this prospect i ve study was to develop a simple , bedside formula to estimate dialytic phosphate removal in stable HD patients . METHODS This was a prospect i ve , r and omized trial . Phosphate and urea elimination were assessed in a representative group of patients at two dialysis centres using r and omly different dialysers ( 1.3 - 2.4 m(2 ) ) . Quantification was performed by partial dialysate collection , concentration measurements in blood and effluent dialysate spot sample s , and Kt/V(urea ) during st and ard high-flux HD . Multiple linear regression analyses were used in 77 % of all data sets to generate an equation to predict phosphate removal . The formula was vali date d in the remaining 23 % of data sets , in the same group of patients using a large capillary filter , and in diabetic patients treated with a small dialyser at different blood flows ( 200 , 250 , and 300 ml/min ) . RESULTS A formula allowing quantification of phosphate removal within one HD session was developed in 18 of 74 patients during 41 treatments ( 137 out of 177 data sets ) and was determined as : M(PO4pred)=0.1 t -17 + 50c(ds60)+11c(b60 ) , where t is treatment time in min , c(ds60 ) and c(b60 ) are phosphate concentrations in dialysate and plasma measured 60 min into HD in mmol/l , and M(PO4pred ) is estimated phosphate removed in mmol . The precision was remarkable ( r(2)=0.92 - 0.94 ) . The comparison of phosphate and Kt/V(urea ) showed a significant association ( r(2)=0.28 ) , albeit with remarkable scatter . CONCLUSIONS We present the first approach to quantify phosphate removal during high-flux HD by a bedside formula . Only 28 % of the variation in phosphate removal was explained by Kt/V(urea ) . It appears that other factors not adequately accounted for by Kt/V(urea ) affect phosphate removal . Therefore , we propose an individual control and quantification of phosphate removal in HD Dialysis is measured as Kt/V , which scales the dose ( Kt ) to body water content ( V ) . Scaling dialysis dose to body surface area ( S(dub ) ) has been advocated , but the implication s of such rescaling have not been examined . We developed a method of rescaling measured Kt/V to S(dub ) and studied the effect of such alternative scaling on the minimum adequacy values that might then be applied in male and female patients of varying body size . We examined anthropometric estimates of V  and  S  ( Watson vs. Dubois estimates ) in 1765 patients enrolled in the HEMO study after excluding patients with amputations . An S-normalized target stdKt/V was defined , and an adequacy ratio ( R ) was computed for each patient as R = D/N where D = delivered stdKt/V ( calculated using the Gotch-Leypoldt equation for stdKt/V ) and N = the S-normalized minimum target value . In the HEMO data set , we determined the extent to which baseline ( prer and omization ) stdKt/V values would have exceeded such an S-based minimum target stdKt/V. The median V(wat):S(dub ) ratios were significantly higher in men ( 21.34 ) than in women ( 18.50 ) . The average of these ( 20 ) was used to normalize the current suggested minimally adequate value ( stdKt/V > or = 2.0/week ) to the S-normalized target value ( stdKt/S > or = 40 L/M(2 ) ) , assuming that average modeled V = average anthropometric V. To achieve this S-normalized target , the required single-pool ( sp ) Kt/V was always higher in women than in men at any level of body size . For small patients ( V(wat ) = 25L ) , required stdKt/V values were 2.05 and 2.21/week for men and women , respectively , corresponding to spKt/V values of 1.31 and 1.52/session . On the other h and , large ( V(wat ) = 50L ) male patients would need spKt/V values of only 1.0/session . Prer and omization baseline dialysis sessions in the HEMO study were found to meet such a new S-based st and ard in almost all ( 766/773 ) men and in 885/992 women . An analysis of scaling dose to anthropometrically estimated liver size ( L ) showed similar gender ratios for V(wat):L and V(wat):S(dub ) , providing a potential physiologic explanation underpinning S-based scaling . S-based scaling of the dialysis dose would require considerably higher doses in small patients and in women , and would allow somewhat lower doses in larger male patients . Current dialysis practice would largely meet such an S-based adequacy st and ard if the dose were normalized to a V(wat):S(dub ) ratio of 20 BACKGROUND Using st and ard hemodialysis regimens , overweight patients often do not reach Kidney Disease Outcomes Quality Initiatives ( KDOQI ) Kt/V targets , and this has been associated with lower health-related quality of life ( HRQL ) . Whether increasing dialysis adequacy in large patients not achieving KDOQI targets improves HRQL is unknown . STUDY DESIGN R and omized blinded crossover study . SETTING & PARTICIPANTS Overweight ( > 80 kg ) underdialyzed patients from 6 dialysis units in 2 Canadian dialysis programs . INTERVENTIONS Six-week treatment periods with a st and ard dialysis regimen ( 4 hours 3 times weekly ) and 3 augmented regimens : 4.5 hours of hemodialysis , 4 hours of hemodialysis with increased dialysate flow , and 4 hours of hemodialysis with 2 dialyzers in parallel . OUTCOMES & MEASUREMENTS The End-Stage Renal Disease Symptom domain of the Kidney Disease Quality -of-Life Short-Form question naire ( primary outcome ) and the Health Utilities Index Mark 2 ( secondary outcome ) . RESULTS We enrolled 18 patients ( mean weight , 109.7 + /- 16.2 [ SD ] kg ) ; 12 completed all 4 regimens .  Mean Kt/Vs during the study were 1.27 ( 95 % confidence interval [ CI ] , 1.19 to 1.35 ) , 1.41 ( 95 % CI , 1.32 to 1.50 ) , 1.31 ( 95 % CI , 1.22 to 1.39 ) , and 1.41 ( 95 % CI , 1.33 to 1.49 ) for patients receiving st and ard dialysis , 4.5 hours of hemodialysis , hemodialysis with increased dialysate flow , and hemodialysis with 2 dialyzers , respectively . Kidney Disease Quality -of-Life End-Stage Renal Disease Symptom domain and Health Utilities Index Mark 2 scores were 75.9 ( 95 % CI , 70.7 to 81.2 ) and 0.69 ( 95 % CI , 0.56 to 0.81 ) for patients receiving st and ard dialysis , respectively . These did not differ when patients received the 3 augmented dialysis regimens ( P = 0.2 and P = 0.5 , respectively ) . LIMITATIONS Small sample size and inability to fully blind patients to the treatment they were receiving . CONCLUSION Improving hemodialysis adequacy for large underdialyzed patients did not lead to improved HRQL . Our findings suggest that augmentation of the dialysis regimen is not required for these patients in the absence of overt uremic symptoms BACKGROUND Muscle cramp is a common complication of  haemodialysis .  The exact mechanism of this complication is still unknown . Many approaches have been used to relieve the muscle cramping but have had variable 
    Output:
    
None of the studies defined adequacy of dialysis as a patient relevant outcome such as survival or quality of life .
Patients had a substantially different underst and ing of the construct dialysis adequacy than the biochemical interpretation reported in the literature .
Being alive , time spent while being on dialysis , fatigue and friendliness of staff were the most prominent themes that patients linked to the construct of dialysis adequacy .
Conclusion Adequacy of dialysis as reported in the literature refers to biochemical outcome measures , most of which are not related with patient relevant outcomes .
For patients , adequate dialysis is a dialysis that enables them to spend as much quality time in their life as possible