Ancillary studies
Ancillary protocols
1) Short operative protocol for the “LUST-BIA subproject”
SPECIFIC
STUDY SHEETS WILL BE DISTRIBUTED AT REQUEST TO CENTRES PARTICIPATING
INTO THIS SUBPROJECT
LUST-BIA Substudy coordinator: Prof. Dr. Adrian Covic (Iasi, Romania) accovic@gmail.com
Inclusion criteria
All patients included in the LUST study, at
centers
equipped with a
Body Composition
Monitoring ( BCM ) device, agreeing to take part in the LUST-BIA subproject, are eligible.
Exclusion criteria
Patients with contraindication for performing bioimpedance measurements (limb amputation,
stent, pregnancy, severe ascites, decompensated cirrhosis) should be excluded.
The center will use a TETRAPOLAR bioimpedance device (BCM - Body Composition Monitor,
Fresenius). The following standard parameters generated by the BMC monitor will be “the study
parameters”:

Overhydration

Total body water

Extracellular water

Intracellular Water

Lean Tissue Mass

Fat Tissue Mass

Body Mass Index.
Additional parameters will also be saved: pre-dialysis weight and prescribed ideal weight.
Frequency of measurement
In both the US-lung scans (active) arm and the control arm, bioimpedance measurements will be
performed at least every 3 months (or more frequently, ideally at 1 month intervals ).
The body composition should be determined 5 minutes before dialysis using the portable wholebody multifrequency bioimpedance analysis device (Body Composition Monitor - BCM® - Fresenius
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Medical Care). The technique involves attaching electrodes to the patient’s non-fistula forearm
and ipsilateral ankle, with the patient in a supine position. All BIA measurements will be
performed by trained BCM personnel.
Nephrologists involved in the LUST study should remain blind to bioimpedance measurements.
This is to avoid that these data could be used for planning of dialysis sessions. To ensure the
blinding of the bioimpedance measurements, all determinations should be performed by an
independent investigator with prior BCM training (for example a dialysis nurse). The
independent investigator will also be responsible for the collection of the raw data in a separate
database that will be sent to the coordinating centre every 6 months.
Furthermore, in centres which already uses the BCM device, all patients included in this substudy
must be “washed out” from any previous BCM-guided ultrafiltration protocol.
The software provided with the Body Composition Monitor by Fresenius allows to extract a file
which contains the full BIA report. This file should be sent to Prof. Covic (accovic@gmail.com) as
well as to the coordinating centre (gtripepi@hotmail.com ).
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2) Short operative protocol for the “Arterial stiffness and aortic pressure
measurements for LUST” subproject
SPECIFIC STUDY SHEETS WILL BE DISTRIBUTED AT REQUEST TO CENTRES PARTICIPATING INTO
THIS SUBPROJECT
LUST-PWV Substudy coordinator: Prof. Dr. Gerard London (France) glondon@club-internet.fr
Inclusion criteria
All patients included in the LUST study are eligible for this subproject.
Frequency of measurement
Measurements should be preferentially performed in a non dialysis day, concurrently with
echocardiography, at baseline and at 6, 12, 24 months in both treatment and control group. In
case this is not possible, it could be measured both before or after dialysis (always with the
simultaneous measure of blood pressure) in the dialysis day closest to the echocardiography
study. For example if Echocardiography is performed on a Thursday (dialysis interval-day),
arterial stiffness can be measured either on the preceding Wednesday (both before and after
dialysis) or on the following Friday (again, both pre- and post-dialysis).
Methods
Measurements should be done in quiet ambiance and stable room temperature. They should be
preceded by 15-minutes rest in supine position to allow a stable blood pressure recording
(mandatory for calibrations). Blood pressure can be measured by automatic validated apparatus
(type Omron), at least 3 times at 1 minute interval, if not Korotroff phases I and V are prerequisite.
No meals, smoking or caffeine are allowed at least 3 hours before the measurement. Sleeping or
speaking should be avoided.
For aortic PWV and aortic pressure recording (by sphygmotonometry) the right carotid artery is
preferred. The measure should be recorded during at least one respiratory cycle (5-6 s), or better
with 10 pressure waves.
The quality of the record should be good. Autovalidation is provided by the systems used, whether
it is Complior or Sphygmocor. For the latest one the reproducibility should be <5% for the diastolic
and systolic parts of the curve. For Sphygmocor measurements verify that heart rate did not
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change significantly. The mean of two measurements is the minimum. If the difference between
the two measures is >0.5 m/s, take a third measure and use the median value.
Measure carotid-femoral distance in a straight line (L) with infantometer. Multiply the recorded
distance by 0.80 for PWV calculation (0.8*L/transit time), but for quality control report 3
measures: carotid-femoral straight line; carotid-suprasternal notch distance; suprasternal notchfemoral artery distance.
Repeated measures during the follow-up should be done in the same conditions as the first one,
i.e. same time of the day.
Aortic PWV is the principal measure, brachial PWV is also useful.
The principal parameters recorded by Sphygmocor and applanation tonometry are aortic
systolic/mean/diastolic/pulse pressures (radial artery pressures is automatically reported);
Augmentation index (radial and aortic)
Left ventricular ejection time/heart period; mean aortic systolic and mean aortic diastolic
pressures to evaluate Buckberg index.
In conclusion the mandatory parameters should be: Aortic PWV-Aortic systolic and Pulse pressureAortic Augmentation index – Buckberg index (5 parameters).
Information about PWV measurements should be provided by each participant centre by typing
data directly in the dedicated sheet in the web-site (see Case Report Form Manual, page 17).
Furthermore, each PWV examination should be uploaded (in pdf format) in the uploading area of
the website specific for each centre (see Case Report Form Manual, pages 20-21). The group of
Prof. London will take care of the data validation.
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3) Short operative protocol for the “ LUST-BNP” subproject
SPECIFIC STUDY SHEETS WILL BE DISTRIBUTED AT REQUEST TO CENTRES PARTICIPATING
INTO THIS SUBPROJECT
LUST-BNP Substudy coordinator: Prof. Dr. Danilo Fliser (Germany) Danilo.Fliser@uniklinikum-saarland.de
Inclusion criteria
All patients included in LUST study are eligible for this subproject.
Blood sampling protocol and bio-banking
Blood sampling for measurement of NT-proBNP and other biomarkers should be performed
serially, before the start of a mid-week dialysis treatment, in parallel with the echocardiographic
assessment at baseline, after 6, 12 and 24 months.
For measurement of NT-proBNP blood should be drawn from a dialysis syringe in a blood
collecting tube containing potassium EDTA (K2EDTA) as detailed above (see “Biobanking” at
pages 12-13). For centres participating only to this subproject (but not to the biobanking project,
see pag. 12-13) just 2 serum or plasma aliquots of 0.5 ml will suffice.
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4) Short operative protocol for the “LUST-24h Ambulatory Blood Pressure
Measurement (ABPM)” subproject
SPECIFIC STUDY SHEETS WILL BE DISTRIBUTED BY REQUEST TO CENTRES PARTICIPATING INTO
THIS SUBPROJECT
LUST-24h ABPM Substudy coordinator: Dr.Francesca Mallamaci (Italy) francesca.mallamaci@libero.it
Information about 24h ABPM measurements should be provided by each participant centre by
typing data directly in the dedicated sheet in the web-site (see Case Report Form Manual, page
17). At the same time, each 24h ABPM examination should be uploaded (in .abp format) in the
uploading area of the website specific for each centre (see Case Report Form Manual, pages 2021). Dr Bilo will take care of the data validation.
24h ABPM should be started in a mid-week non-dialysis day and cover a 24h period (we strongly
advice to perform a 25h monitoring in order to compensate possible missing measurements).
Measurement intervals should be 15 minutes both during the day and the night.
24h ABPM should be started preferably in the morning hours (9 A.M.-11 A.M.).
All used devices should meet the criteria of the AAMI recommendations (Spacelab is the preferred
device).
24h ABPM should be done at baseline and repeated after 6 months.
The placement of the device should be preceded by a standard measurement with a calibrated
sphygmomanometer. If a difference higher than ±10 mmHg for systolic and ±5 mmHg for diastolic
BP is found between the sphygmomanometric measurement and the first measurement by the
24h ABPM device, the cuff should be checked and/or replaced.
The cuff should be placed in the non-fistula arm.
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Appendix 1 - Cardiovascular drugs administration in patients where the
treatment goal (LC<15) is not achieved by UF alone (see KDIGO consensus
document, Kidney Int 2010; 77: 273–284).
Carvedilol will be started at the dose of 3.125 mg twice a day for two weeks in order to test
tolerance to this drug. In patients able to tolerate carvedilol, the dose will doubled at two-week
intervals to a target dose of 25 mg twice a day. When the dose increase is not tolerated for the
appearance of adverse reactions such as HR >50 beats/min or arterial hypotension (BP>90/60 mm
Hg), the dose will be halved (Cice G et al, JACC 2003). If the trial goal (<15 LC) is not achieved and
the treatment is tolerated a second drug will be added.
Fosinopril will be started at a dose of 5 mg (QD). Blood pressure will be measured every 30 min for
4–6 h after administration of this dose. Patients who will tolerate the initial dose will enter into a
3- to 6-week up-titration period. The dose will be increased weekly in increments of 5mg until the
target dose of 20 mg daily will be achieved. This drug does not require any specific supplement to
compensate dialysis losses.
Other options are possible but these will require supplementary doses for dialysis.
ACE INHIBITORS

Ramipril (trial dose 2.5 mg) titrated to 10 mg QD. Supplement after dialysis 2.5 mg.

Trandolapril (trial dose 1 mg) titrated to 4 mg QD. Supplement for dialysis 0.5 mg.

Lisinopril (trial dose 2.5 mg) titrated to 10 mg QD. Supplement after dialysis 2.5 mg.

Benazapril (trial dose 5 mg) titrated to 20 mg QD. Supplement after dialysis 5-10 mg.

Enalapril (trial dose 2.5 mg) titrated to 10 mg QD. Supplement after dialysis 2.5 mg.
SARTANS (may be used as an alternative to ACE inhibitors)

Losartan (trial dose 25 mg) titrated to 100 mg QD. NO supplement after dialysis needed.

Valsartan (trial dose 40 mg) titrated to 320 mg QD. “

Irbesartan (trial dose 75 mg) titrated to 300 mg QD. “

Telmisartan (trial dose 20 mg) titrated to 80 mg QD. “

Candesartan (trial dose 4 mg) titrated to 32 mg QD. “

Olmesartan (trail dose 10 mg) titrated to 40 mg QD. “
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Appendix 2 – List of standard, routine measurements.

Pre dialysis Urea

Post dialysis Urea

Serum Creatinine

24h Urinary Creatinine

GOT

GPT

Albumin

Total Cholesterol

HDL

LDL

Triglycerides

C Reactive Protein

Haemoglobin

Ferritin

Calcium

Phosphorous

PTHi

25 OH vit. D

Iron

Transferrin

Glucose

HBsAg

HBs antibodies

HCV antibodies

CMV antibodies
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