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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Shibata M, Tawada H, Nagai K, Taniguchi S. Supportive Effects of Online Hemodiafiltration Therapy on the Nutritional State and Lipid Profile in Very Elderly Dialysis Patients. Blood Purif 2021; 51:690-697. [PMID: 34695820 DOI: 10.1159/000518704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 07/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Online hemodiafiltration (HDF) therapy has been recognized as one of the potential dialysis modalities. However, the long-term effects of online HDF therapy on very elderly dialysis patients older than 75 years have yet to be fully elucidated. METHODS Seventy-four very elderly patients older than 75 years undergoing maintenance dialysis therapy were studied retrospectively. Twenty-four (mean ± SE, 81.5 ± 1.0 years) were treated by predilution online HDF, and fifty (81.2 ± 0.6 years) were treated by conventional hemodialysis (HD) for 3 years. Laboratory data related to the nutritional state and lipid profile were collected. Body composition was measured by a bioelectrical impedance method. RESULTS Dry weight and body mass index decreased in HD patients (2.9%, p = 0.003 and 3.1%, p = 0.001, respectively), while no significant changes were found in online HDF patients. Serum albumin levels reduced in both HD and online HDF groups (3.5%, p = 0.003 and 2.9%, p = 0.026, respectively). The geriatric nutritional risk index decreased in HD patients (3.0%, p < 0.001), while no significant change was shown in online HDF patients. Body composition analysis demonstrated a significant decrease in intracellular water and increases in extracellular water and edema ratio in both groups. Fat mass and %fat showed significant decreases in HD patients (8.1%, p = 0.003 and 7.3%, p = 0.003, respectively), but no significant changes in online HDF patients. Among laboratory data, serum high-density lipoprotein cholesterol levels did not change in HD patients. However, the levels elevated significantly (10.6%, p = 0.03) in online HDF patients. DISCUSSION/CONCLUSION These results indicated that the time-dependent deterioration of the nutritional state in very elderly dialysis patients was inevitable; however, such deterioration was not prominent in online HDF patients. Moreover, the lipid profile showed unique changes in online HDF patients. In order to treat very elderly dialysis patients, online HDF should preferentially be taken into consideration because the maintenance of general condition seems to be a practical goal against the natural time-dependent deterioration.
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Affiliation(s)
- Masanori Shibata
- Japan Association for Clinical Engineers, Tokyo, Japan.,Department of Hemodialysis, Koujukai Rehabilitation Hospital, Kita-Nagoya, Japan
| | | | - Kojiro Nagai
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Abstract
AbstractEvidence concerning online hemodiafiltration (ol-HDF) includes increased uremic toxin removal, prevention of dialysis-related hypotension, improved survival, and recovery of dialysis-related uncertain symptoms. In particular, evidence has been shown regarding prevention of dialysis hypotension and improvement of survival, but the mechanism of its manifestation is still unclear and its effects themselves are questionable. In Japan, pre dilution ol-HDF is mainly performed, and improvement in survival rate has been shown on the condition of convection volume is 40 L/session or more. In particular, the removal of α1-microglubulin (αMG), which is a medium-middle solute, is targeted. The antioxidant action (Heme Scavenger) of αMG, is presumed, but in dialysis patients, the majority in serum are deteriorated (oxidized) αMG. It has been pointed out that removing the deteriorated αMG by ol-HDF may produce new αMG from the liver and lead to recovery of the original antioxidant effect. However, clinical evidence of this mechanism is desired. Obtaining evidence for the indicated αMG removal activity of ol-HDF will lead to advancement in HDF.
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Zhang ZY, Li MX, Yu H, Zhao J, Xiao FL, Xuan F, Zhao YX. Combination of Multiple Hemodialysis Modes: Better Treatment Options for Patients Under Maintenance Hemodialysis. Ther Clin Risk Manag 2021; 17:127-133. [PMID: 33542633 PMCID: PMC7853439 DOI: 10.2147/tcrm.s288023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/28/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Chronic renal failure has become a major public health concern and treatment strategies are urgently needed. We aimed to investigate whether combination of hemodialysis modes was superior to regular hemodialysis for patients under maintenance hemodialysis. Patients and Methods A total of 144 patients with end-stage renal failure (ESRF) were enrolled in this single-center retrospective study. Patients received regular hemodialysis (HD) were included in HD group (n=52), patients received regular HD plus hemodiafiltration (HDF) in HD/HDF group (n=47), patients received the combination of regular HD, HDF and hemoperfusion (HP) in HD/HDF/HP group (n=45). After 1-month and 24-months treatment, therapeutic effects were assessed in terms of nutritional status, control of complications, dialysis adequacy, mean arterial pressure (MAP), infection rate and living quality. Results When patients received 1-month treatment, there were no statistically significant differences among three groups. After 24-months treatment, patients in HD/HDF and HD/HDF/HP group presented with better dialysis adequacy, lower MAP and infection rate, higher serum albumin, hemoglobin and calcium levels, lower serum phosphorus and intact parathyroid hormone levels, lower incidence of malnutrition and the Hamilton Depression Scale score, higher the Barthel Index score than HD group (P<0.05). The levels of calcium, phosphorus and intact parathyroid hormone in HD/HDF/HP group were lower than those in HD/HDF group (P<0.05). Conclusion Our finding highly indicated that combination of hemodialysis modes was superior to regular HD for patients with ESRF in nutritional status, control of complications, dialysis adequacy, and living quality.
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Affiliation(s)
- Zhi-Yong Zhang
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Ming-Xu Li
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Hai Yu
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Jun Zhao
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Feng-Lin Xiao
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Fang Xuan
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Yi-Xin Zhao
- Department of Nephrology, The Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
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Lee YH, Shin YS, Lee SY, Kim YG, Lee SH, Moon JY, Jeong KH, Hwang HS, Ahn SY, Lee HJ, Lee DY, Ko EJ, Cho HJ, Yang DH, Jeong HY. Effects of online hemodiafiltration on anemia and nutritional status in chronic hemodialysis patients. Kidney Res Clin Pract 2020; 39:103-111. [PMID: 32036641 PMCID: PMC7105619 DOI: 10.23876/j.krcp.19.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/04/2019] [Accepted: 12/04/2019] [Indexed: 12/23/2022] Open
Abstract
Background Online hemodiafiltration (OL-HDF) offers considerable advantages in clearance of molecules of various sizes. However, evidence of clinical effects of OL-HDF is scarce in Korea. In this study, we investigated changes in laboratory values over more than 12 months after switching to OL-HDF. Methods Adult patients with end-stage renal disease undergoing hemodialysis (HD) were prospectively enrolled in a K-cohort (CRIS no. KCT0003281) from 6 tertiary hospitals in South Korea. We recruited 435 patients, 339 of whom were on HD at enrollment. One hundred eighty-two patients were followed for more than 24 months. Among them, 44 were switched to OL-HDF for more than 12 months without conversion to HD. We used a paired t test to compare baseline and 24-month follow-up results. Results The mean age of the subjects was 61.2 ± 12.2 years, and 62.6% were male. The baseline hemoglobin level was not significantly different between HD and OL-HDF group (10.61 ± 1.15 vs. 10.46 ± 1.03 g/dL, P = 0.437). However, the baseline serum protein and albumin levels were significantly lower in the OL-HDF group (6.82 ± 0.49 vs. 6.59 ± 0.48 g/dL, P = 0.006; 3.93 ± 0.28 vs. 3.73 ± 0.29 g/dL, P < 0.001). In patients switched to OL-HDF, levels of hemoglobin and serum albumin significantly increased (10.46 ± 1.03 vs. 11.08 ± 0.82 g/dL, P = 0.001; 3.73 ± 0.29 vs. 3.87 ± 0.30 g/dL, P = 0.001). The normalized protein catabolic rate decreased after 24 months, but the change was not significant (1.07 ± 0.25 vs. 1.03 ± 0.21 g/kg/day, P = 0.433). Although the dose of erythropoiesis-stimulating agent was lower in patients who converted to HDF, it was not significantly different (-115.7 ± 189.7 vs. -170.5 ± 257.1 P = 0.206). Conclusion OL-HDF treatment over more than 12 months was associated with no harmful effects on anemia and nutritional status.
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Affiliation(s)
- Yu Ho Lee
- Division of Nephrology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Yoon Soo Shin
- Division of Nephrology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - So-Young Lee
- Division of Nephrology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Yang Gyun Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ju Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kyung Hwan Jeong
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hong Joo Lee
- Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, Republic of Korea
| | - Dong-Young Lee
- Division of Nephrology, Department of Internal Medicine, VHS Medical Center, Seoul, Republic of Korea
| | - Eun-Jung Ko
- Department of Internal Medicine, Sa-lang Hospital, Ansan, Republic of Korea
| | - Hye Jeong Cho
- Division of Nephrology, Department of Internal Medicine, International Naeun Hospital, Anyang, Republic of Korea
| | - Dong Ho Yang
- Division of Nephrology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Hye Yun Jeong
- Division of Nephrology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
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Canaud B, Vienken J, Ash S, Ward RA. Hemodiafiltration to Address Unmet Medical Needs ESKD Patients. Clin J Am Soc Nephrol 2018; 13:1435-1443. [PMID: 29511057 PMCID: PMC6140578 DOI: 10.2215/cjn.12631117] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hemodiafiltration combines diffusive and convective solute removal in a single therapy by ultrafiltering 20% or more of the blood volume processed using a high-flux hemodialyzer and maintaining fluid balance by infusing sterile nonpyrogenic replacement fluid directly into the patient's blood. In online hemodiafiltration, the large volumes of replacement fluid required are obtained by online filtration of standard dialysate through a series of bacteria- and endotoxin-retaining filters. Currently available systems for online hemodiafiltration are on the basis of conventional dialysis machines with added features to safely prepare and infuse replacement fluid and closely control fluid balance. Hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis, and recently completed randomized, controlled clinical trials suggest better patient survival with online hemodiafiltration compared with standard high-flux hemodialysis when a high convection volume is delivered. Hemodiafiltration is also associated with improvements in other clinical outcomes, such as a reduction in intradialytic hypotension, and it is now used routinely to treat >100,000 patients, mainly in Europe and Japan.
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Affiliation(s)
- Bernard Canaud
- Center of Excellence Medical, Fresenius Medical Care, Bad Homburg, Germany
- University of Montpellier, Research and Training Unit Medicine, Montpellier, France
| | | | - Stephen Ash
- Indiana University Health Arnett Hospital, Lafayette, Indiana
- HemoCleanse Technologies, LLC, Lafayette, Indiana
- Ash Access Technology, Inc., Lafayette, Indiana; and
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Maduell F. Hemodiafiltration versus conventional hemodialysis: Should “conventional” be redefined? Semin Dial 2018; 31:625-632. [DOI: 10.1111/sdi.12715] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Francisco Maduell
- Department of Nephrology; Hospital Clínic Barcelona; Barcelona Spain
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Abe M, Hamano T, Wada A, Nakai S, Masakane I. Effect of dialyzer membrane materials on survival in chronic hemodialysis patients: Results from the annual survey of the Japanese Nationwide Dialysis Registry. PLoS One 2017; 12:e0184424. [PMID: 28910324 PMCID: PMC5598977 DOI: 10.1371/journal.pone.0184424] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 08/23/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Little information is available regarding which type of dialyzer membrane results in good prognosis in patients on chronic hemodialysis. Therefore, we conducted a cohort study from a nationwide registry of hemodialysis patients in Japan to establish the association between different dialyzer membranes and mortality rates. METHODS We followed 142,412 patients on maintenance hemodialysis (female, 39.1%; mean age, 64.8 ± 12.3 years; median dialysis duration, 7 [4-12] years) for a year from 2008 to 2009. We included patients treated with seven types of high-flux dialyzer membranes at baseline, including cellulose triacetate (CTA), ethylene vinyl alcohol (EVAL), polyacrylonitrile (PAN), polyester polymer alloy (PEPA), polyethersulfone (PES), polymethylmethacrylate (PMMA), and polysulfone (PS). Cox regression was used to estimate the association between baseline dialyzers and all-cause mortality as hazard ratios (HRs) and 95% confidence intervals for 1-year mortality adjusting for potential confounders, and propensity score matching analysis was performed. RESULTS The distribution of patients treated with each membrane was as follows: PS (56.0%), CTA (17.3%), PES (12.0%), PEPA (7.5%), PMMA (4.9%), PAN (1.2%), and EVAL (1.1%). When data were adjusted using basic factors, with PS as a reference group, the mortality rate was significantly higher in all groups except for the PES group. When data were further adjusted for dialysis-related factors, HRs were significantly higher for the CTA, EVAL, and PEPA groups. When the data were further adjusted for nutrition-and inflammation-related factors, HRs were significantly lower for the PMMA and PES groups compared with the PS group. After propensity score matching, HRs were significantly lower for the PMMA group than for the PS group. CONCLUSION The results suggest that the use of different membrane types may affect mortality in hemodialysis patients. However, further long-term prospective studies are needed to clarify these findings, including whether the use of the PMMA membrane can improve prognosis.
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Affiliation(s)
- Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Wada
- Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Shigeru Nakai
- Department of Clinical Engineering, Fujita Health University, Aichi, Japan
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Wakamatsu T, Yamamoto S, Kamimura K, Nakatsue T, Iino N, Iguchi S, Kaneko Y, Goto S, Kazama JJ, Narita I. Hemodiafiltration for hepatic encephalopathy induced by Budd-Chiari syndrome in a patient with end-stage kidney disease. CEN Case Rep 2017; 5:125-130. [PMID: 28508963 DOI: 10.1007/s13730-015-0209-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/25/2015] [Indexed: 11/30/2022] Open
Abstract
A 36-year-old woman who was undergoing dialysis for end-stage kidney disease (ESKD) was admitted to our hospital with consciousness disorder. She was diagnosed with Budd-Chiari syndrome due to antiphospholipid syndrome at the age of 28 years. Her kidney function and leg edema gradually deteriorated. After initiation of hemodialysis (HD), transient loss of consciousness due to hepatic encephalopathy during HD treatment occurred frequently. Her kidney replacement therapy was changed to online hemodiafiltration (HDF), which dramatically improved her hepatic coma. Compared with HD, HDF contributed to the increase in Fischer's ratio and decrease in tryptophan level, which has a high protein-bound property. This case suggests that HDF may be beneficial for hepatic encephalopathy in ESKD patients by modulating the amino acid profile.
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Affiliation(s)
- Takuya Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan.
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takeshi Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Noriaki Iino
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Seitaro Iguchi
- Department of Community Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshikatsu Kaneko
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Shin Goto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Junichiro James Kazama
- Blood Purification Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
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Canaud B, Chénine L, Leray-Moraguès H, Patrier L, Rodriguez A, Gontier-Picard A, Moréna M. [Online hemodiafiltration: Practical aspects, safety and efficacy]. Nephrol Ther 2017; 13:189-201. [PMID: 28483384 DOI: 10.1016/j.nephro.2017.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Purification of high molecular uremic toxins by conventional hemodialysis is limited. It remains associated with a high morbidity and excessively high mortality. Online hemodiafiltration using a high permeability hemodiafilter, an ultrapure dialysate, and which tends to maximize substitution volumes, provides a high efficiency and low bio-incompatibility renal supplementation. Regular use of online hemodiafiltration is associated with reduced morbidity (reduction of intradialytic hypotension episodes, improved blood pressure control, reduced inflammatory profile, better anemia correction and prevention of β2-microglobulin-associated amyloidosis). Recently, several cohort studies have shown that hemodiafiltration with high substitution volume was associated with a significant reduction in mortality. Randomized studies have been conducted in Europe to confirm these facts. The high safety of online hemodiafiltration has been confirmed in clinical practice by prospective studies. Online hemodiafiltration has reached its full maturity phase and is expected to represent the new standard of renal replacement therapy.
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Affiliation(s)
- Bernard Canaud
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Association pour l'installation à domicile des épurations rénales (Aider), 746, rue de la Croix-de-Lavit, 34192 Montpellier, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France.
| | - Leïla Chénine
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - Hélène Leray-Moraguès
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Association pour l'installation à domicile des épurations rénales (Aider), 746, rue de la Croix-de-Lavit, 34192 Montpellier, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - Laure Patrier
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France
| | - Annie Rodriguez
- Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - A Gontier-Picard
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - Marion Moréna
- Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
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Watanabe Y, Kawanishi H, Suzuki K, Nakai S, Tsuchida K, Tabei K, Akiba T, Masakane I, Takemoto Y, Tomo T, Itami N, Komatsu Y, Hattori M, Mineshima M, Yamashita A, Saito A, Naito H, Hirakata H, Minakuchi J. Japanese society for dialysis therapy clinical guideline for "Maintenance hemodialysis: hemodialysis prescriptions". Ther Apher Dial 2015; 19 Suppl 1:67-92. [PMID: 25817933 DOI: 10.1111/1744-9987.12294] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kalbfleisch J, Wolfe R, Bell S, Sun R, Messana J, Shearon T, Ashby V, Padilla R, Zhang M, Turenne M, Pearson J, Dahlerus C, Li Y. Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes. J Am Soc Nephrol 2015; 26:2641-5. [PMID: 25882829 DOI: 10.1681/asn.2014050512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 03/14/2015] [Indexed: 12/28/2022] Open
Abstract
Standardized mortality ratios (SMRs) reported by Medicare compare mortality at individual dialysis facilities with the national average, and are currently adjusted for race. However, whether the adjustment for race obscures or clarifies disparities in quality of care for minority groups is unknown. Cox model-based SMRs were computed with and without adjustment for patient race for 5920 facilities in the United States during 2010. The study population included virtually all patients treated with dialysis during this period. Without race adjustment, facilities with higher proportions of black patients had better survival outcomes; facilities with the highest percentage of black patients (top 10%) had overall mortality rates approximately 7% lower than expected. After adjusting for within-facility racial differences, facilities with higher proportions of black patients had poorer survival outcomes among black and non-black patients; facilities with the highest percentage of black patients (top 10%) had mortality rates approximately 6% worse than expected. In conclusion, accounting for within-facility racial differences in the computation of SMR helps to clarify disparities in quality of health care among patients with ESRD. The adjustment that accommodates within-facility comparisons is key, because it could also clarify relationships between patient characteristics and health care provider outcomes in other settings.
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Affiliation(s)
- John Kalbfleisch
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | | | - Sarah Bell
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Rena Sun
- Kidney Epidemiology and Cost Center
| | - Joseph Messana
- Kidney Epidemiology and Cost Center, Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Tempie Shearon
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Valarie Ashby
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Robin Padilla
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Min Zhang
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Marc Turenne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Claudia Dahlerus
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Yi Li
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
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Schiffl H. Impact of advanced dialysis technology on the prevalence of dialysis-related amyloidosis in long-term maintenance dialysis patients. Hemodial Int 2013; 18:136-41. [PMID: 23718290 DOI: 10.1111/hdi.12057] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Dialysis-related amyloidosis (DRA) is a unique type of amyloidosis (beta-2 microglobulin) predominantly in end-stage renal disease. Its clinical manifestations add to increased morbidity and reduced quality of life. There seems to be a relative risk reduction in DRA manifestations when hemodialysis (HD) patients are treated with advanced HD technology, but changes of the course of DRA are uncertain. The aim of our investigation was to evaluate the prevalence and severity of carpal tunnel syndrome (CTS) in long-term dialysis patients receiving either conventional or high-flux, online-produced ultrapure dialysis fluid. The cross-sectional study included 147 HD patients (at least 10 years). The definitive diagnosis of CTS was made histologically or by the coexistence of CTS with other radiological DRA manifestations (bone cysts, arthropathies). The two HD patient groups did not differ significantly in age at start of HD, gender, major co-morbid diseases, anuria, and dialysis vintage. The conventional HD group had significantly higher circulating beta-2 microglobulin and C-reactive protein (CRP) levels. The prevalence of DRA was 68% for the conventional HD group and 28% for the advanced HD group. Duration of dialysis treatment was the only significant risk factor for the development of clinical DRA manifestations in both study groups, but CTS, bone cysts, or arthropathies occurred significantly earlier in conventional HD patients. The prevalence and severity of DRA have decreased with advances in dialysis technology during the last two decades, although its occurrence is simply delayed.
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Affiliation(s)
- Helmut Schiffl
- Department of Internal Medicine IV, University Hospital, Munich, Germany
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Divert to ULTRA: differences in infused volumes and clearance in two on-line hemodiafiltration treatments. Int J Artif Organs 2013; 35:435-43. [PMID: 22669588 DOI: 10.5301/ijao.5000106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mixed diffusive-convective dialysis therapies offer greater removal capabilities than conventional dialysis. The aim of this study was to compare two different on-line, post-dilution hemodiafiltration (HDF) treatments with regard to achieved convective volume and middle-molecule dialysis efficiency: standard volume control (sOL-HDF) and automated control of the transmembrane pressure (TMP) (UC-HDF). METHODS We enrolled 30 ESRD patients (55.9 ± 14.0 years, 20/10 M/F) in a randomized, prospective, cross-over study. The patients received a 3-month period of sOL-HDF followed by UC-HDF for a further 3 months, or vice versa, using the same dialysis machine. In sOL-HDF, fixed exchange volumes were set according to a filtration fraction greater than or equal to 25%. In UC-HDF therapy, the exchanged volume was driven by a biofeedback system controlling the TMP and its set point in a double loop. Patients maintained their treatment time, dialyzer, blood flow rate, and anticoagulant regimen unchanged throughout the study. RESULTS Greater convective volumes were achieved in UC-HDF than in sOL-HDF (23.8 ± 3.9 vs.19.8 ± 4.8 L; p<0.001) with high pre-dialysis Ht value (sOL-HDF 34.0 ± 4.5% and UC-HDF 34.0 ± 4.4%; p = 0.91). The average clearance values of ß2m and P were higher in UC-HDF than in sOL-HDF (respectively 123 ± 24 vs. 111 ± 22 ml/min, p<0.002 and 158 ± 26 vs. 152 ± 25 ml/min, p<0.05). Moreover, the UC-HDF mode led to a significantly increased rate of call-free sessions from 88% to 97% (p<0.0001). CONCLUSIONS This study showed that the biofeedback module, applied to the automatic control of TMP in on-line HDF, results in higher convective volumes and correspondingly higher ß2m and P clearances. By making the HDF treatment more automated and less complex to perform, it significantly reduced the staff workload.
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Ledebo I. Development of hemodiafiltration therapy--a historical perspective. Blood Purif 2013; 35 Suppl 1:6-10. [PMID: 23466371 DOI: 10.1159/000346218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hemodiafiltration (HDF) was created in the late 1970s to combine the best of hemodialysis (HD) and hemofiltration, i.e. superior removal of both small and large solutes. Thus, optimal conditions for both diffusion and convection are required. The need for large volumes of sterile fluid has shaped the evolution of HDF, and regulatory issues around systems for on-line fluid preparation have delayed the clinical development of the therapy. Not until such systems became generally available in the mid-1990 s was it possible to increase the efficiency of HDF therapy to match and exceed the upgrade that had taken place for HD. Results from recent studies indicate that the potential for improving the outcome of dialysis lies in increasing the convective clearance of HDF above that of high-flux HD.
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Sakurai K. Biomarkers for evaluation of clinical outcomes of hemodiafiltration. Blood Purif 2013; 35 Suppl 1:64-8. [PMID: 23466382 DOI: 10.1159/000346364] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
β2-Microglobulin (β2-MG) is the substance that causes dialysis amyloidosis, and its predialysis value is useful for evaluating the quality of dialysis therapy itself. In addition, β2-MG is also an important biomarker for evaluating the removal performance of hemodialysis and hemodiafiltration (HDF). However, since β2-MG has a molecular weight of 11.8 kDa and can be efficiently removed by diffusion with existing high-performance dialyzers, a higher molecular weight substance should be used for evaluating removal performance of HDF, in which diffusion and convection are performed simultaneously. α1-Microglobulin (α1-MG) has a molecular weight of 33 kDa, and it is removed by convection during dialysis. When we used α1-MG to evaluate the removal performance of HDF in a study based on our own cases, we were able to describe the distinctive features and benefits of HDF with precision. α1-MG removal rate exactly paralleled the changes in symptoms. Kt/V and the β2-MG removal rate, however, did not undergo significant changes as the symptoms fluctuated. α1-MG should be used as a biomarker for evaluation of clinical outcomes of HDF.
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Fujimori A. Clinical Comparison of Super High-Flux HD and On-Line HDF. Blood Purif 2013; 35 Suppl 1:81-4. [DOI: 10.1159/000346363] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Tsuchida K, Minakuchi J. Clinical Benefits of Predilution On-Line Hemodiafiltration. Blood Purif 2013; 35 Suppl 1:18-22. [DOI: 10.1159/000346221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Gejyo F, Amano I, Ando T, Ishida M, Obayashi S, Ogawa H, Ono T, Kanno Y, Kitaoka T, Kukita K, Kurihara S, Sato M, Shin J, Suzuki M, Takahashi S, Taguma Y, Takemoto Y, Nakazawa R, Nakanishi T, Nakamura H, Hara S, Hiramatsu M, Furuya R, Masakane I, Tsuchida K, Motomiya Y, Morita H, Yamagata K, Yoshiya K, Yamakawa T. Survey of the Effects of a Column for Adsorption of β2-Microglobulin in Patients With Dialysis-Related Amyloidosis in Japan. Ther Apher Dial 2012; 17:40-7. [DOI: 10.1111/j.1744-9987.2012.01130.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Schmid H, Schiffl H. Hemodiafiltration and survival of end-stage renal disease patients: the long journey goes on. Int Urol Nephrol 2012; 44:1435-40. [DOI: 10.1007/s11255-012-0232-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 06/12/2012] [Indexed: 11/28/2022]
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Stefánsson BV, Abramson M, Nilsson U, Haraldsson B. Hemodiafiltration improves plasma 25-hepcidin levels: a prospective, randomized, blinded, cross-over study comparing hemodialysis and hemodiafiltration. NEPHRON EXTRA 2012; 2:55-65. [PMID: 22619668 PMCID: PMC3350355 DOI: 10.1159/000336482] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background/Aims Data from studies comparing the effect of hemodiafiltration (HDF) and conventional hemodialysis (HD) on clinically important outcomes are insufficient to support superiority of HDF. None of these studies has been participant-blinded. Methods We performed a prospective, randomized, and patient-blinded cross-over study. Twenty patients on chronic HD received either HD for 2 months followed by post-dilution HDF for 2 months or in opposite order. A range of clinical parameters, as well as markers of inflammation, oxidative stress and iron metabolism was measured. Results The two treatments were similar with respect to dialysis-related complications, quality of life, and the biomarkers of oxidative stress and inflammation. Compared to HD, 25-hepcidin and β2-microglobulin were 38 and 32%, respectively, lower after 60 days of HDF (p < 0.001 and p < 0.01, respectively). The consumption of ESA (erythropoietin-stimulating agent) and LMWH (low-molecular-weight heparin) was significantly higher with HDF. Conclusion In short term, HDF is not superior to HD regarding dialysis-related complications. The higher ESA consumption observed with HDF can be explained by blood clotting in tubing and dialyzers, as more anticoagulation was needed with post-dilution HDF. In a longer perspective, lowering serum hepcidin levels may improve pathological iron homeostasis.
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Affiliation(s)
- Bergur V Stefánsson
- Departments of Molecular and Clinical Medicine and Nephrology, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Spiegel B, Bolus R, Desai AA, Zagar P, Parker T, Moran J, Solomon MD, Khawar O, Gitlin M, Talley J, Nissenson A. Dialysis practices that distinguish facilities with below- versus above-expected mortality. Clin J Am Soc Nephrol 2010; 5:2024-33. [PMID: 20876677 DOI: 10.2215/cjn.01620210] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality rates vary widely among dialysis facilities even after adjustment with standardized mortality ratios (SMRs). This variation may occur because top-performing facilities use practices not shared by others, because the SMR fails to capture key patient characteristics, or both. Practices were identified that distinguish top- from bottom-performing facilities by SMR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cross-sectional survey was performed of staff across three organizations. Staff members rated the perceived quality of their units' patient-, provider-, and facility-level practices using a six-point Likert scale. Facilities were divided into those with above- versus below-expected mortality on the basis of SMRs from U.S. Renal Data Service facility reports. Mean Likert scores were computed for each practice using t tests. Practices that were statistically significant (P ≤ 0.05) and achieved at least a medium effect size of ≥0.4 were reported. Significant predictors were entered into a linear regression model. RESULTS Dialysis facilities with below-expected mortality reported that patients in their unit were more activated and engaged, physician communication and interpersonal relationships were stronger, dieticians were more resourceful and knowledgeable, and overall coordination and staff management were superior versus facilities with above-expected mortality. Staff ratings of these practices explained 31% of the variance in SMRs. CONCLUSIONS Patient-, provider-, and facility-level practices partly explain SMR variation among facilities. Improving SMRs may require processes that reflect a coordinated, multidisciplinary environment (i.e., no one group, practice, or characteristic will drive facility-level SMRs). Understanding and improving SMRs will require a holistic view of the facility.
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Affiliation(s)
- Brennan Spiegel
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA.
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Weng CJ, Chang MY, Chen YC, Tian YC, Fang JT, Yang CW. Long-Term Online Hemodiafiltration Does Not Reduce the Frequency and Severity of Acquired Cystic Kidney Disease in Hemodialysis Patients. Ren Fail 2009; 31:555-61. [DOI: 10.1080/08860220903003412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Tiranathanagul K, Praditpornsilpa K, Katavetin P, Srisawat N, Townamchai N, Susantitaphong P, Tungsanga K, Eiam-Ong S. On-line Hemodiafiltration in Southeast Asia: A Three-year Prospective Study of a Single Center. Ther Apher Dial 2009; 13:56-62. [DOI: 10.1111/j.1744-9987.2009.00654.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Les alternatives à l’hémodialyse conventionnelle. Nephrol Ther 2007. [DOI: 10.1016/s1769-7255(07)78755-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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26
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Canaud B, Bragg-Gresham JL, Marshall MR, Desmeules S, Gillespie BW, Depner T, Klassen P, Port FK. Mortality risk for patients receiving hemodiafiltration versus hemodialysis: European results from the DOPPS. Kidney Int 2006; 69:2087-93. [PMID: 16641921 DOI: 10.1038/sj.ki.5000447] [Citation(s) in RCA: 245] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemodiafiltration (HDF) is used sporadically for renal replacement therapy in Europe but not in the US. Characteristics and outcomes were compared for patients receiving HDF versus hemodialysis (HD) in five European countries in the Dialysis Outcomes and Practice Patterns Study. The study followed 2165 patients from 1998 to 2001, stratified into four groups: low- and high-flux HD, and low- and high-efficiency HDF. Patient characteristics including age, sex, 14 comorbid conditions, and time on dialysis were compared between each group using multivariate logistic regression. Cox proportional hazards regression assessed adjusted differences in mortality risk. Prevalence of HDF ranged from 1.8% in Spain to 20.1% in Italy. Compared to low-flux HD, patients receiving low-efficiency HDF had significantly longer average duration of end-stage renal disease (7.0 versus 4.7 years), more history of cancer (15.4 versus 8.7%), and lower phosphorus (5.3 versus 5.6 mg/dl); patients receiving high-efficiency HDF had significantly more lung disease (15.5 versus 10.2%) and received a higher single-pool Kt/V (1.44 versus 1.35). High-efficiency HDF patients had lower crude mortality rates than low-flux HD patients. After adjustment, high-efficiency HDF patients had a significant 35% lower mortality risk than those receiving low-flux HD (relative risk=0.65, P=0.01). These observational results suggest that HDF may improve patient survival independently of its higher dialysis dose. Owing to possible selection bias, the potential benefits of HDF must be tested by controlled clinical trials before recommendations can be made for clinical practice.
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Affiliation(s)
- B Canaud
- Department of Nephrology, Lapeyronie University Hospital, Montpellier, France.
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Kooman JP, van der Sande FM, Beerenhout CM, Leunissen KM. On-Line Filtration Therapies: Emerging Horizons. Blood Purif 2006; 24:159-62. [PMID: 16340182 DOI: 10.1159/000090116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Pozzoni P, Filippo S, Manzoni C, Locatelli F. The relevance of convection in clinical practice: A critical review of the literature. Hemodial Int 2006; 10 Suppl 1:S33-8. [PMID: 16441866 DOI: 10.1111/j.1542-4758.2006.01188.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Convective treatments (high-flux hemodialysis (HD), hemodiafiltration and hemofiltration) are characterized by enhanced removal of middle and large molecular weight solutes compared with conventional low-flux HD. As these molecules are claimed to play an important role in the genesis of many complications of chronic HD, the availability of these techniques represented an intriguing innovation and a possible means to improve the still poor prognosis of HD patients. Here we will critically review the most important published studies comparing convective treatments with low-flux HD on chronic morbidity, preservation of residual renal function, and long-term survival.
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Affiliation(s)
- Pietro Pozzoni
- Department of Nephrology and Dialysis, A. Manzoni Hospital, Lecco, Italy
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Schiffl H. Hemodiafiltration does not increase the risk for mortality in esrd. Am J Kidney Dis 2005; 46:167-8; author reply 168-9. [PMID: 15983973 DOI: 10.1053/j.ajkd.2005.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Furuya R, Kumagai H, Takahashi M, Sano K, Hishida A. Ultrapure dialysate reduces plasma levels of beta2-microglobulin and pentosidine in hemodialysis patients. Blood Purif 2005; 23:311-6. [PMID: 15980621 DOI: 10.1159/000086554] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Accepted: 04/14/2005] [Indexed: 12/24/2022]
Abstract
BACKGROUND beta2-Microglobulin (beta2MG) and carbonyl stress are reported to contribute to the development of dialysis-related amyloidosis. The aim of this study was to determine whether the purity of dialysate affects plasma levels of beta2MG and pentosidine (a surrogate marker of carbonyl stress) in hemodialysis patients. METHODS Sixteen patients on hemodialysis with a polysulfone membrane participated in this study. We switched the dialysate from conventional dialysate (endotoxin level 0.055-0.066 endotoxin units (EU)/ml) to ultrapure dialysate (endotoxin level <0.001 EU/ml), followed patients for 6 months, and then switched back to conventional dialysate once again. Plasma levels of beta2MG, pentosidine, CRP and interleukin-6 (IL-6) were determined before the switch to ultrapure dialysate, 1 and 6 months after the switch to ultrapure dialysate, and 1 month after the switch back to conventional dialysate. RESULTS The switch from conventional to ultrapure dialysate significantly decreased plasma levels of beta2MG, from 30.1 +/- 1.4 to 27.1 +/- 1.4 mg/dl (p < 0.05) and pentosidine, from 1,535.8 +/- 107.5 to 1,267.6 +/- 102.9 nmol/l (p < 0.01) after 1 month of use. The change of dialysate also significantly decreased plasma levels of CRP, from 0.28 +/- 0.09 to 0.14 +/- 0.05 mg/dl (p < 0.05) and IL-6, from 9.4 +/- 2.7 to 3.5 +/- 0.8 pg/ml (p < 0.01) over the 1-month period. These changes in plasma levels of beta2MG, pentosidine, CRP and IL-6 were maintained over 6 months after switching to ultrapure dialysate and returned to basal levels by switching back to a conventional dialysate. CONCLUSIONS Ultrapure dialysate decreases plasma levels of beta2MG, pentosidine and inflammatory markers in hemodialysis patients. The use of ultrapure dialysate might be useful in preventing and/or treating complications of dialysis, such as dialysis-related amyloidosis, atherosclerosis and malnutrition.
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Affiliation(s)
- Ryuichi Furuya
- Renal Division, Department of Internal Medicine, Iwata City Hospital, Iwata, Japan
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Abstract
When introduced in the 1970s, convective dialysis therapies were considered an attractive alternative to hemodialysis (HD), but technical and economical limitations prevented wide clinical application. Today, these therapies (i.e. hemofiltration and hemodiafiltration) are receiving renewed interest from the renal community. The main reason is the disappointment with current chronic dialysis therapy, which despite continuous integration of technical and pharmaceutical progress, has not provided significantly improved survival. The recent HEMO study showed that HD, even when administered at high dose and with high-flux membranes, has reached the limit of benefit for a representative dialysis population. At the same time there is new evidence supporting convective therapies. The extended range of solutes that is removed by convection as opposed to diffusion includes many molecules associated with uremic symptoms and complications. The hemodynamic stability characteristic of convective therapies is confirmed also in comparison with modern HD. Observational data indicates a survival benefit for patients treated with large volumes of convection. Continuously applied convective therapies are the preferred choice in severe cases of acute renal failure, and new membrane development may take these therapies to new applications of blood purification in the intensive care unit.
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Abstract
Hemodiafiltration appears to be the most effective technique of renal replacement therapy but several drawbacks are not counterbalanced by significant advantages. Although optimal transfer for both small and middle molecules can be achieved, there is no difference in mortality risk between HDF and HD patients. The infusion of a large amount of dialysate containing residual acetate of 2-7 mmol/l could lead to impaired cardiac contractile functions and carbonyl stress whereas loss of amino acids and water-soluble vitamins along with high UF rate could lead to malnutrition. Moreover, as substitution fluid is prepared on-line, contaminated fluid could be inadvertently infused to patients. Stringent maintenance rules are required for the production of sterile and non-pyrogenic dialysis solutions. Finally, daily hemodialysis could be the most promising mode of renal replacement therapy since it leads to a more stable 'milieu interieur' than other techniques whatever the mode of solutes removal when performed three times a week.
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Affiliation(s)
- Nguyen Khoa Man
- National Institute of Health and Medical Research, INSERM U507, Department of Nephrology, Hospital Necker, Paris, France.
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Canaud B, Lévesque R, Krieter D, Desmeules S, Chalabi L, Moragués H, Morena M, Cristol JP. On-Line Hemodiafiltration as Routine Treatment of End-Stage Renal Failure: Why Pre- or Mixed Dilution Mode Is Necessary in On-Line Hemodiafiltration Today? Blood Purif 2005; 22 Suppl 2:40-8. [PMID: 15655323 DOI: 10.1159/000081874] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hemodiafiltration (HDF) is a well-recognized treatment modality that offers a way of optimizing renal replacement therapy efficacy of end-stage renal disease (ESRD) patients. On-line production of substitution fluid by the 'cold sterilization' process (ultrafiltration) gives access to an unlimited amount of sterile and non-pyrogenic IV grade solution. This advantageous low-cost solution may therefore be employed to develop various forms of high-flux HDF modalities (ol-HDF). High-flux post-dilutional HDF (post-HDF) has mainly been used in clinical practice since it offers the most efficient and best compromise between diffusive and convective clearances. Nowadays, the new targets in anemia correction have created hemorheological conditions that render high filtration rate more difficult to achieve and/or at the expense of higher transmembrane pressure. To overcome this new challenging condition and keeping the same concept, it has been proposed to develop alternative modalities with various sites of fluid substitution (predilution, mixed pre-post with various percentages) in HDF. In this presentation we discuss the benefits of using pre-HDF and show how to match performances with post-HDF. Potential advantages of new ol-HDF options (pre-, mixed and mid-dilution) that are advocated have to be demonstrated in clinical trials. On-line HDF is a multipurpose treatment method that is employed to improve care and outcomes of ESRD patients. Due to its versatility, ol-HDF should be considered as a technical platform permitting to personalize and tailor treatment to patients' needs. The mode of substitution (post-, pre-, mixed or mid-dilution) should be established according to hemorheological conditions of the individual patient.
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Affiliation(s)
- Bernard Canaud
- Department of Nephrology, Lapeyronie University Hospital, Montpellier, France.
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Ledebo I. Ultrapure Dialysis Fluid – Direct and Indirect Benefits in Dialysis Therapy. Blood Purif 2005; 22 Suppl 2:20-5. [PMID: 15655318 DOI: 10.1159/000081869] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The fluid quality description 'ultrapure' means practically free from bacteria and endotoxin. In quantitative terms it is defined as <0.1 CFU/ml and <0.03 EU/ml. The requirements on endotoxin as well as bacteria should be fulfilled, because these two entities are not strictly correlated. Ultrapure dialysis fluid can be prepared from standard quality fluid by a single step of controlled ultrafiltration. Recent clinical studies demonstrate that the use of ultrapure dialysis fluid in hemodialysis is associated with patient benefits indicating a less inflammatory state compared to hemodialysis with standard fluid. By applying one additional step of controlled ultrafiltration, ultrapure dialysis fluid can be further purified to such high microbiological quality that it can be used for infusion. This opens up the possibility for convective therapies, hemodiafiltration and hemofiltration, for which large volumes of sterile infusion solution are needed. With optimal application of these therapies, solute removal is enhanced, qualitatively as well as quantitatively, and fluid management is facilitated through improved hemodynamic stability.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology, Hospital General de Castellón, Avenue Benicasim s/n, 12004 Castellón, Spain.
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Rabindranath KS, Strippoli GFM, Daly C, Roderick PJ, Wallace SA, MacLeod AM. High-flux versus low-flux haemodialysis membranes for end-stage renal disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2004. [DOI: 10.1002/14651858.cd005016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Ing TS, Chebrolu SB, Kjellstrand CM. “In Search of Optimal Renal Replacement Therapy” Symposium. Hemodial Int 2004; 8:2-3. [DOI: 10.1111/j.1492-7535.2004.00072.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Beta-2 microglobulin is the most widely studied low-molecular-weight protein in end-stage renal disease. It is known to cause dialysis-related amyloidosis (DRA), by virtue of its retention when renal function fails, its deposition in tissues, its aggregation into fibrils, and its ability to become glycosylated. The onset of DRA may be protracted by the use of noncellulosic membranes, especially when high-volume hemodiafiltration is used in the treatment of renal failure. Adsorptive methods have been developed to improve the removal of beta-2 microglobulin. There seems to be a relative risk reduction in mortality when patients are treated with dialysis membranes that have a higher clearance of beta-2 microglobulin.
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Locatelli F, Manzoni C, Di Filippo S. The importance of convective transport. KIDNEY INTERNATIONAL. SUPPLEMENT 2002:115-20. [PMID: 11982825 DOI: 10.1046/j.1523-1755.61.s80.21.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite technological advances in dialysis equipment and modalities, survival, morbidity, and quality of life of hemodialysis patients are still severely affected by acute intradialytic and long-term complications, possibly related to the treatment itself. Convective treatments, such as high-flux hemodialysis, hemodiafiltration, and hemofiltration are increasingly suggested as further improvements over standard diffusive hemodialysis. The membranes used for these techniques are high-flux semisynthetic and synthetic membranes. Characteristics of these membranes are high permeability, which allows convective removal of water and electrolytes and higher clearance of middle and large molecular weight solutes, and high biocompatibility, which minimizes the "inflammatory response" secondary to interactions between blood and the artificial material of the hemodialysis system. METHODS With the specific aim of verifying the superiority of convective treatments in reducing morbidity and mortality, we performed a review of the published literature. RESULTS Some epidemiological studies suggest that convective treatments reduce morbidity and mortality among dialysis patients. However, the results of the published prospective randomized controlled trials are conflicting. Moreover, since convective treatments are usually performed with synthetic biocompatible membranes, it is hard to separate the effect of convection from the effect of biocompatibility. CONCLUSIONS To finally assess the effect of high-flux membranes on morbidity and mortality, the results of two randomized, controlled clinical trials (HEMO study and MPO study) specifically designed with this aim are needed.
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