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Pedreros-Rosales C, Jara A, Lorca E, Mezzano S, Pecoits-Filho R, Herrera P. Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond. Toxins (Basel) 2023; 15:531. [PMID: 37755957 PMCID: PMC10535648 DOI: 10.3390/toxins15090531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.
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Affiliation(s)
- Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción 4070386, Chile
- Nephrology Service, Hospital Las Higueras, Talcahuano 4270918, Chile
| | - Aquiles Jara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Eduardo Lorca
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
| | - Sergio Mezzano
- Instituto de Medicina, Facultad de Medicina, Universidad Austral, Valdivia 5110566, Chile
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI 48108, USA
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Patricia Herrera
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
- Nephrology Service, Hospital del Salvador, Santiago 8320000, Chile
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Mizuiri S, Nishizawa Y, Doi T, Okubo A, Shigemoto K, Usui K, Arita M, Naito T, Doi S, Masaki T. Convection volume, β2-microglobulin and α1-microglobulin reduction ratios, and body composition in predilution online haemodiafiltration. Nephrology (Carlton) 2022; 27:601-609. [PMID: 35278013 DOI: 10.1111/nep.14038] [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: 12/14/2021] [Revised: 02/24/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
Abstract
AIM The effect of convection volume (CV) in patients on predilution online haemodiafiltration (Pre-OL-HDF) was evaluated. METHODS We conducted a retrospective, cross-sectional study in 126 patients on Pre-OL-HDF. Dialysis conditions, laboratory data, and same day post-dialysis body composition measurements using bioimpedance spectroscopy were assessed. Patients were divided into two groups according to their CV: ≥ median value and < median value. Linear regression analyses for reduction ratios (RRs) of β2-microglobulin and α1-microglobulin, and body composition, were conducted. RESULTS Age, dialysis vintage, and CVs of the study patients were 64 ± 12 years, 81 (48-154) months, and 43.2 (38.5-55.9) L/session, respectively. The higher CV (≥ 43 L/session) group (n=66) had significantly higher RRs of β2-microglobulin and α1-microglobulin, lean tissue index, body cell mass index, total body water (TBW), extracellular water (ECW), and intracellular water (ICW) compared with the lower CV (< 43 L/session) group (n = 60; P < 0.01). Serum albumin and fat tissue index were not significantly different between the groups. CV/ECW, CV/TBW, and CV/ICW but not un-adjusted CV, were significant determinants for β2-microglobulin and α1-microglobulin RRs (P < 0.05). Lean tissue and body cell mass indexes, but not the fat tissue index, showed significant associations with CV, and RRs of β2-microglobulin and α1-microglobulin (P < 0.05). CONCLUSIONS Among patients on Pre-OL-HDF, higher values in the lean tissue index and body cell mass index were observed in those with higher CV versus lower CV, and CV adjusted to body water may be useful to prescribe individualized conditions for Pre-OL-HDF. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sonoo Mizuiri
- Division of Nephrology, Ichiyokai Harada Hospital, 7-10 Kairoyama-cho, Saeki-ku, Hiroshima, Japan
| | - Yoshiko Nishizawa
- Division of Nephrology, Ichiyokai Harada Hospital, 7-10 Kairoyama-cho, Saeki-ku, Hiroshima, Japan
| | - Toshiki Doi
- Division of Nephrology, Ichiyokai Harada Hospital, 7-10 Kairoyama-cho, Saeki-ku, Hiroshima, Japan.,Department of Nephrology, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, Japan
| | - Aiko Okubo
- Division of Nephrology, Ichiyokai Harada Hospital, 7-10 Kairoyama-cho, Saeki-ku, Hiroshima, Japan.,Department of Nephrology, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, Japan
| | - Kenichiro Shigemoto
- Division of Nephrology, Ichiyokai Harada Hospital, 7-10 Kairoyama-cho, Saeki-ku, Hiroshima, Japan
| | - Koji Usui
- Ichiyokai Ichiyokai Clinic, 10-3 Asahien, Saeki-ku, Hiroshima, Japan
| | - Michiko Arita
- Iciyokai East Clinic, 1-3-53 Danbaraminami Minami-ku, Hiroshima, Japan
| | - Takayuki Naito
- Ichiyokai Yokogawa Clinic, 2-7-9 Yokogawacho Nishi-ku, Hiroshima, Japan
| | - Shigehiro Doi
- Department of Nephrology, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, Japan
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Canaud B, Blankestijn PJ, Grooteman MPC, Davenport A. Why and how high volume hemodiafiltration may reduce cardiovascular mortality in stage 5 chronic kidney disease dialysis patients? A comprehensive literature review on mechanisms involved. Semin Dial 2021; 35:117-128. [PMID: 34842306 DOI: 10.1111/sdi.13039] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
Online hemodiafiltration (HDF) is an established renal replacement modality for patients with end stage chronic kidney disease that is now gaining rapid clinical acceptance worldwide. Currently, there is a growing body of evidence indicating that treatment with HDF is associated with better outcomes and reduced cardiovascular mortality for dialysis patients. In this comprehensive review, we provide an update on the potential mechanisms which may improve survival in HDF treated patients. The strongest evidence is for better hemodynamic stability and reduced endothelial dysfunction associated with HDF treatments. Clinically, this is marked by a reduced incidence of intradialytic hypotensive episodes, with a better hemodynamic response to ultrafiltration, mediated by an increase in total peripheral vascular resistance and extra-vascular fluid recruitment, most likely driven by the negative thermal balance associated with online HDF therapy. In addition, endothelial function appears to be improved due to a combination of a reduction of the inflammatory and oxidative stress complex syndrome and exposure to circulating cardiovascular uremic toxins. Reports of reversed cardiovascular remodeling effects with HDF may be confounded by volume and blood pressure management, which are strongly linked to center clinical practices. Currently, treatment with HDF appears to improve the survival of dialysis patients predominantly due to a reduction in their cardiovascular burden, and this reduction is linked to the sessional convection volume exchanged.
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Affiliation(s)
- Bernard Canaud
- Department of Nephrology, Montpellier University, Montpellier, France.,Global Medical Office, FMC, Deutschland, Bad Homburg, Germany
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Muriel P C Grooteman
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital. University College London, London, UK
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Expanded home hemodialysis: case reports. Int Urol Nephrol 2020; 52:977-980. [DOI: 10.1007/s11255-020-02455-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/27/2020] [Indexed: 12/18/2022]
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Schiffl H. Online hemodiafiltration and mortality risk in end-stage renal disease patients: A critical appraisal of current evidence. Kidney Res Clin Pract 2019; 38:159-168. [PMID: 31137926 PMCID: PMC6577208 DOI: 10.23876/j.krcp.18.0160] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/24/2019] [Accepted: 03/10/2019] [Indexed: 12/15/2022] Open
Abstract
The life expectancy of end-stage renal disease patients undergoing regular hemodialysis (HD) remains significantly lower than in the general population. Reducing excess mortality by improving renal replacement options is an unmet medical need. Online post-dilution hemodiafiltration (HDF) has been promoted as the gold standard, offering improved clinical outcomes, based on numerous observational studies that suggest a reduced mortality risk and lower morbidity with HDF compared with standard HD. However, most randomized controlled trials (RCTs) have failed to demonstrate a significant beneficial effect of HDF on all-cause mortality. The effects on secondary outcomes were often negligible or absent. Unfortunately, these RCTs were characterized by a moderate to high risk of bias. In post-hoc analyses of the largest RCTs and meta-analysis of individual participant data from four RCTs, HDF patients receiving the highest convection volume consistently and dose-dependently saw superior outcomes. However, as these studies were not designed a priori to clarify this issue, and there are no indisputable mechanisms underlying reduced mortality risks, we cannot exclude the possibility that the health status of patients (with vascular access as a proxy) may affect outcomes more than the convective technique itself. There is currently insufficient evidence to support the contention that high-volume HDF confers relevant benefits to patients over standard HD. The conflicting data of published RCTs reduce confidence in the superiority of high-volume convective therapy. Hopefully, ongoing large RCTs (for example, CONVINCE) may supply an indisputable answer to the crucial question of high-volume HDF.
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Affiliation(s)
- Helmut Schiffl
- Department of Internal Medicine IV, Medical Center of the University of Munich, Munich, Germany
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Piccoli GB, Cabiddu G, Breuer C, Jadeau C, Testa A, Brunori G. Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices? J Clin Med 2019; 8:jcm8020276. [PMID: 30823518 PMCID: PMC6406585 DOI: 10.3390/jcm8020276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 12/15/2022] Open
Abstract
Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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Santos García A, Macías Carmona N, Vega Martínez A, Abad Estébanez S, Linares Grávalos T, Aragoncillo Sauco I, Verdalles Guzmán U, Panizo González N, Cruzado Vega L, López Gómez JM. Removal capacity of different high-flux dialyzers during postdilution online hemodiafiltration. Hemodial Int 2018; 23:50-57. [PMID: 30367698 DOI: 10.1111/hdi.12685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/02/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The aim of this study is to compare molecule removal and albumin leakage in postdilution online hemodiafiltration with different high-flux dialyzers. METHODS We studied seven high-flux dialyzers (Polyflux 210H®, Evodial 2.2®, FxCordiax1000®, Elisio21H®, TS-2.1SL®, XevontaHi20®, VitaPES 210-HF®) in 6 patients. The reduction ratio (RR) of small- and middle-sized molecules was calculated. Dialysate samples were collected to estimate the albumin leakage. FINDINGS Global differences between dialyzers were observed in the RR of ß2 microglobulin (P =0.003) and prolactin (P =0.013). The mean loss of albumin in the dialysate per session varied between 114 ± 67 mg (with Evodial 2.2) and 2621 ± 1363 mg per session (with XevontaHi20). We found global differences between dialyzers in total albumin loss (P = 0.05). DISCUSSION We demonstrated that the performance of high-flux dialyzers was different among the types and that not all high-flux dialyzers should be considered equal.
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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García-Prieto A, Vega A, Linares T, Abad S, Macías N, Aragoncillo I, Torres E, Hernández A, Barbieri D, Luño J. Evaluation of the efficacy of a medium cut-off dialyser and comparison with other high-flux dialysers in conventional haemodialysis and online haemodiafiltration. Clin Kidney J 2018; 11:742-746. [PMID: 30288272 PMCID: PMC6165747 DOI: 10.1093/ckj/sfy004] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/19/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Online haemodiafiltration (OL-HDF) has been shown to reduce all-cause mortality versus conventional haemodialysis (HD); however, it is not always available. In these situations, a novel class of membranes with a higher pore size, medium cut-off (MCO) dialysers, could be promising. The aim of this study is to evaluate the efficacy of an MCO dialyser in the removal of small and medium-size molecules and compare it with standard high-flux (HF) dialysers in HD and OL-HDF. METHODS In this crossover study, 18 prevalent HD patients were studied in three single mid-week dialysis treatments during three consecutive weeks as follows: first week with OL-HDF with a standard HF dialyser, second week with conventional HD with a standard HF dialyser and third week with conventional HD with an MCO dialyser. Reduction ratios (RRs) of different-sized molecules and albumin losses were collected for the different dialysers. RESULTS MCO HD provided a greater reduction of middle and larger middle molecules compared with standard HF HD [rate reduction (RR) β2-microglobulin 74.7% versus 69.7%, P=0.01; RR myoglobin 62.5% versus 34.3%, P=0.001; RR prolactin 60% versus 32.8%, P=0.001; RR α1-glycoprotein 2.8% versus -0.1%, P=0.01]. We found no difference in the clearance of small and larger middle molecules comparing MCO HD with OL-HDF. Albumin losses were 0.03 g/session with MCO HD and 3.1 g/session with OL-HDF (P=0.001). CONCLUSION MCO HD is superior to standard HF HD in the removal of middle and larger middle molecules and it is not inferior to OL-HDF in the clearance of small and larger middle molecules. Thus it could be an alternative in patients in which it is not possible to perform OL-HDF.
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Affiliation(s)
- Ana García-Prieto
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Esther Torres
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Andrés Hernández
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Diego Barbieri
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Luño
- Nephrology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Marano M, Fanelli F. Overcoming glucose delivery by on-line hemodiafiltration: a feasible chimera for diabetics on dialysis. J Nephrol 2018; 32:151-154. [PMID: 29876826 DOI: 10.1007/s40620-018-0503-5] [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: 02/27/2018] [Accepted: 05/25/2018] [Indexed: 11/25/2022]
Abstract
The increasing number of patients with diabetes undergoing renal replacement therapy has raised interest in the issue of glucose delivery with the substitution fluid-over 20 g per session. The ideal situation would be to have a glucose-containing bath to avoid glycemic disarrays and a glucose-free substitution fluid. But this seems a chimera because the substitution fluid is nothing else than an ultrapure dialysis bath. In this technical note, we present a cheap solution to realize the desired mix, using a commercially available glucose-free dialysate and adding glucose in the inlet dialysate compartment of the dialyzer by means of a common pump and a unique handmade T-tube. Our in vitro experiments showed glucose levels in the dialysate (mean ± SD, mg/dl): 99.7 ± 4.6 at baseline, 100.7 ± 7.3 at mid-session and 100.7 ± 2.1 at the end of dialysis, whereas measurements in the substitution fluid always gave a "low" output (p < 0.0001). Similar results were obtained in single 1- and 4-h in vivo experiments carried out in a non-diabetic overweight hemodialysis patient. Our simple, yet unequivocal, results lay the foundation for assembling a hemodialysis machine equipped with an infusion pump to modify the on-line substitution fluid without affecting the dialysate. This would overcome the ethical issue of delivering glucose intravenously in certain groups of patients.
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Affiliation(s)
- Marco Marano
- Hemodialysis Unit, Maria Rosaria Clinic, Via Colle San Bartolomeo, 50-80045, Pompeii, Naples, Italy.
| | - Fabrizio Fanelli
- Technical Dialysis and Clinical Application Specialist Nipro Medical Europe Italian Branch, Milan, Italy
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11
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Marano M. On the Advantage of Glucose Delivery by On-Line Hemodiafiltration. Ther Apher Dial 2018; 22:560. [PMID: 29862638 DOI: 10.1111/1744-9987.12702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/10/2018] [Accepted: 04/13/2018] [Indexed: 01/05/2023]
Affiliation(s)
- Marco Marano
- Hemodialysis Unit, Maria Rosaria Clinic, Pompeii, Italy
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