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Zhou Z, Kuang H, Wang F, Liu L, Zhang L, Fu P. High cut-off membranes in patients requiring renal replacement therapy: a systematic review and meta-analysis. Chin Med J (Engl) 2023; 136:34-44. [PMID: 36848147 PMCID: PMC10106154 DOI: 10.1097/cm9.0000000000002150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Whether high cut-off (HCO) membranes are more effective than high-flux (HF) membranes in patients requiring renal replacement therapy (RRT) remains controversial. The aim of this systematic review was to investigate the efficacy of HCO membranes regarding the clearance of inflammation-related mediators, β2-microglobulin and urea; albumin loss; and all-cause mortality in patients requiring RRT. METHODS We searched all relevant studies on PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure, with no language or publication year restrictions. Two reviewers independently selected studies and extracted data using a prespecified extraction instrument. Only randomized controlled trials (RCTs) were included. Summary estimates of standardized mean differences (SMDs) or weighted mean differences (WMDs) and risk ratios (RRs) were obtained by fixed-effects or random-effects models. Sensitivity analyses and subgroup analyses were performed to determine the source of heterogeneity. RESULTS Nineteen RCTs involving 710 participants were included in this systematic review. Compared with HF membranes, HCO membranes were more effective in reducing the plasma level of interleukin-6 (IL-6) (SMD -0.25, 95% confidence interval (CI) -0.48 to -0.01, P = 0.04, I2 = 63.8%); however, no difference was observed in the clearance of tumor necrosis factor-α (TNF-α) (SMD 0.03, 95% CI -0.27 to 0.33, P = 0.84, I2 = 4.3%), IL-10 (SMD 0.22, 95% CI -0.12 to 0.55, P = 0.21, I2 = 0.0%), or urea (WMD -0.27, 95% CI -2.77 to 2.23, P = 0.83, I2 = 19.6%). In addition, a more significant reduction ratio of β 2 -microglobulin (WMD 14.8, 95% CI 3.78 to 25.82, P = 0.01, I2 = 88.3%) and a more obvious loss of albumin (WMD -0.25, 95% CI -0.35 to -0.16, P < 0.01, I2 = 40.8%) could be observed with the treatment of HCO membranes. For all-cause mortality, there was no difference between the two groups (risk ratio [RR] 1.10, 95% CI 0.87 to 1.40, P = 0.43, I2 = 0.0%). CONCLUSIONS Compared with HF membranes, HCO membranes might have additional benefits on the clearance of IL-6 and β 2-microglobulin but not on TNF-α, IL-10, and urea. Albumin loss is more serious with the treatment of HCO membranes. There was no difference in all-cause mortality between HCO and HF membranes. Further larger high-quality RCTs are needed to strengthen the effects of HCO membranes.
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Affiliation(s)
- Zhifeng Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huang Kuang
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Fang Wang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Lu Liu
- Preventive Medicine, West China School of Public Health, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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Duarte Silveira MA, Malta-Santos H, Rebouças-Silva J, Teles F, Batista dos Santos Galvão E, Pinto de Souza S, Dantas Dutra FR, Dantas Gomes MM, Teixeira MB, Miranda Rebelo da Conceição LF, Nascimento CS, Vasques Nonaka CK, Cezar RS, Pena Batista PB, Berretta AA, Borges VM, da Hora Passos R. Effects of Standardized Brazilian Green Propolis Extract (EPP-AF®) on Inflammation in Haemodialysis Patients: A Clinical Trial. Int J Nephrol 2022; 2022:1035475. [PMID: 36457860 PMCID: PMC9708369 DOI: 10.1155/2022/1035475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Patients on haemodialysis (HD) present a significant inflammatory status, which has a pronounced negative impact on their outcomes. Propolis is a natural resin with anti-inflammatory and immunomodulatory properties. We assessed the safety and impact of a standardized Brazilian green propolis extract (EPP-AF®) on the inflammatory status in patients under conventional HD. METHODS Patients were assigned to receive 200 mg/day of EPP-AF® for 4 weeks followed by 4 weeks without the drug, and changes in plasma levels of interleukins (ILs), interferon gamma (IFN-γ), tumour necrosis factor-alpha (TNF-α), and high-sensitivityc-reactive protein (HsCRP) were measured. A heatmap was used to illustrate trends in data variation. RESULTS In total, 37 patients were included in the final analysis. Patients presented an exacerbated inflammatory state at baseline. During EPP-AF® use, there was a significant reduction in IFN-γ (p=0.005), IL-13 (p=0.04 2), IL-17 (p=0.039), IL-1ra (p=0.008), IL-8 (p=0.009), and TNF-α (p < 0.001) levels compared to baseline, and significant changes were found in Hs-CRP levels. The heatmap demonstrated a pattern of pronounced proinflammatory status at baseline, especially in patients with primary glomerulopathies, and a clear reduction in this pattern during the use of EPP-AF®. There was a tendency to maintain this reduction after suspension of EPP-AF®. No significant side effects were observed. CONCLUSION Patients under haemodialysis presented a pronounced inflammatory status, and EPP-AF® was demonstrated to be safe and associated with a significant and maintained reduction in proinflammatory cytokines in this population. This trial is registered with Clinicaltrials.gov NCT04072341.
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Affiliation(s)
- Marcelo Augusto Duarte Silveira
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
- UNIME Medical School, Fazenda Pitangueira, Lauro de Freitas, Bahia 42700000, Brazil
| | - Hayna Malta-Santos
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rua Waldemar Falcão 121, Candeal, Salvador, BA 40296710, Brazil
- School of Medicine, Federal University of Bahia, Rua Augusto Viana s/n, Canela, Salvador, BA 40110909, Brazil
| | - Jéssica Rebouças-Silva
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rua Waldemar Falcão 121, Candeal, Salvador, BA 40296710, Brazil
- School of Medicine, Federal University of Bahia, Rua Augusto Viana s/n, Canela, Salvador, BA 40110909, Brazil
| | - Flávio Teles
- School of Medicine, Federal University of Alagoas, Av. Lourival de Melo Mota S/N, Tabuleiro do Martins 57072900, Maceió, Alagoas, Brazil
| | - Erica Batista dos Santos Galvão
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
| | - Sergio Pinto de Souza
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
- Escola Bahiana de Medicina e Saúde Pública-EBMSP, Av. Dom João VI 275, Brotas, Salvador, BA 40290000, Brazil
| | - Fábio Ricardo Dantas Dutra
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
| | - Marcel Miranda Dantas Gomes
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
| | - Maurício Brito Teixeira
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
- Escola Bahiana de Medicina e Saúde Pública-EBMSP, Av. Dom João VI 275, Brotas, Salvador, BA 40290000, Brazil
- Universidade do Estado da Bahia (UNEB), Rua Silveira Martin 2555, Cabula, Salvador, BA 41150000, Brazil
| | - Luis Filipe Miranda Rebelo da Conceição
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
| | - Carolina Sa Nascimento
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
| | - Carolina Kymie Vasques Nonaka
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rua Waldemar Falcão 121, Candeal, Salvador, BA 40296710, Brazil
| | - Rodrigo Silva Cezar
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
| | - Paulo Benigno Pena Batista
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
- UNIME Medical School, Fazenda Pitangueira, Lauro de Freitas, Bahia 42700000, Brazil
| | - Andresa Aparecida Berretta
- Research, Development and Innovation Department, Apis Flora Indl. Coml. Ltd, Rua Triunfo 945, Subse-tor Sul 3, Ribeirão Preto, SP 14020670, Brazil
| | - Valeria M. Borges
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rua Waldemar Falcão 121, Candeal, Salvador, BA 40296710, Brazil
- School of Medicine, Federal University of Bahia, Rua Augusto Viana s/n, Canela, Salvador, BA 40110909, Brazil
| | - Rogerio da Hora Passos
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Nephrology Department, Avenida São Rafael 2152, São Marcos, Salvador, BA 41253190, Brazil
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Effects of Expanded Hemodialysis with Medium Cut-Off Membranes on Maintenance Hemodialysis Patients: A Review. MEMBRANES 2022; 12:membranes12030253. [PMID: 35323729 PMCID: PMC8953230 DOI: 10.3390/membranes12030253] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 02/04/2023]
Abstract
Kidney failure is associated with high morbidity and mortality. Hemodialysis, the most prevalent modality of renal replacement therapy, uses the principle of semipermeable membranes to remove solutes and water in the plasma of patients with kidney failure. With the evolution of hemodialysis technology over the last half century, the clearance of small water-soluble molecules in such patients is adequate. However, middle molecules uremic toxins are still retained in the plasma and cause cardiovascular events, anemia, and malnutrition, which significantly contribute to poor quality of life and high mortality in maintenance hemodialysis patients. A new class of membrane, defined as a medium cut-off (MCO) membrane, has emerged in recent years. Expanded hemodialysis with MCO membranes is now recognized as the artificial kidney model closest to natural kidney physiology. This review summarizes the unique morphological characteristics and internal filtration–backfiltration mechanism of MCO membranes, and describes their effects on removing uremic toxins, alleviating inflammation and cardiovascular risk, and improving quality of life in maintenance hemodialysis patients.
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Catar R, Moll G, Kamhieh-Milz J, Luecht C, Chen L, Zhao H, Ernst L, Willy K, Girndt M, Fiedler R, Witowski J, Morawietz H, Ringdén O, Dragun D, Eckardt KU, Schindler R, Zickler D. Expanded Hemodialysis Therapy Ameliorates Uremia-Induced Systemic Microinflammation and Endothelial Dysfunction by Modulating VEGF, TNF-α and AP-1 Signaling. Front Immunol 2021; 12:774052. [PMID: 34858433 PMCID: PMC8632537 DOI: 10.3389/fimmu.2021.774052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/20/2021] [Indexed: 12/15/2022] Open
Abstract
Abstract Systemic chronic microinflammation and altered cytokine signaling, with adjunct cardiovascular disease (CVD), endothelial maladaptation and dysfunction is common in dialysis patients suffering from end-stage renal disease and associated with increased morbidity and mortality. New hemodialysis filters might offer improvements. We here studied the impact of novel improved molecular cut-off hemodialysis filters on systemic microinflammation, uremia and endothelial dysfunction. Human endothelial cells (ECs) were incubated with uremic serum obtained from patients treated with two different hemodialysis regimens in the Permeability Enhancement to Reduce Chronic Inflammation (PERCI-II) crossover clinical trial, comparing High-Flux (HF) and Medium Cut-Off (MCO) membranes, and then assessed for their vascular endothelial growth factor (VEGF) production and angiogenesis. Compared to HF membranes, dialysis with MCO membranes lead to a reduction in proinflammatory mediators and reduced endothelial VEGF production and angiogenesis. Cytokine multiplex screening identified tumor necrosis factor (TNF) superfamily members as promising targets. The influence of TNF-α and its soluble receptors (sTNF-R1 and sTNF-R2) on endothelial VEGF promoter activation, protein release, and the involved signaling pathways was analyzed, revealing that this detrimental signaling was indeed induced by TNF-α and mediated by AP-1/c-FOS signaling. In conclusion, uremic toxins, in particular TNF-signaling, promote endothelial maladaptation, VEGF expression and aberrant angiogenesis, which can be positively modulated by dialysis with novel MCO membranes. Translational Perspective and Graphical Abstract Systemic microinflammation, altered cytokine signaling, cardiovascular disease, and endothelial maladaptation/dysfunction are common clinical complications in dialysis patients suffering from end-stage renal disease. We studied the impact of novel improved medium-cut-off hemodialysis filters on uremia and endothelial dysfunction. We can show that uremic toxins, especially TNF-signaling, promote endothelial maladaptation, VEGF expression and aberrant angiogenesis, which can be positively modulated by dialysis with novel improved medium-cut-off membranes.
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Affiliation(s)
- Rusan Catar
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Guido Moll
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Berlin-Brandenburg School for Regenerative Therapies (BSRT), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Julian Kamhieh-Milz
- Institute of Transfusion Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Christian Luecht
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Lei Chen
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Hongfan Zhao
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Lucas Ernst
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Kevin Willy
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Department of Cardiology, University Hospital Münster, Münster, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Janusz Witowski
- Department of Pathophysiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Henning Morawietz
- Division of Vascular Endothelium and Microcirculation, Department of Medicine III, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Olle Ringdén
- Division of Therapeutic Immunology (TIM), Department of Laboratory Medicine (LABMED), Karolinska Institutet, Stockholm, Sweden
| | - Duska Dragun
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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Gusev E, Solomatina L, Zhuravleva Y, Sarapultsev A. The Pathogenesis of End-Stage Renal Disease from the Standpoint of the Theory of General Pathological Processes of Inflammation. Int J Mol Sci 2021; 22:ijms222111453. [PMID: 34768884 PMCID: PMC8584056 DOI: 10.3390/ijms222111453] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease can progress to end-stage chronic renal disease (ESRD), which requires the use of replacement therapy (dialysis or kidney transplant) in life-threatening conditions. In ESRD, irreversible changes in the kidneys are associated with systemic changes of proinflammatory nature and dysfunctions of internal organs, skeletal muscles, and integumentary tissues. The common components of ESRD pathogenesis, regardless of the initial nosology, are (1) local (in the kidneys) and systemic chronic low-grade inflammation (ChLGI) as a risk factor for diabetic kidney disease and its progression to ESRD, (2) inflammation of the classical type characteristic of primary and secondary autoimmune glomerulonephritis and infectious recurrent pyelonephritis, as well as immune reactions in kidney allograft rejection, and (3) chronic systemic inflammation (ChSI), pathogenetically characterized by latent microcirculatory disorders and manifestations of paracoagulation. The development of ChSI is closely associated with programmed hemodialysis in ESRD, as well as with the systemic autoimmune process. Consideration of ESRD pathogenesis from the standpoint of the theory of general pathological processes opens up the scope not only for particular but also for universal approaches to conducting pathogenetic therapies and diagnosing and predicting systemic complications in severe nephropathies.
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Reis T, Anwar S, Neves FDADR, Ronco C. Disruptive technologies for hemodialysis: medium and high cutoff membranes. Is the future now? ACTA ACUST UNITED AC 2021; 43:410-416. [PMID: 33836041 PMCID: PMC8428648 DOI: 10.1590/21758239-jbn-2020-0273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 01/19/2023]
Abstract
In the past decade, a new class of hemodialysis (HD) membranes (high retention
onset class) became available for clinical use. The high cutoff (HCO) and the
medium cutoff (MCO) membranes have wider pores and more uniformity in pore size,
allowing an increased clearance of uremic toxins. Owing to the mechanism of
backfiltration/internal filtration, middle molecules are dragged by the
convective forces, and no substitution solution is needed. The HCO dialyzer is
applied in septic patients with acute kidney injury requiring continuous kidney
replacement therapy. The immune response is modulated thanks to the removal of
inflammatory mediators. Another current application for the HCO dialyzer is in
hematology, for patients on HD secondary to myeloma-kidney, since free light
chains are more efficiently removed with the HCO membrane, reducing their
deleterious effect on the renal tubules. In its turn, the MCO dialyzer is used
for maintenance HD patients. A myriad of clinical trials published in the last
three years consistently demonstrates the ability of this membrane to remove
uremic toxins more efficiently than the high-flux membrane, an evolutionary
disruption in the HD standard of care. Safety concerns regarding albumin loss as
well as blood contamination from pyrogens in the dialysate have been overcome.
In this update article, we explore the rise of new dialysis membranes in the
light of the scientific evidence that supports their use in clinical
practice.
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Affiliation(s)
- Thiago Reis
- Universidade de Brasília, Faculdade de Ciências da Saúde, Laboratório de Farmacologia Molecular, Brasília, DF, Brasil.,San Bortolo Hospital, International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy.,Clínica de Doenças Renais de Brasília, Departamento de Nefrologia, Brasília, DF, Brasil.,Academia Nacional de Medicina, Programa Jovens Lideranças Médicas, Rio de Janeiro, RJ, Brasil
| | - Siddiq Anwar
- Abu Dhabi Health Services (SEHA) Company, Department of Nephrology, Abu Dhabi, United Arab Emirates
| | | | - Claudio Ronco
- San Bortolo Hospital, International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy.,University of Padova, Department of Medicine, Padova, Italy
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High cut-off dialysis mitigates pro-calcific effects of plasma on vascular progenitor cells. Sci Rep 2021; 11:1144. [PMID: 33441772 PMCID: PMC7807056 DOI: 10.1038/s41598-020-80016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/10/2020] [Indexed: 11/08/2022] Open
Abstract
Mortality of patients with end-stage renal disease tremendously exceeds that of the general population due to excess cardiovascular morbidity. Large middle-sized molecules (LMM) including pro-inflammatory cytokines are major drivers of uremic cardiovascular toxicity and cannot be removed sufficiently by conventional high-flux (HFL) hemodialysis. We tested the ability of plasma from 19 hemodialysis patients participating in a trial comparing HFL with high cut-off (HCO) membranes facilitating removal of LMM to induce calcification in mesenchymal stromal cells (MSC) functioning as vascular progenitors. HCO dialysis favorably changed plasma composition resulting in reduced pro-calcific activity. LMM were removed more effectively by HCO dialysis including FGF23, a typical LMM we found to promote osteoblastic differentiation of MSC. Protein-bound uremic retention solutes with known cardiovascular toxicity but not LMM inhibited proliferation of MSC without direct toxicity in screening experiments. We could not attribute the effect of HCO dialysis on MSC calcification to distinct mediators. However, we found evidence of sustained reduced inflammation that might parallel other anti-calcifying mechanisms such as altered generation of extracellular vesicles. Our findings imply protection of MSC from dysfunctional differentiation by novel dialysis techniques targeted at removal of LMM. HCO dialysis might preserve their physiologic role in vascular regeneration and improve outcomes in dialysis patients.
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Sahathevan S, Khor BH, Ng HM, Abdul Gafor AH, Mat Daud ZA, Mafra D, Karupaiah T. Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review. Nutrients 2020; 12:E3147. [PMID: 33076282 PMCID: PMC7602515 DOI: 10.3390/nu12103147] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.
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Affiliation(s)
- Sharmela Sahathevan
- Dietetics Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia;
| | - Ban-Hock Khor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (B.-H.K.); (A.H.A.G.)
| | - Hi-Ming Ng
- School of Medicine, Faculty of Health & Medical Sciences, Taylor’s University Lakeside Campus, No 1, Jalan Taylors, Subang Jaya 47500, Malaysia;
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (B.-H.K.); (A.H.A.G.)
| | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, UPM Serdang 43400, Malaysia;
| | - Denise Mafra
- Post Graduation Program in Medical Sciences and Post-Graduation Program in Cardiovascular Sciences, (UFF), Federal Fluminense University Niterói-Rio de Janeiro (RJ), Niterói-RJ 24033-900, Brazil;
| | - Tilakavati Karupaiah
- School of BioSciences, Faculty of Health & Medical Sciences, Taylor’s University Lakeside Campus, No 1, Jalan Taylors, Subang Jaya 47500, Malaysia
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Haider T, Diaz-Canestro C, Pentz B, Montero D. Intravascular albumin loss is strongly associated with plasma volume withdrawal in dialysis patients. Hemodial Int 2020; 25:86-93. [PMID: 32996274 DOI: 10.1111/hdi.12881] [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: 12/04/2019] [Revised: 08/10/2020] [Accepted: 09/14/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Low circulating albumin closely predicts mortality in end-stage renal disease (ESRD) patients. The cause(s) of hypoalbuminemia (hALB) in ESRD patients remains to be elucidated. The aim of the present study was to determine the role of plasma volume (PV) withdrawal in the reduction of total circulating albumin and essential blood solutes induced by hemodialysis (HD). METHODS PV determined with high-precision automated carbon monoxide-rebreathing, total circulating as well as concentration of plasma albumin and electrolytes were assessed prior to and after 4-hour HD in 10 ESRD patients. FINDINGS Baseline PV ranged from 3.5 to 6.2 l. After HD, PV was decreased by 689 ± 566 mL (-16%) (P = 0.004). Total circulating albumin was largely reduced after HD (170.8 ± 35.1 vs. 146.1 ± 48.9 g, P = 0.008), while albumin concentration was unaltered. According to a strong linear relationship (r = 0.91, P < 0.001), one-third of total circulating albumin is lost from the intravascular compartment for every liter of PV removed. Similar results were found regarding Na+ and Ca2+ electrolytes. DISCUSSION Total circulating albumin, but not albumin concentration, is substantially reduced by HD in proportion to the amount of PV removed from the circulation. This study highlights the potential contributing role of PV withdrawal to hALB in ESRD patients.
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Affiliation(s)
- Thomas Haider
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Candela Diaz-Canestro
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Brandon Pentz
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - David Montero
- University Heart Center, University Hospital Zurich, Zurich, Switzerland.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.,Cumming School of Medicine, Calgary, Alberta, Canada
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10
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Grubb A. Shrunken pore syndrome - a common kidney disorder with high mortality. Diagnosis, prevalence, pathophysiology and treatment options. Clin Biochem 2020; 83:12-20. [PMID: 32544475 DOI: 10.1016/j.clinbiochem.2020.06.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
Invasive studies show that the glomerular sieving coefficients for 5-30 kDa plasma proteins in the human kidney may be selectively reduced compared to those for small molecules < 0.9 kDa, commonly used to measure glomerular filtration rate (GFR). Identification of this pathophysiological state, called shrunken pore syndrome (SPS), can easily and non-invasively be done by comparing estimations of GFR using cystatin C (13.3 kDa) and creatinine (0.113 kDa). SPS is present if the estimate of GFR using cystatin C is lower than 60 or 70% of the estimate using creatinine in the absence of non-renal influences on cystatin C or creatinine. All studies of SPS show that the 3- or 5-year mortality is strongly increased and high hazard ratios for mortality associated with SPS have been observed for many different patient cohorts, including cohorts with normal measured GFR, no albuminuria and no diagnosis. The prevalence of SPS in the cohorts so far investigated is between 0.2 and 36%. Proteome studies of SPS demonstrate that the high mortality associated with the syndrome might be caused by the accumulation of 10-30 kDa signalling proteins promoting development of atherosclerosis and thus suggesting use of monoclonal antibodies to reduce the levels of the most detrimental signalling proteins as a treatment option. The KDIGO recommendations for classification of chronic kidney disease (CKD) comprise determination, or estimation, of GFR and analysis of albuminuria and therefore cannot identify a large fraction of the patients with SPS. The high prevalence and mortality of SPS and the possible treatment options strongly suggest that the KDIGO recommendations should be expanded to include determination of cystatin C to be able to identify all patients with SPS.
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Affiliation(s)
- Anders Grubb
- Department of Clinical Chemistry and Pharmacology, Institute of Laboratory Medicine, Lund University, S-22185 Lund, Sweden.
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11
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Thammathiwat T, Tiranathanagul K, Limjariyakul M, Chariyavilaskul P, Takkavatakarn K, Susantitaphong P, Meesangnin S, Wittayalertpanya S, Praditpornsilpa K, Eiam-Ong S. Super high-flux hemodialysis provides comparable effectiveness with high-volume postdilution online hemodiafiltration in removing protein-bound and middle-molecule uremic toxins: A prospective cross-over randomized controlled trial. Ther Apher Dial 2020; 25:73-81. [PMID: 32356365 DOI: 10.1111/1744-9987.13508] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022]
Abstract
Although high-volume postdilution online hemodiafiltration (ol-HDF) is superior to high-flux HD in removing all kinds of uremic toxins and improving survival, this treatment is not available in most HD centers. The present study was conducted to compare the effectiveness in removals of protein-bound (indoxyl sulfate [IS]), middle-molecule [beta-2 microglobulin (B2M) and alpha-1 microglobulin (A1MG)], and small-molecule uremic toxins between super high-flux HD (SHF-HD), HD with a novel SHF dialyzer and high-volume postdilution ol-HDF in a noninferiority fashion. Fifteen prevalent HD patients were randomly allocated into two sequences of 12-week treatment periods of SHF-HD treatment and later high-volume postdilution ol-HDF period or vice versa. Each treatment period was divided by a wash-out phase of 4-week high-flux HD. Twelve of 15 patients could complete the study. When compared with high-volume postdilution ol-HDF (convective volume of 24.4 ± 3.52 L), SHF-HD provided comparable reduction ratio values of IS, B2M, and A1MG with mean difference of 5.87 (95% confidence interval [CI] -1.63, 13.37), 1.98 (95% CI,-0.21, 4.18), and 22.96 (95% CI, -1.91, 47.83), respectively. The spKt/Vurea was not different. The predialysis levels of all uremic toxins at baseline and after 12-week treatment did not differ between both groups. Although albumin loss in dialysate in SHF-HD was greater than high-volume postdilution ol-HDF, the serum albumin levels after 12-week SHF-HD treatment were significantly higher than baseline. In conclusion, SHF-HD provides noninferior effectiveness to high-volume postdilution ol-HDF in removing various uremic toxins with significantly increased serum albumin levels despite higher albumin loss. SHF-HD might be an effectively alternative treatment when high-volume postdilution ol-HDF is not available.
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Affiliation(s)
- Theerachai Thammathiwat
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Khajohn Tiranathanagul
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Maneerut Limjariyakul
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pajaree Chariyavilaskul
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srichan Meesangnin
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Nursing, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Supeecha Wittayalertpanya
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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12
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New Insights into the Roles of Monocytes/Macrophages in Cardiovascular Calcification Associated with Chronic Kidney Disease. Toxins (Basel) 2019; 11:toxins11090529. [PMID: 31547340 PMCID: PMC6784181 DOI: 10.3390/toxins11090529] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease (CVD) is an important cause of death in patients with chronic kidney disease (CKD), and cardiovascular calcification (CVC) is one of the strongest predictors of CVD in this population. Cardiovascular calcification results from complex cellular interactions involving the endothelium, vascular/valvular cells (i.e., vascular smooth muscle cells, valvular interstitial cells and resident fibroblasts), and monocyte-derived macrophages. Indeed, the production of pro-inflammatory cytokines and oxidative stress by monocyte-derived macrophages is responsible for the osteogenic transformation and mineralization of vascular/valvular cells. However, monocytes/macrophages show the ability to modify their phenotype, and consequently their functions, when facing environmental modifications. This plasticity complicates efforts to understand the pathogenesis of CVC-particularly in a CKD setting, where both uraemic toxins and CKD treatment may affect monocyte/macrophage functions and thereby influence CVC. Here, we review (i) the mechanisms by which each monocyte/macrophage subset either promotes or prevents CVC, and (ii) how both uraemic toxins and CKD therapies might affect these monocyte/macrophage functions.
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13
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van Gelder MK, Abrahams AC, Joles JA, Kaysen GA, Gerritsen KGF. Albumin handling in different hemodialysis modalities. Nephrol Dial Transplant 2019; 33:906-913. [PMID: 29106652 DOI: 10.1093/ndt/gfx191] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/20/2017] [Indexed: 11/14/2022] Open
Abstract
Hypoalbuminemia is a major risk factor for morbidity and mortality in dialysis patients. With increasing interest in highly permeable membranes and convective therapies to improve removal of middle molecules, transmembrane albumin loss increases accordingly. Currently, the acceptable upper limit of albumin loss for extracorporeal renal replacement therapies is unknown. In theory, any additional albumin loss should be minimized because it may contribute to hypoalbuminemia and adversely affect the patient's prognosis. However, hypoalbuminemia-associated mortality may be a consequence of inflammation and malnutrition, rather than low albumin levels per se. The purpose of this review is to give an overview of albumin handling with different extracorporeal renal replacement strategies. We conclude that the acceptable upper limit of dialysis-related albumin loss remains unknown. Whether enhanced middle molecule removal outweighs the potential adverse effects of increased albumin loss with novel highly permeable membranes and convective therapies is yet to be determined.
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Affiliation(s)
- Maaike K van Gelder
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George A Kaysen
- Department of Medicine Division of Nephrology, University of California, Davis, CA, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, CA, USA
| | - Karin G F Gerritsen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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14
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Zickler D, Luecht C, Willy K, Chen L, Witowski J, Girndt M, Fiedler R, Storr M, Kamhieh-Milz J, Schoon J, Geissler S, Ringdén O, Schindler R, Moll G, Dragun D, Catar R. Tumour necrosis factor-alpha in uraemic serum promotes osteoblastic transition and calcification of vascular smooth muscle cells via extracellular signal-regulated kinases and activator protein 1/c-FOS-mediated induction of interleukin 6 expression. Nephrol Dial Transplant 2019; 33:574-585. [PMID: 29228352 DOI: 10.1093/ndt/gfx316] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/24/2017] [Indexed: 12/15/2022] Open
Abstract
Background Vascular calcification is enhanced in uraemic chronic haemodialysis patients, likely due to the accumulation of midsize uraemic toxins, such as interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Here we have assessed the impact of uraemia on vascular smooth muscle cell (VSMC) calcification and examined the role of IL-6 and TNF-α as possible mediators and, most importantly, its underlying signalling pathway in VSMCs. Methods VSMCs were incubated with samples of uraemic serum obtained from patients treated with haemodialysis for renal failure in the Permeability Enhancement to Reduce Chronic Inflammation-I clinical trial. The VSMCs were assessed for IL-6 gene regulation and promoter activation in response to uraemic serum and TNF-α with reporter assays and electrophoretic mobility shift assay and for osteoblastic transition, cellular calcification and cell viability upon osteogenic differentiation. Results Uraemic serum contained higher levels of TNF-α and IL-6 compared with serum from healthy individuals. Exposure of VSMCs to uraemic serum or recombinant TNF-α lead to a strong upregulation of IL-6 mRNA expression and protein secretion, which was mediated by activator protein 1 (AP-1)/c-FOS-pathway signalling. Uraemic serum induced osteoblastic transition and calcification of VSMCs could be strongly attenuated by blocking TNF-α, IL-6 or AP-1/c-FOS signalling, which was accompanied by improved cell viability. Conclusion These results demonstrate that uraemic serum contains higher levels of uraemic toxins TNF-α and IL-6 and that uraemia promotes vascular calcification through a signalling pathway involving TNF-α, IL-6 and the AP-1/c-FOS cytokine-signalling axis. Thus treatment modalities aiming to reduce systemic TNF-α and IL-6 levels in chronic haemodialysis patients should be evaluated in future clinical trials.
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Affiliation(s)
- Daniel Zickler
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Christian Luecht
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Kevin Willy
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Lei Chen
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Janusz Witowski
- Department of Pathophysiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle, Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle, Germany
| | - Markus Storr
- Department of Research and Development, Gambro Dialysatoren GmbH, Hechingen, Germany
| | | | - Janosch Schoon
- Berlin-Brandenburg Center and School for Regenerative Therapies(BCRT/BSRT)
- Julius Wolff Institute for Biomechanics and Muskuloskeletal Regeneration (JWI), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sven Geissler
- Berlin-Brandenburg Center and School for Regenerative Therapies(BCRT/BSRT)
- Julius Wolff Institute for Biomechanics and Muskuloskeletal Regeneration (JWI), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Olle Ringdén
- Division of Therapeutic Immunology (TIM), Department of Laboratory Medicine (LABMED), Karolinska Institutet, Stockholm, Sweden
| | - Ralf Schindler
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Guido Moll
- Berlin-Brandenburg Center and School for Regenerative Therapies(BCRT/BSRT)
- Julius Wolff Institute for Biomechanics and Muskuloskeletal Regeneration (JWI), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Division of Therapeutic Immunology (TIM), Department of Laboratory Medicine (LABMED), Karolinska Institutet, Stockholm, Sweden
| | - Duska Dragun
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Rusan Catar
- Clinic for Nephrology and Critical Care Medicine, Charite-Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
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15
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Trojanowicz B, Ulrich C, Fiedler R, Martus P, Storr M, Boehler T, Werner K, Hulko M, Zickler D, Willy K, Schindler R, Girndt M. Modulation of leucocytic angiotensin-converting enzymes expression in patients maintained on high-permeable haemodialysis. Nephrol Dial Transplant 2018; 33:34-43. [PMID: 28992224 DOI: 10.1093/ndt/gfx206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 04/29/2017] [Indexed: 01/22/2023] Open
Abstract
Background High mortality of haemodialysis patients is associated with systemic chronic inflammation and overactivation of the renin-angiotensin system (RAS). Insufficient elimination of pro-inflammatory immune mediators, especially in the molecular weight range of 15-45 kDa, may be one of the reasons for this. Employment of haemodialysis membranes with increased permeability was shown to ameliorate the inflammatory response and might modulate the effects of local RAS. In this study, we tested the impact of high cut-off (HCO), medium cut-off (MCO) and high-flux (HF) dialysis on leucocytic transcripts of angiotensin-converting enzymes (ACE and ACE2). Additionally, the impact of HCO, MCO and HF sera and dialysates on local ACEs and inflammation markers was tested in THP-1 monocytes. Methods Patients' leucocytes were obtained from our recent clinical studies comparing HCO and MCO dialysers with HF. The cells were subjected to quantitaive polymerase chain reaction (qPCR) analyses with TaqMan probes specific for ACE, ACE2 and angiotensin II (AngII) and Ang1-7 receptors. Sera and dialysates from the clinical trials as well as samples from in vitro dialysis were tested on THP-1 monocytic cells. The cells were subjected to qPCR analyses with TaqMan probes specific for ACE, ACE2, interleukin-6 and tumour necrosis factor α and immunocytochemistry with ACE and ACE2 antibodies. Results Leucocytes obtained from patients treated with HCO or MCO demonstrated decreased transcript expression of ACE, while ACE2 was significantly upregulated as compared with HF. Receptors for AngII and Ang1-7 remained unchanged. THP-1 monocytes preconditioned with HCO and MCO patients' or in vitro dialysis sera reflected the same expressional regulation of ACE and ACE2 as those observed in HCO and MCO leucocytes. As a complementary finding, treatment with HCO and MCO in vitro dialysates induced a pro-inflammatory response of the cells as demonstrated by elevated messenger RNA expression of tumour necrosis factor α and interleukin-6, as well as upregulation of ACE and decreased levels of ACE2. Conclusions Taken together, these data demonstrate that employment of membranes with high permeability eliminates a spectrum of mediators from circulation that affect the RAS components in leucocytes, especially ACE/ACE2.
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Affiliation(s)
- Bogusz Trojanowicz
- Department of Internal Medicine II, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Christof Ulrich
- Department of Internal Medicine II, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Markus Storr
- Department of Research and Development, Gambro Dialysatoren, Hechingen, Germany
| | - Torsten Boehler
- Department of Research and Development, Gambro Dialysatoren, Hechingen, Germany
| | - Kristin Werner
- Department of Research and Development, Gambro Dialysatoren, Hechingen, Germany
| | - Michael Hulko
- Department of Research and Development, Gambro Dialysatoren, Hechingen, Germany
| | - Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Kevin Willy
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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16
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Abstract
The objectives of hemodialysis have moved from the diffusive clearance of small molecular weight uremic toxins and achieving dialyzer urea adequacy targets to emphasis on improving clinical outcomes in end stage renal failure patients by increasing larger sized uremic toxin clearance. Clinical emphasis in the last few decades has focused on increasing middle molecule weight toxin clearance by hemodiafiltration. Although long-term data is still lacking, short-term outcomes appear promising. Advancements in nanotechnology have now introduction a new generation of medium cut-off membrane dialyzers which allow diffusive clearance of similar middle molecular weight uremia toxin clearance as hemodiafiltration, without increased albumin losses. As these dialyzers have only recently been introduced into clinical practice, no long-term outcomes are available to determine the relative benefits or advantages of this approach. As dialyzers are now designed to maximize diffusive or convective clearance, or provide a combination, then clinicians can now choose dialyzers tailored to the individual patient needs depending on clinical circumstances. We review the key important features in choosing a dialyzer for patients with end stage renal failure and acute kidney injury.
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Affiliation(s)
- Sabrina Haroon
- National University Hospital, UCL department of renal medicine, London, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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17
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Kohlová M, Amorim CG, Araújo A, Santos-Silva A, Solich P, Montenegro MCBSM. The biocompatibility and bioactivity of hemodialysis membranes: their impact in end-stage renal disease. J Artif Organs 2018; 22:14-28. [DOI: 10.1007/s10047-018-1059-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/08/2018] [Indexed: 12/15/2022]
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18
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Updates on the Mechanisms and the Care of Cardiovascular Calcification in Chronic Kidney Disease. Semin Nephrol 2018; 38:233-250. [DOI: 10.1016/j.semnephrol.2018.02.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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19
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Schepers E, Glorieux G, Eloot S, Hulko M, Boschetti-de-Fierro A, Beck W, Krause B, Van Biesen W. Assessment of the association between increasing membrane pore size and endotoxin permeability using a novel experimental dialysis simulation set-up. BMC Nephrol 2018; 19:1. [PMID: 29304774 PMCID: PMC5756443 DOI: 10.1186/s12882-017-0808-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background Membranes with increasing pore size are introduced to enhance removal of large uremic toxins with regular hemodialysis. These membranes might theoretically have higher permeability for bacterial degradation products. In this paper, permeability for bacterial degradation products of membranes of comparable composition with different pore size was investigated with a new in vitro set-up that represents clinical flow and pressure conditions. Methods Dialysis was simulated with an AK200 machine using a low-flux, high-flux, medium cut-off (MCO) or high cut-off (HCO) device (n = 6/type). A polyvinylpyrrolidone-solution (PVP) was recirculated at blood side. At dialysate side, a challenge solution containing a filtrated lysate of two water-borne bacteria (Pseudomonas aeruginosa and Pelomononas saccharophila) was infused in the dialysate flow (endotoxin ≥ 4EU/ml). Blood and dialysate flow were set at 400 and 500 ml/min for 60 min. PVP was sampled before (PVPpre) and after (PVPpost) the experiment and dialysate after 5 and 55 min. Limulus Amebocyte Lysate (LAL) test was performed. Additionally, samples were incubated with a THP-1 cell line (24 h) and IL-1β levels were measured evaluating biological activity. Results The LAL-assay confirmed presence of 9.5 ± 7.4 EU/ml at dialysate side. For none of the devices the LAL activity in PVPpre vs. PVPpost was significantly different. Although more blood side PVP solutions had a detectable amount of endotoxin using a highly sensitive LAL assay in the more open vs traditional membranes, the permeability for endotoxins of the 4 tested dialysis membranes was not significantly different but the number of repeats is small. None of the PVP solutions induced IL-1β in the THP-1 assay. Conclusions A realisitic in vitro dialysis was developed to assess membrane translocation of bacterial products. LAL activity on the blood side after endotoxin exposure did not change for all membranes. Also, none of the PVPpost solutions induced IL-1β in the THP-1 bio-assay.
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Affiliation(s)
- Eva Schepers
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium.
| | - Griet Glorieux
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium
| | - Sunny Eloot
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium
| | | | | | - Werner Beck
- Baxter International Inc., R&D, Hechingen, Germany
| | - Bernd Krause
- Baxter International Inc., R&D, Hechingen, Germany
| | - Wim Van Biesen
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium
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20
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Willy K, Girndt M, Voelkl J, Fiedler R, Martus P, Storr M, Schindler R, Zickler D. Expanded Haemodialysis Therapy of Chronic Haemodialysis Patients Prevents Calcification and Apoptosis of Vascular Smooth Muscle Cells in vitro. Blood Purif 2017; 45:131-138. [PMID: 29402827 DOI: 10.1159/000484925] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Vascular calcification is a common phenomenon in patients with chronic kidney disease and strongly associated with increased cardiovascular mortality. Vascular calcification is an active process mediated in part by inflammatory processes in vascular smooth muscle cells (VSMC). These could be modified by the insufficient removal of proinflammatory cytokines through conventional high-flux (HF) membranes. Recent trials demonstrated a reduction of inflammation in VSMC by use of dialysis membranes with a higher and steeper cut-off. These membranes caused significant albumin loss. Therefore, the effect of high retention Onset (HRO) dialysis membranes on vascular calcification and its implications in vitro was evaluated. METHODS In the PERCI II trial, 48 chronic dialysis patients were dialyzed using HF and HRO dialyzers and serum samples were collected. Calcifying VSMC were incubated with the serum samples. Calcification was determined using alizarin red staining (AZR) and determination of alkaline phosphatase (ALP) activity. Furthermore, apoptosis was evaluated, and release of matrix Gla protein (MGP), osteopontin (OPN) and growth differentiation factor 15 (GDF-15) were measured in cell supernatants. RESULTS Vascular calcification in vitro was significantly reduced by 24% (ALP) and 36% (AZR) after 4 weeks of HRO dialysis and by 33% (ALP) and 48% (AZR) after 12 weeks of dialysis using HRO membranes compared to HF dialysis. Apoptosis was significantly lower in the HRO group. The concentrations of MGP and OPN were significantly elevated after incubation with HF serum compared to HRO serum and healthy controls. Similarly, GDF-15 release in the supernatant was elevated after incubation with HF serum, an effect significantly ameliorated after treatment with HRO medium. CONCLUSIONS Expanded haemodialysis therapy reduces the pro-calcific potential of serum from dialysis patients in vitro. With a markedly reduced albumin filtration compared to high cut-off dialysis, use of the HRO dialyzers may possibly provide a treatment option for chronic dialysis patients to reduce the progression of vascular calcification.
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Affiliation(s)
- Kevin Willy
- Charité University Medicine Berlin, Campus Virchow Clinic, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Jakob Voelkl
- Department of Internal Medicine and Cardiology, Charité Campus Virchow, Charité Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Markus Storr
- Department of Research and Development, Gambro Dialysatoren GmbH, Hechingen, Germany
| | - Ralf Schindler
- Charité University Medicine Berlin, Campus Virchow Clinic, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany
| | - Daniel Zickler
- Charité University Medicine Berlin, Campus Virchow Clinic, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany
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Tangvoraphonkchai K, Davenport A. Enhancing dialyser clearance-from target to development. Pediatr Nephrol 2017; 32:2225-2233. [PMID: 28401301 DOI: 10.1007/s00467-017-3647-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 01/18/2023]
Abstract
Products of metabolism accumulate in kidney failure and potentially have toxic effects. Traditionally these uraemic toxins are classified as small, middle-sized and protein-bound toxins, and clearance during dialysis is affected by diffusion, convection and adsorption. As current dialysis practice effectively clears small solutes, increasing evidence supports a toxic effect for middle-sized and protein-bound toxins. Therefore, newer approaches to standard dialysis practice are required to look beyond urea clearance. Current dialysers have been developed to effectively clear small solutes and secondly to increase middle-sized toxin clearances. However, there is no ideal dialyser which can effectively clear all uraemic toxins. Advances in nanotechnology have led to improvements in manufacturing, with the production of smoother membrane surfaces and uniformity of pore size. The introduction of haemodiafiltration has led to changes in dialyser design to improve convective clearances. Both diffusional and convectional clearances can be increased by changing dialyser designs to alter blood and dialysate flows, and novel dialyser designs using microfluidics offer more efficient solute clearances. Adjusting surface hydrophilicity and charge alter adsorptive properties, and greater clearance of protein-bound toxins can be achieved by adding carbon or other absorptive monoliths into the circuit or by developing composite dialyser membranes. Other strategies to increase protein-bound toxins clearances have centred on disrupting binding and so displacing toxins from proteins. Just as the hollow fibre design replaced the flat plate dialyser, we are now entering a new era of dialyser designs aimed to increase the spectrum of uraemic toxins which can be cleared by dialysis.
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Affiliation(s)
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, Rowland Hill Street, London, NW3 2PF, UK.
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In Vitro Benchmark of Cytokine Removal by Dialyzers with Various Permeability Profiles. Int J Artif Organs 2017; 40:615-621. [DOI: 10.5301/ijao.5000639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 12/12/2022]
Abstract
Purpose Removal of cytokines is relevant for dialysis patients as they are suspected to promote cardiovascular complications. The objective of this study was to benchmark membranes with different permeability profiles under standardized in vitro test conditions using miniaturized devices with respect to their ability to remove cytokines from human serum and to lower cell activating potential. Methods In vitro dialysis was used to dialyze cytokine enriched serum in 3 independent experiments per tested membrane. IL-6 in the serum and dialysate was measured at defined times by enzyme-linked immunosorbent assay. IL-8, IL-1β, IL-6 and TNF-α in dialysate were measured by immunoassay. Dialysate samples were subjected to cultured tubular epithelial cells or human fibroblasts to study cell activation via IL-6 generation. Dialysate samples were added to human whole blood with subsequent analysis of granulocyte and monocyte activation by detection of CD11b. Results IL-6 decreased in serum and increased in dialysate during in vitro dialysis. IL-8, IL-1β, and TNF-α were identified in dialysate. Dialysate added to cell cultures increased IL-6 concentration in culture medium or increased expression of CD11b. High cut-off membranes showed the strongest transfer of cytokines, albumin and total proteins from serum to dialysate and led to strongest cell activation. This effect was lower for medium cutoff membranes and lowest for conventional high-flux membranes. Conclusions This study demonstrated an in vitro test by which membranes were benchmarked with respect to cytokine and cell activation removal capacity. Cell activation levels could be influenced by the choice of membrane by altering cytokine concentration levels.
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Willy K, Hulko M, Storr M, Speidel R, Gauss J, Schindler R, Zickler D. In Vitro Dialysis of Cytokine-Rich Plasma With High and Medium Cut-Off Membranes Reduces Its Procalcific Activity. Artif Organs 2017; 41:803-809. [PMID: 28524237 DOI: 10.1111/aor.12884] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/18/2016] [Accepted: 09/26/2016] [Indexed: 12/28/2022]
Abstract
Recently developed high-flux (HF) dialysis membranes with extended permeability provide better clearance of middle-sized molecules such as interleukins (ILs). Whether this modulation of inflammation influences the procalcific effects of septic plasma on vascular smooth muscle cells (VSMCs) is not known. To assess the effects of high cut-off (HCO) and medium cut-off (MCO) membranes on microinflammation and in vitro vascular calcification we developed a miniature dialysis model. Plasma samples from lipopolysaccharide-spiked blood were dialyzed with HF, HCO, and MCO membranes in an in vitro miniature dialysis model. Afterwards, IL-6 concentrations were determined in dialysate and plasma. Calcifying VSMCs were incubated with dialyzed plasma samples and vascular calcification was assessed. Osteopontin (OPN) and matrix Gla protein (MGP) were measured in VSMC supernatants. IL-6 plasma concentrations were markedly lower with HCO and MCO dialysis. VSMC calcification was significantly lower after incubation with MCO- and HCO-serum compared to HF plasma. MGP and OPN levels in supernatants were significantly lower in the MCO but not in the HCO group compared to HF. In vitro dialysis of cytokine-enriched plasma samples with MCO and HCO membranes reduces IL-6 levels. The induction of vascular calcification by cytokine-enriched plasma is reduced after HCO and MCO dialysis.
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Affiliation(s)
- Kevin Willy
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Michael Hulko
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Markus Storr
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Rose Speidel
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Julia Gauss
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Ralf Schindler
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Daniel Zickler
- Nephrology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
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Kim D, Choi IC, Park JW. Severe Destructive Tendinopathy in the Wrist Due to Dialysis-Related Amyloidosis. J Hand Surg Asian Pac Vol 2017; 22:376-379. [PMID: 28774247 DOI: 10.1142/s0218810417720273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dialysis-related amyloidosis (DRA) is a specific subtype of amyloidosis with several clinical presentations. Herein we report a case of severe destructive tendinopathy around the wrist associated with long-standing hemodialysis (HD). A 63-year-old female patient who had been on regular HD for 23 years suffered from symptoms of pain and a palpable mass around the wrist. Magnetic resonance imaging showed an ill-defined soft tissue mass around the extensor tendons that partially invaded the wrist joint. We performed surgical excision and tenolysis for the mass. The operative finding revealed an ill-defined yellowish soft tissue mass extensively invading the extensor tendons and wrist joint. The tendon fibers were severely fibrillated and showed impending rupture due to the infiltrated mass. Histological examination showed DRA. Amyloidosis-induced tendinopathy should be considered when a patient on long-term HD complains of an unusual mass-like lesion in the extremity and/or nonspecific joint stiffness. Early surgical intervention improves patient's disability and decreases the risk of spontaneous tendon rupture.
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Affiliation(s)
- Dongmin Kim
- * Department of Orthopedic Surgery, College of Medicine, Korea University, Seoul, South Korea
| | - In Cheul Choi
- † Hand and Microsurgery Center, Seoul Barunsesang Hospital, Seongnam, Korea
| | - Jong Woong Park
- * Department of Orthopedic Surgery, College of Medicine, Korea University, Seoul, South Korea
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Medium Cut-Off (MCO) Membranes Reduce Inflammation in Chronic Dialysis Patients-A Randomized Controlled Clinical Trial. PLoS One 2017; 12:e0169024. [PMID: 28085888 PMCID: PMC5234772 DOI: 10.1371/journal.pone.0169024] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/08/2016] [Indexed: 11/26/2022] Open
Abstract
Background To increase the removal of middle-sized uremic toxins a new membrane with enhanced permeability and selectivity, called Medium Cut-Off membrane (MCO-Ci) has been developed that at the same time ensures the retention of albumin. Because many middle-sized substances may contribute to micro-inflammation we hypothesized that the use of MCO-Ci influences the inflammatory state in hemodialysis patients. Methods The randomized crossover trial in 48 patients compared MCO-Ci dialysis to High-flux dialysis of 4 weeks duration each plus 8 weeks extension phase. Primary endpoint was the gene expression of TNF-α and IL-6 in peripheral blood mononuclear cells (PBMCs), secondary endpoints were plasma levels of specified inflammatory mediators and cytokines. Results After four weeks of MCO-Ci the expression of TNF-α mRNA (Relative quantification (RQ) from 0.92 ± 0.34 to 0.75 ± 0.31, -18.5%, p<0.001)-α and IL-6 mRNA (RQ from 0.78 ± 0.80 to 0.60 ± 0.43, -23.1%, p<0.01) was reduced to a significantly greater extent than with High-flux dialyzers (TNF mRNA-RQ: -14.3%; IL-6 mRNA-RQ: -3.5%). After retransformation of logarithmically transformed data, measurements after MCO were reduced to 82% of those after HF (95% CI 74%–91%). 4 weeks use of MCO-Ci resulted in long-lasting change in plasma levels of several cytokines and other substances with a significant decrease for sTNFR1, kappa and lambda free light chains, urea and an increase for Lp-PLA2 (PLA2G7) compared to High-flux. Albumin levels dropped significantly after 4 weeks of MCO dialysis but increased after additional 8 weeks of MCO dialysis. Twelve weeks treatment with MCO-Ci was well tolerated regarding the number of (S)AEs. In the extension period levels of CRP, TNF-α-mRNA and IL-6 mRNA remained stable in High-flux as well as in MCO-Ci. Conclusions MCO-Ci dialyzers modulate inflammation in chronic HD patients to a greater extent compared to High-flux dialyzers. Transcription of pro-inflammatory cytokines in peripheral leukocytes is markedly reduced and removal of soluble mediators is enhanced with MCO dialysis. Serum albumin concentrations stabilize after an initial drop. These results encourage further trials with longer treatment periods and clinical endpoints.
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Trojanowicz B, Ulrich C, Fiedler R, Storr M, Boehler T, Martus P, Pawlak M, Glomb MA, Henning C, Templin M, Werner K, Zickler D, Willy K, Schindler R, Girndt M. Impact of serum and dialysates obtained from chronic hemodialysis patients maintained on high cut-off membranes on inflammation profile in human THP-1 monocytes. Hemodial Int 2016; 21:348-358. [DOI: 10.1111/hdi.12494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Bogusz Trojanowicz
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
| | - Christof Ulrich
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
| | - Roman Fiedler
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
| | - Markus Storr
- Department of Research and Development; Gambro Dialysatoren GmbH; Hechingen Germany
| | - Torsten Boehler
- Department of Research and Development; Gambro Dialysatoren GmbH; Hechingen Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biostatistics, University of Tübingen; Germany
| | | | - Marcus A. Glomb
- Food Chemistry, Institute for Chemistry, Martin-Luther-University Halle; Germany
| | - Christian Henning
- Food Chemistry, Institute for Chemistry, Martin-Luther-University Halle; Germany
| | | | - Kristin Werner
- Department of Research and Development; Gambro Dialysatoren GmbH; Hechingen Germany
| | - Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine; Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic; Berlin Germany
| | - Kevin Willy
- Department of Nephrology and Internal Intensive Care Medicine; Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic; Berlin Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine; Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic; Berlin Germany
| | - Matthias Girndt
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
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Zickler D, Willy K, Girndt M, Fiedler R, Martus P, Storr M, Schindler R. High cut-off dialysis in chronic haemodialysis patients reduces serum procalcific activity. Nephrol Dial Transplant 2016; 31:1706-12. [PMID: 27445317 DOI: 10.1093/ndt/gfw293] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/03/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vascular calcification is enhanced in chronic dialysis patients, possibly due to the insufficient removal of various intermediate molecular weight uraemic toxins such as interleukins with conventional membranes. In this study, we assessed the modulation of in vitro vascular calcification with the use of high cut-off (HCO) membranes in chronic dialysis patients. METHODS In a PERCI trial, 43 chronic dialysis patients were treated with conventional high-flux and HCO filters for 3 weeks in a randomized order following a 2-period crossover design. After each phase, serum predialysis samples were drawn. Calcifying human coronary vascular smooth muscle cells (VSMCs) were incubated with the patient's serum samples. Calcification was assessed with alkaline phosphatase (ALP) and alizarin red staining. In the clinical trial, HCO dialysis reduced the serum levels of the soluble tumour necrosis factor receptor (sTNFR) 1 and 2, vascular cell adhesion molecule 1 (VCAM-1) and soluble interleukin-2 receptor (sIL2R). We therefore investigated the in vitro effects of these mediators on vascular calcification. RESULTS VSMCs incubated with HCO dialysis serum showed a 26% reduction of ALP with HCO serum compared with high-flux serum. Alizarin was 43% lower after incubation with the HCO serum compared with the high-flux serum. While sIL2R and sTNFR 1 and 2 showed no effects on VSMC calcification, VCAM-1 caused a dose-dependent enhancement of calcification. CONCLUSIONS The use of HCO dialysis membranes in chronic dialysis patients reduces the procalcific effects of serum on VSMC in vitro. The mechanisms of the strong effect of HCO on in vitro calcification are not completely understood. One factor may be lower levels of VCAM-1 in HCO serum samples, since VCAM-1 was able to induce vascular calcification in our experiments. Neither sTNFR 1, sTNFR 2 nor sIL2R enhance vascular calcification in vitro. Regardless of the mechanisms, our results encourage further studies of highly permeable filters in chronic dialysis patients.
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Affiliation(s)
- Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Kevin Willy
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Markus Storr
- Department of Research and Development, Gambro Dialysatoren GmbH, Hechingen, Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin, Germany
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Haemodialysis and haemodiafiltration lead to similar changes in vascular stiffness during treatment. Int J Artif Organs 2016; 39:228-34. [PMID: 27312434 DOI: 10.5301/ijao.5000503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Haemodiafiltration (HDF) has been reported to cause less hypotension than haemodialysis (HD). We hypothesized that HDF causes less change in vascular tone, thereby reducing hypotension. METHODS Aortic pulse wave velocity (PWVao) was measured in 284 patients, during a single dialysis session using cooled dialysate (117 HD, 177 HDF). Patient groups were matched for age, sex and cardiovascular comorbidity. RESULTS Systolic blood pressure (SBP) declined from 144 ± 26 to 133 ± 26 after 20 minutes, and to 131 ± 26 mmHg post HD, and for HDF from 152 ± 26 to 143 ± 27 after 20 minutes, then to 138 ± 27 mmHg post HDF. Net Ultrafiltration rates to achieve weight loss were similar; HD 0.13 ± 0.06 vs HDF 0.12 ± 0.05 mL/kg/min. PWVao did not change after 20 minutes HD 0.42(-0.7 to 1.3), HDF 0.5 (-0.6 to 1.8) or at the end of the session: HD -0.39 (1.5 to 1.2), HDF -0.41(-2.0 to 1.3) m/s. Aortic augmentation index (AiAxo), assessment of vascular tone fell significantly with both HD; 20 minutes by 6.2 (-2.5 to 14), end 5.6 (-6.7 to 13.9), and HDF 20 min by 4.2 (-2.5 to 10), end 7.8 (-0.8 to 19.3), with no difference between HD and HDF. The ultrafiltration rate correlated with % change in aortic SBP (r = 0.28 p = 0.004), but not with changes in PWVao or augmentation indices. CONCLUSIONS Blood pressure declined during both HD and HDF treatments, as did augmentation indices, unrelated to weight loss, suggesting a reduction in vascular stiffness occurs independently of treatment modality. We did not observe an advantage for HDF.
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