1
|
Bowry SK, Kircelli F, Nandakumar M, Vachharajani TJ. Clinical relevance of abstruse transport phenomena in haemodialysis. Clin Kidney J 2021; 14:i85-i97. [PMID: 34987788 PMCID: PMC8711756 DOI: 10.1093/ckj/sfab183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/12/2022] Open
Abstract
Haemodialysis (HD) utilizes the bidirectional properties of semipermeable membranes to remove uraemic toxins from blood while simultaneously replenishing electrolytes and buffers to correct metabolic acidosis. However, the nonspecific size-dependent transport across membranes also means that certain useful plasma constituents may be removed from the patient (together with uraemic toxins), or toxic compounds, e.g. endotoxin fragments, may accompany electrolytes and buffers of the dialysis fluids into blood and elicit severe biological reactions. We describe the mechanisms and implications of these undesirable transport processes that are inherent to all HD therapies and propose approaches to mitigate the effects of such transport. We focus particularly on two undesirable events that are considered to adversely affect HD therapy and possibly impact patient outcomes. Firstly, we describe how loss of albumin (and other essential substances) can occur while striving to eliminate larger uraemic toxins during HD and why hypoalbuminemia is a clinical condition to contend with. Secondly, we describe the origins and mode of transport of biologically active substances (from dialysis fluids with bacterial contamination) into the blood compartment and biological reactions they elicit. Endotoxin fragments activate various proinflammatory pathways to increase the underlying inflammation associated with chronic kidney disease. Both phenomena involve the physical as well as chemical properties of membranes that must be selected judiciously to balance the benefits with potential risks patients may encounter, in both the short and long term.
Collapse
Affiliation(s)
- Sudhir K Bowry
- Dialysis-at-Crossroads (D@X) Advisory, Bad Nauheim, Germany
| | - Fatih Kircelli
- Global Medical Information and Education, Fresenius Medical Care, Bad Homburg, Germany
| | | | - Tushar J Vachharajani
- Department of Hypertension and Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Canaud B, Stephens MP, Nikam M, Etter M, Collins A. Multitargeted interventions to reduce dialysis-induced systemic stress. Clin Kidney J 2021; 14:i72-i84. [PMID: 34987787 PMCID: PMC8711765 DOI: 10.1093/ckj/sfab192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Hemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure simultaneously induces persistent physiological changes that adversely affect several organs. Dialysis patients experience this systemic stress condition usually thrice weekly and sometimes more frequently depending on the treatment schedule. Dialysis-induced systemic stress results from multifactorial components that include treatment schedule (i.e. modality, treatment time), hemodynamic management (i.e. ultrafiltration, weight loss), intensity of solute fluxes, osmotic and electrolytic shifts and interaction of blood with components of the extracorporeal circuit. Intradialytic morbidity (i.e. hypovolemia, intradialytic hypotension, hypoxia) is the clinical expression of this systemic stress that may act as a disease modifier, resulting in multiorgan injury and long-term morbidity. Thus, while lifesaving, HD exposes the patient to several systemic stressors, both hemodynamic and non-hemodynamic in origin. In addition, a combination of cardiocirculatory stress, greatly conditioned by the switch from hypervolemia to hypovolemia, hypoxemia and electrolyte changes may create pro-arrhythmogenic conditions. Moreover, contact of blood with components of the extracorporeal circuit directly activate circulating cells (i.e. macrophages-monocytes or platelets) and protein systems (i.e. coagulation, complement, contact phase kallikrein-kinin system), leading to induction of pro-inflammatory cytokines and resulting in chronic low-grade inflammation, further contributing to poor outcomes. The multifactorial, repetitive HD-induced stress that globally reduces tissue perfusion and oxygenation could have deleterious long-term consequences on the functionality of vital organs such as heart, brain, liver and kidney. In this article, we summarize the multisystemic pathophysiological consequences of the main circulatory stress factors. Strategies to mitigate their effects to provide more cardioprotective and personalized dialytic therapies are proposed to reduce the systemic burden of HD.
Collapse
Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Melanie P Stephens
- MSL & Medical Strategies for Innovative Therapies, Fresenius Medical Care, Waltham, MA, USA
| | - Milind Nikam
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Michael Etter
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
| |
Collapse
|
3
|
Said N, Lau WJ, Ho YC, Lim SK, Zainol Abidin MN, Ismail AF. A Review of Commercial Developments and Recent Laboratory Research of Dialyzers and Membranes for Hemodialysis Application. MEMBRANES 2021; 11:767. [PMID: 34677533 PMCID: PMC8540739 DOI: 10.3390/membranes11100767] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/18/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022]
Abstract
Dialyzers have been commercially used for hemodialysis application since the 1950s, but progress in improving their efficiencies has never stopped over the decades. This article aims to provide an up-to-date review on the commercial developments and recent laboratory research of dialyzers for hemodialysis application and to discuss the technical aspects of dialyzer development, including hollow fiber membrane materials, dialyzer design, sterilization processes and flow simulation. The technical challenges of dialyzers are also highlighted in this review, which discusses the research areas that need to be prioritized to further improve the properties of dialyzers, such as flux, biocompatibility, flow distribution and urea clearance rate. We hope this review article can provide insights to researchers in developing/designing an ideal dialyzer that can bring the best hemodialysis treatment outcomes to kidney disease patients.
Collapse
Affiliation(s)
- Noresah Said
- Advanced Membrane Technology Research Centre (AMTEC), School of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Malaysia; (N.S.); (M.N.Z.A.); (A.F.I.)
| | - Woei Jye Lau
- Advanced Membrane Technology Research Centre (AMTEC), School of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Malaysia; (N.S.); (M.N.Z.A.); (A.F.I.)
| | - Yeek-Chia Ho
- Centre of Urban Resource Sustainability, Department of Civil and Environmental Engineering, Institute of Self-Sustainable Building, Universiti Teknologi PETRONAS, Seri Iskandar 32610, Malaysia;
| | - Soo Kun Lim
- University Malaya Primary Care Research Group (UMPCRG), Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
| | - Muhammad Nidzhom Zainol Abidin
- Advanced Membrane Technology Research Centre (AMTEC), School of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Malaysia; (N.S.); (M.N.Z.A.); (A.F.I.)
| | - Ahmad Fauzi Ismail
- Advanced Membrane Technology Research Centre (AMTEC), School of Chemical and Energy Engineering, Universiti Teknologi Malaysia, Skudai 81310, Malaysia; (N.S.); (M.N.Z.A.); (A.F.I.)
| |
Collapse
|
4
|
Verma S, Singh P, Khurana S, Ganguly NK, Kukreti R, Saso L, Rana DS, Taneja V, Bhargava V. Implications of oxidative stress in chronic kidney disease: a review on current concepts and therapies. Kidney Res Clin Pract 2021; 40:183-193. [PMID: 34078023 PMCID: PMC8237115 DOI: 10.23876/j.krcp.20.163] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 02/05/2021] [Indexed: 01/04/2023] Open
Abstract
Moderate levels of endogenous reactive oxygen species (ROS) are important for various cellular activities, but high levels lead to toxicity and are associated with various diseases. Levels of ROS are maintained as a balance between oxidants and antioxidants. Accumulating data suggest that oxidative stress is a major factor in deterioration of renal function. In this review, we highlight the possible mechanism by which oxidative stress can lead to chronic kidney disease (CKD). This review also describes therapies that counter the effect of oxidative stress in CKD patients. Numerous factors such as upregulation of genes involved in oxidative phosphorylation and ROS generation, chronic inflammation, vitamin D deficiency, and a compromised antioxidant defense mechanism system cause progressive detrimental effects on renal function that eventually lead to loss of kidney function. Patients with renal dysfunction are highly susceptible to oxidative stress, as risk factors such as diabetes, renal hypertension, dietary restrictions, hemodialysis, and old age predispose them to increased levels of ROS. Biomolecular adducts (DNA, proteins, and lipids) formed due to reaction with ROS can be used to determine oxidative stress levels. Based on the strong correlation between oxidative stress and CKD, reversal of oxidative stress is being explored as a major therapeutic option. Xanthine oxidase inhibitors, dietary antioxidants, and other agents that scavenge free radicals are gaining interest as treatment modalities in CKD patients.
Collapse
Affiliation(s)
- Sagar Verma
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Priyanka Singh
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Shiffali Khurana
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Ritushree Kukreti
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Luciano Saso
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | | | - Vibha Taneja
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| |
Collapse
|
5
|
Weatherall SL, Chambers AB, Mermel LA. Do Bacteremic patients with end-stage renal disease have a fever when presenting to the emergency department? A paired, retrospective cohort study. BMC Emerg Med 2020; 20:2. [PMID: 31918657 PMCID: PMC6953182 DOI: 10.1186/s12873-019-0298-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022] Open
Abstract
Background Fever is a common symptom when patients present to Emergency Departments. It is unclear if the febrile response of bacteremic hemodialysis-dependent patients differs from bacteremic patients not receiving hemodialysis. The objective of this study was to compare Emergency Departments triage temperatures of patients with and without hemodialysis-dependent end-stage rental disease who have Staphylococcus aureus bacteremia and determine the incidence of afebrile S. aureus bacteremia. Methods Paired, retrospective cohort study of 37 patients with and 37 patients without hemodialysis hospitalized with Methicillin-resistant or Methicillin-susceptible S. aureus bacteremia. Emergency Department triage temperatures were reviewed for all patients, as were potential confounding variables. Results 54% (95% CI, 38–70%) and 82% (95% CI 65–91%) of hemodialysis and non-hemodialysis patients did not have a detectable fever (<100.4 °F) at triage. Triage temperatures were 100.5 °F (95% CI 99.9–101.2 °F) and 99.0 °F (95% CI 98.4–99.6 °F) in the hemodialysis and non-hemodialysis cohorts, respectively (p < 0.001). Triage temperature in patients with and without diabetes mellitus was 99.2 °F (95% CI 98.4–99.9 °F) and 100.4 °F (95% CI 99.7–101.0 °F), respectively (p = 0.03). We were unable to detect a significant effect of diabetes mellitus and other potential confounding variables on differences in temperature between the hemodialysis and non-hemodialysis cohorts (all interactions p > 0.19). Conclusions Hemodialysis-dependent patients with S. aureus bacteremia had significantly higher temperatures than non- hemodialysis-dependent end stage renal disease patients but more than half of patients were without detectable fever at triage, possibly reflecting use of insensitive methods for measuring temperature. Absence of fever at presentation to the Emergency Department should not delay blood culture acquisition in patients who are at increased risk of S. aureus bacteremia.
Collapse
Affiliation(s)
| | - Alison B Chambers
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, USA
| | - Leonard A Mermel
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA. .,Division if Infectious Diseases, Rhode Island Hospital, 593 Eddy St, Providence, RI, 02903, USA.
| |
Collapse
|
6
|
Liakopoulos V, Roumeliotis S, Zarogiannis S, Eleftheriadis T, Mertens PR. Oxidative stress in hemodialysis: Causative mechanisms, clinical implications, and possible therapeutic interventions. Semin Dial 2018; 32:58-71. [PMID: 30288786 DOI: 10.1111/sdi.12745] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Oxidative stress (OS) is the result of prooxidant molecules overwhelming the antioxidant defense mechanisms. Hemodialysis (HD) constitutes a state of elevated inflammation and OS, due to loss of antioxidants during dialysis and activation of white blood cells triggering production of reactive oxygen species. Dialysis vintage, dialysis methods, and type and condition of vascular access, biocompatibility of dialyzer membrane and dialysate, iron administration, and anemia all can play a role in aggravating OS, which in turn has been associated with increased morbidity and mortality. Oral or intravenous administration of antioxidants may detoxify the oxidative molecules and at least in part repair OS-mediated tissue damage. Lifestyle interventions and optimization of a highly biocompatible HD procedure might ameliorate OS development in dialysis.
Collapse
Affiliation(s)
- Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotirios Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Theodoros Eleftheriadis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| |
Collapse
|
7
|
Tao J, Sun Y, Li X, Li H, Liu S, Wen Y, Duan L, Li Y, Li X. Conventional versus Ultrapure Dialysate for Lowering Serum Lipoprotein(a) Levels in Patients on Long-Term Hemodialysis: A Randomized Trial. Int J Artif Organs 2018. [DOI: 10.1177/039139881003300504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose In patients on long-term hemodialysis, high lipoprotein(a) [Lp(a)] levels are difficult to lower with medications, although they remain a risk factor for cardiovascular disease. We investigated whether ultrapure dialysate (UPD) could lower Lp(a). Methods: We randomly assigned patients stabilized on long-term dialysis to either a low-flux synthetic polysulphone membrane (the UPD group; n=14) or to a conventional dialysate (the CD group; n=13). Blood samples were collected 1 week before dialysis and 1 week, 1 month, 6 months and 12 months after dialysis; Lp(a) was measured by the immunotur-bidimetry method. Hemoglobin, interleukin-6, hypersensitive C-reactive protein, β2 microglobulin and albumin were also measured. The erythropoietin dosage, Kt/V, and normalized protein catabolic rate were recorded monthly. Results At 12 months, mean (SD) serum levels of Lp(a) in the CD patients increased from 143.46 (125.11) to 283.89 (145.81) mg/L (p<0.01), whereas levels in the UPD group remained unchanged: 131.38 (201.45) to 120.90 (122.11) mg/L. Endotoxin levels in the 10 CD patients who completed the study ranged from 0.116 to 0.349 EU/mL and were undetectable in the 11 UPD patients who completed the study. The cultures were less than 200 CFU/mL in CD patients and negative all the time for all UPD patients. Changes in Lp(a) from baseline values were lower in the UPD group than in the CD group (p<0.05). However, changes in other variables did not differ between groups. Conclusions Ultrapure dialysate can prevent the rise of Lp(a), potentially decreasing the risk of cardiovascular disease in hemodialysis patients.
Collapse
Affiliation(s)
- Jianling Tao
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Yang Sun
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Xuemei Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Hang Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Shiqin Liu
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Yubing Wen
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Lin Duan
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Yan Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| | - Xuewang Li
- Division of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing - China
| |
Collapse
|
8
|
Wang WJ, Cheng MH, Lin JH, Weng CS. Effect of a rosmarinic acid supplemented hemodialysis fluid on inflammation of human vascular endothelial cells. Braz J Med Biol Res 2017; 50:e6145. [PMID: 29069222 PMCID: PMC5649864 DOI: 10.1590/1414-431x20176145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/15/2017] [Indexed: 12/23/2022] Open
Abstract
Chronic systemic inflammation and repetitive damage of vascular endothelia by incompatible dialysis system are probable causes of cardiovascular disease in patients on dialysis. The present study aimed to assess in vitro biocompatibility and anti-inflammatory effect of hemodialysis fluid supplemented with rosmarinic acid (RA) using human umbilical vein endothelial cells (HUVEC). HUVECs (5×106 cells/mL) were pre-exposed to 1 μg/mL of lipopolysaccharides (LPS) and incubated with RA-supplemented hemodialysis fluid (HDF). Cytotoxicity was assessed qualitatively by morphologic assessment and quantitatively by MTT assay. Expressions of proinflammatory mediators were assessed using quantitative real-time PCR and production of NO was quantified. Phosphorylation of AKT and nuclear localization of nuclear factor kappa B (NF-κB) were examined using western blotting. Exposure of HUVECs to RA-supplemented HDF had no influence on morphology and viability. Inhibition of proinflammatory mediator production in HUVECs by RA supplementation to HDF was significant in a dose-dependent manner. Exposure to RA-supplemented HDF resulted in a decrease in nitric oxide synthase expression and reduction of NO production in LPS-stimulated HUVECs. RA supplementation of HDF suppressed Akt activation in LPS-stimulated HUVECs. In addition, the level of cellular IκB was increased in parallel to a reduced nuclear translocation of NF-κB in LPS-induced endothelial cells. Our results suggest that RA-supplemented HDF is biocompatible and significantly suppressed inflammation induced in endothelial cells. In this respect, the use of HDF supplemented with RA could alleviate inflammation and improve long-term treatment of patients with renal failure on dialysis. Further clinical studies are required to confirm the effects.
Collapse
Affiliation(s)
- W-J. Wang
- Department of Biomedical Engineering, Chung Yuan Christian University, Chungli, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - M-H. Cheng
- Department of Rehabilitation, TaoYuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - J-H. Lin
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - C-S. Weng
- Department of Biomedical Engineering, Chung Yuan Christian University, Chungli, Taiwan
| |
Collapse
|
9
|
Oxidative Stress in Hemodialysis Patients: A Review of the Literature. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:3081856. [PMID: 29138677 PMCID: PMC5613374 DOI: 10.1155/2017/3081856] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
Hemodialysis (HD) patients are at high risk for all-cause mortality and cardiovascular events. In addition to traditional risk factors, excessive oxidative stress (OS) and chronic inflammation emerge as novel and major contributors to accelerated atherosclerosis and elevated mortality. OS is defined as the imbalance between antioxidant defense mechanisms and oxidant products, the latter overwhelming the former. OS appears in early stages of chronic kidney disease (CKD), advances along with worsening of renal failure, and is further exacerbated by the HD process per se. HD patients manifest excessive OS status due to retention of a plethora of toxins, subsidized under uremia, nutrition lacking antioxidants and turn-over of antioxidants, loss of antioxidants during renal replacement therapy, and leukocyte activation that leads to accumulation of oxidative products. Duration of dialysis therapy, iron infusion, anemia, presence of central venous catheter, and bioincompatible dialyzers are several factors triggering the development of OS. Antioxidant supplementation may take an overall protective role, even at early stages of CKD, to halt the deterioration of kidney function and antagonize systemic inflammation. Unfortunately, clinical studies have not yielded unequivocal positive outcomes when antioxidants have been administered to hemodialysis patients, likely due to their heterogeneous clinical conditions and underlying risk profile.
Collapse
|
10
|
Roy A, De S. State-of-the-Art Materials and Spinning Technology for Hemodialyzer Membranes. SEPARATION AND PURIFICATION REVIEWS 2016. [DOI: 10.1080/15422119.2016.1256323] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Anirban Roy
- Department of Chemical Engineering, Indian Institute of Technology, Kharagpur, West Bengal, India
| | - Sirshendu De
- Department of Chemical Engineering, Indian Institute of Technology, Kharagpur, West Bengal, India
| |
Collapse
|
11
|
Desai N. Basics of base in hemodialysis solution: Dialysate buffer production, delivery and decontamination. Indian J Nephrol 2015. [PMID: 26199467 PMCID: PMC4495470 DOI: 10.4103/0971-4065.147369] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemodialysis requires the use of high volumes of freshly prepared, clean dialysate to foster the removal of low molecular weight metabolites (i.e., urea) and to correct the electrolyte and acid-base imbalance of chronic renal failure. Dialysate is produced by mixing clean, AAMI grade water with both an acid and base concentrate. This purpose of this report is to describe production, mixing and delivery of the buffer component of dialysate, and to also to address the cost, safety and feasibility of producing online bicarbonate. As endotoxin contaminated dialysate has been associated with the release of key mediators in acute and chronic inflammatory diseases associated with long-term hemodialysis therapy, aspects of disinfecting a bicarbonate delivery loop are also addressed.
Collapse
Affiliation(s)
- N Desai
- Department of Nephrology, Louis Stokes Veterans Affairs Medical Center, University Hospitals of Cleveland, Ohio, USA
| |
Collapse
|
12
|
Hasegawa T, Nakai S, Masakane I, Watanabe Y, Iseki K, Tsubakihara Y, Akizawa T. Dialysis fluid endotoxin level and mortality in maintenance hemodialysis: a nationwide cohort study. Am J Kidney Dis 2015; 65:899-904. [PMID: 25641063 DOI: 10.1053/j.ajkd.2014.12.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 12/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The quality of dialysis fluid water might play an important role in hemodialysis patient outcomes. Although targeted endotoxin levels of dialysis fluid vary among countries, evidence of the contribution of these levels to mortality in hemodialysis patients is lacking. STUDY DESIGN Retrospective cohort study using data from the Japan Renal Data Registry, a nationwide annual survey. SETTING & PARTICIPANTS 130,781 patients receiving thrice-weekly in-center hemodialysis for more than 6 months were enrolled at 2,746 facilities in Japan at the end of 2006. None of the patients changed facility or treatment modality during 2007. PREDICTOR Highest endotoxin level in dialysis fluid reported by each facility during 2006. Patients were categorized by facility endotoxin level into the following groups: <0.001, 0.001 to <0.01, 0.01 to <0.05, 0.05 to <0.1, and ≥0.1EU/mL. Age, sex, dialysis vintage, diabetes mellitus as a primary cause of end-stage renal disease, Kt/V, normalized protein catabolic rate, dialysis session duration, serum albumin, and hemoglobin were measured as potential confounders. OUTCOME All-cause mortality, censored by transplantation; withdrawal from dialysis treatment; or end of follow-up. RESULTS Of 130,781 hemodialysis patients, 91.2% had facility endotoxin levels below the limit set for dialysis fluid in Japan (<0.05EU/mL). During a 1-year follow-up, 8,978 (6.9%) patients died of all causes. The rate of all-cause mortality at 1 year was highest in the ≥0.1-EU/mL category (88.0 deaths/1,000 person-years). Patients in the ≥0.1-EU/mL group exhibited an increased risk of all-cause mortality of 28% (95% CI, 10%-48%) compared to the <0.001-EU/mL group. LIMITATIONS Endotoxin level in dialysis fluid is reported as categorical data. No information about variation in endotoxin levels in dialysis fluid over time. CONCLUSIONS Higher facility endotoxin levels in dialysis fluid may be related to increased risk for all-cause mortality among hemodialysis patients. Correcting this modifiable facility water management practice might improve the outcome of hemodialysis patients.
Collapse
Affiliation(s)
- Takeshi Hasegawa
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan; Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan; Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan.
| | - Shigeru Nakai
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Fujita Health University, Toyoake, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Yabuki Hospital, Yamagata, Japan
| | - Yuzo Watanabe
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Kasugai Municipal Hospital, Kasugai, Japan
| | - Kunitoshi Iseki
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Faculty of Medicine, University of Ryukyus, Okinawa, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| |
Collapse
|
13
|
Tovbin D, Novack V, Wiessman MP, Abd Elkadir A, Zlotnik M, Douvdevani A. Circulating cell-free DNA in hemodialysis patients predicts mortality. Nephrol Dial Transplant 2012; 27:3929-35. [PMID: 22833622 DOI: 10.1093/ndt/gfs255] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Circulating cell-free DNA (CFD) appears following cell damage and DNA release, and increases in hemodialysis (HD) patients particularly following HD. We hypothesized that CFD is an integrative marker of tissue damage and can be an independent predictor for all-cause mortality in HD patients. METHODS In a prospective study, CFD levels before and after HD were evaluated in 31 chronic HD patients with no acute disease, using the reported rapid non-cumbersome inexpensive fluorometric assay developed in our laboratory. Follow-up levels were assessed at 18 months in 22 patients. All-cause mortality was a primary endpoint. RESULTS During 42 months of follow-up, 13 of the 31 (41.9%) patients died. The decedents were older than the survivors (mean age 69.9 versus 61.5 years, P = 0.06), but did not differ in end-stage renal disease (ESRD) duration, gender, albumin and hemoglobin, diabetes mellitus and weight. Post-dialysis CFD levels were significantly lower in survivors (median 688 versus 880 ng/mL, P = 0.01). The sensitivity and specificity of CFD levels of 850 ng/mL to predict 42 months (3.5 years) mortality were 73 and 75%, respectively, and the area under the receiver-operating characteristic curve was 0.77 [95% confidence interval (CI) 0.60-0.94]. The Cox proportional hazard regression model showed that CFD higher than 850 ng/mL adjusted for age, ESRD duration, weight and creatinine (stepwise model) was highly predictive of all-cause death with a hazard ratio of 8.0 (95% CI 2.3-28.5, P = 0.001). CONCLUSIONS Post-dialysis CFD level is an independent predictor of all-cause mortality in patients undergoing HD. We propose that CFD detection is an inexpensive applicable tool for identifying patients at risk and their follow-up.
Collapse
Affiliation(s)
- David Tovbin
- Department of Nephrology, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | | | | | | | | | | |
Collapse
|
14
|
Lee K, Min BG, Lee KK, Yun YM, Blagg CR. Evaluation of a new method for pulse push/pull hemodialysis: comparison with conventional hemodialysis. ASAIO J 2012; 58:232-7. [PMID: 22395115 DOI: 10.1097/mat.0b013e318248d8d7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The repetition of forward and backward filtration during hemodialysis (HD) increases convective mass transfer, and thus, the authors devised a method of achieving cyclic repletion of ultrafiltration and backfiltration. Hemodialytic efficiencies of the developed unit are described. The devised method, named pulse push/pull hemodialysis (PPPHD), is based on the utilization of dual pulsation in a dialysate stream. Clearances of solutes with different molecular weights were determined, and in vivo hemodialytic performance was investigated in a canine renal failure model. Urea and creatinine reduction and albumin (ALB) loss were monitored, and the results obtained were compared with those of a conventional high-flux hemodialysis (CHD). Dialysis sessions were repeated eight times for PPPHD and six times for CHD by alternating PPPHD and CHD sessions in a single animal, which remained stable throughout the experiments. Urea and creatinine reductions for the PPPHD unit were 49.2 ± 2% and 44.3 ± 3.3%, respectively, which were slightly higher than those obtained for the CHD. Total protein and ALB levels were preserved by both methods. However, in vitro results revealed that PPPHD achieved significantly greater inulin clearance than CHD. The developed PPPHD unit facilitates repetitive filtration and improves convective mass transfer during HD, without the need for external replacement infusion.
Collapse
|
15
|
Lee K, Mun CH, Min BG, Won YS. A dual-chambered hemodialyzer for convection-enhanced hemodialysis. Artif Organs 2012; 36:E78-82. [PMID: 22236108 DOI: 10.1111/j.1525-1594.2011.01402.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Convective clearance during hemodialysis (HD) improves dialysis outcomes in kidney failure patients, and, thus, trials have been undertaken to increase convective mass transfer, which is directly related to internal filtration rates. The authors designed a new hemodialyzer to increase the internal filtration rates, and here describe the hemodialytic efficacy of the devised unit. The developed dual-chambered hemodialyzer (DCH) contains two separate chambers for dialysate flow within a single housing. By placing a flow restrictor on the dialysate stream between these two chambers, dialysate pressures are regulated independently. Dialysate is maintained at a higher pressure than blood pressure in one chamber, and at a lower pressure in the other chamber. The dialysis performance of the DCH was investigated using an acute canine renal failure model. Urea and creatinine reductions and albumin loss were monitored, and forward and backward filtration rates were measured. No procedurally related malfunction was encountered, and animals remained stable without any complications. Urea and creatinine reductions after 4-h dialysis treatments were 75.2 ± 6.5% and 67.7 ± 8.9%, respectively. Post-treatment total protein and albumin levels remained at pretreatment values. Total filtration volume was 4.98 ± 0.5 L over 4 h, whereas the corresponding backfiltration (BF) volume was 4.77 ± 0.6 L. The developed dual-chamber dialyzer has the benefit of providing independent control of forward filtration and BF rates. HD using this dialyzer provides a straightforward means of increasing the internal filtration and convective dose.
Collapse
Affiliation(s)
- Kyungsoo Lee
- AnC Bio Inc., and Interdisciplinary Program in Bioengineering, Seoul National University Department of Biomedical Engineering, Seoul National University, Seoul, Korea.
| | | | | | | |
Collapse
|
16
|
Rostoker G, Griuncelli M, Loridon C, Bourlet T, Illouz E, Benmaadi A. Modulation of oxidative stress and microinflammatory status by colloids in refractory dialytic hypotension. BMC Nephrol 2011; 12:58. [PMID: 22013952 PMCID: PMC3231981 DOI: 10.1186/1471-2369-12-58] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 10/20/2011] [Indexed: 01/10/2023] Open
Abstract
Background Intradialytic hypotension may adversely affect the outcome of chronic hemodialysis. Therapeutic albumin has powerful anti-oxidant and anti-inflammatory properties. We have recently shown that systematic colloid infusion during hemodialysis sessions improves hemodynamic parameters in most dialysis hypotension-prone patients unresponsive to usual of preventive measures. We postulated that frequent hypotensive episodes may lead to a noxious inflammatory response mediated by oxidative stress induced by ischemia-reperfusion. The aim of this study was therefore to analyze the effect of 20% albumin and 4% gelatin infusions on oxidative stress and microinflammatory status in hypotension-prone patients unresponsive to usual preventive measures. Methods Prospective cross-over study (lasting 20 weeks) of routine infusion of 200 ml of 20% albumin versus 200 ml of 4% gelatin in 10 patients with refractory intradialytic hypotension. We analyzed the effect of 20% albumin and 4% gelatin on microinflammatory status, oxidative stress, serum nitrite and nitrate levels by analysis of variance. Results A significant decrease in serum ceruloplasmin and serum C3 was observed during the albumin period (p < 0.05, repeated measure ANOVA). A significant decrease in serum hydrogen peroxide was seen during albumin and gelatin administration (p < 0.01, repeated measure ANOVA) and a very large decrease in serum lipid peroxides was observed during the albumin period only (p < 0.01, Friedman test). Serum lactoferrin, serum proinflammatory cytokines and serum nitrite and nitrate levels remained stable during the different periods of this pilot trial. Conclusions We conclude that the improvement in microinflammatory status observed during colloid infusion in hypotension-prone dialysis patients may be related to a decrease in ischemia-reperfusion of noble organs, together with a specific reduction in oxidative stress by albumin. Trial registration ISRCTN 20957055
Collapse
Affiliation(s)
- Guy Rostoker
- Service de Néphrologie et de Dialyse, Hôpital Privé Claude Galien, 20 route de Boussy, 91480 Quincy sous Sénart, France.
| | | | | | | | | | | |
Collapse
|
17
|
Lee K, Wook Lee D, Goo Min B, Kap Lee K, Min Yun Y. Development of a New Method for Pulse Push/Pull Hemodialysis. J Med Device 2011. [DOI: 10.1115/1.4004316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Although hemodiafiltration is presumed to be a gold standard for higher convective therapy for kidney failure patients, the repetition of forward and backward filtration during hemodialysis increases the total filtration volume and convective clearance. Hence, the authors describe a new method of enhancing forward filtration and backfiltration. The devised method, named pulse push/pull hemodialysis (PPPHD), is based on the utilization of dual pulsation in a dialysate stream; namely, pulsatile devices in the dialysate stream both upstream (a dialysate pump) and downstream (an effluent pump) of the dialyzer. Fluid management accuracy of the unit was assessed using fresh bovine blood, and its hemodialytic performance was investigated in a canine renal failure model. Forward filtration rates during PPPHD were maintained at the levels of dialysate flow rates. Fluid balancing error was less than ±0.84% of total dialysate volume, when 97.4 ± 1.66L of pure dialysate was circulated for 4 hs. The animal remained stable without any complication. Urea and creatinine reductions were 56.9 ± 1.6 and 52.8 ± 2.3%, respectively, and albumin levels remained uniform throughout treatment. The devised PPPHD unit offers a simple, but efficient strategy of combined simultaneous diffusive and convective solute transport for ESRD patients, without the need for external replacement infusion.
Collapse
Affiliation(s)
| | | | - Byoung Goo Min
- Department of Biomedical Engineering, Seoul National University, Seoul, Korea
| | | | - Young Min Yun
- School of Veterinary Medicine, Jeju National University, Jeju, Korea
| |
Collapse
|
18
|
Mactier R, Hoenich N, Breen C. Renal Association Clinical Practice Guideline on haemodialysis. Nephron Clin Pract 2011; 118 Suppl 1:c241-86. [PMID: 21555899 DOI: 10.1159/000328072] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 12/01/2009] [Indexed: 11/19/2022] Open
Affiliation(s)
- Robert Mactier
- Renal Services, NHS Greater Glasgow and Clyde and NHS Forth Valley.
| | | | | |
Collapse
|
19
|
Morena M, Patrier L, Jaussent I, Bargnoux AS, Dupuy AM, Badiou S, Leray-Moragues H, Klouche K, Canaud B, Cristol JP. Reduced glomerular filtration rate, inflammation and HDL cholesterol as main determinants of superoxide production in non-dialysis chronic kidney disease patients. Free Radic Res 2011; 45:735-45. [DOI: 10.3109/10715762.2011.574291] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Marion Morena
- Laboratoire de Biochimie, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
- Institut de Recherche et de Formation en Dialyse, CHRU Montpellier, F-34000 France
- UMR 204, Nutripass, F-34000 France
| | - Laure Patrier
- Laboratoire de Biochimie, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
- UMR 204, Nutripass, F-34000 France
- Service de Néphrologie-Hémodialyse et Soins Intensifs, CHRU, Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
| | - Isabelle Jaussent
- INSERM, U1061, Montpellier, F-34093 France; Univ Montpellier 1, Montpellier, F-34000 France
| | - Anne-Sophie Bargnoux
- Laboratoire de Biochimie, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
- UMR 204, Nutripass, F-34000 France
| | - Anne-Marie Dupuy
- Laboratoire de Biochimie, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
| | - Stéphanie Badiou
- Laboratoire de Biochimie, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
- UMR 204, Nutripass, F-34000 France
| | - Hélène Leray-Moragues
- Service de Néphrologie-Hémodialyse et Soins Intensifs, CHRU, Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
| | - Kada Klouche
- UMR 204, Nutripass, F-34000 France
- Service de Réanimation Métabolique, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
| | - Bernard Canaud
- Institut de Recherche et de Formation en Dialyse, CHRU Montpellier, F-34000 France
- UMR 204, Nutripass, F-34000 France
- Service de Néphrologie-Hémodialyse et Soins Intensifs, CHRU, Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
| | - Jean-Paul Cristol
- Laboratoire de Biochimie, CHRU Montpellier, F-34000 France; Univ Montpellier 1, Montpellier, F-34000 France
- UMR 204, Nutripass, F-34000 France
| |
Collapse
|
20
|
Terrier-Lenglet A, Nollet A, Liabeuf S, Barreto DV, Brazier M, Lemke HD, Vanholder R, Choukroun G, Massy ZA. [Plasma malondialdehyde may not predict mortality in patient with chronic kidney disease]. Nephrol Ther 2011; 7:219-24. [PMID: 21316322 DOI: 10.1016/j.nephro.2010.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 12/23/2010] [Accepted: 12/23/2010] [Indexed: 12/21/2022]
Abstract
The role of oxidative stress in patients with chronic kidney disease (CKD) as a potential marker of morbidity and mortality remains poorly evaluated. The aim of the present study aims was thus: to determine plasma levels of malondialdehyde (MDA), end product of lipid peroxidation in patients at different CKD stages (predialysis and dialysis); to evaluate the association between plasma MDA levels and vascular disease or overall and cardiovascular mortality. Plasma MDA levels evaluated by HPLC, pulse wave velocity, aortic calcification score were evaluated in 94 CKD patients (67±13 years, 54% males, 29% at CKD stages 2-3, 32% at stages 4-5, 39% at stage 5D) prospectively followed for mortality. We observed that the plasma MDA levels were increased in patient with CKD and augmented progressively with CKD stages. However, we did not find any independent association between plasma levels of MDA and pulse wave velocity, aortic calcification score, or overall and cardiovascular mortality. Our results suggest that plasma MDA is not a useful biomarker in CKD patients.
Collapse
Affiliation(s)
- Aurélie Terrier-Lenglet
- Service de pharmacologie, centre de recherche clinique, CHU Amiens-Sud, avenue René-Laennec, 80054 Amiens, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Praditpornsilpa K, Tiranathanagul K, Susantitaphong P, Katavetin P, Trakarnvanich T, Townamchai N, Kanjanabuch T, Avihingsanon Y, Tungsanga K, Eiam-Ong S. Effects of Different Levels of Endotoxin Contamination on Inflammatory Cytokine Production by Peripheral Blood Mononuclear Cells after High-Flux Hemodialysis. Blood Purif 2011; 32:112-6. [DOI: 10.1159/000324394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 01/14/2011] [Indexed: 11/19/2022]
|
22
|
Bowry SK, Gatti E. Impact of Hemodialysis Therapy on Anemia of Chronic Kidney Disease: The Potential Mechanisms. Blood Purif 2011; 32:210-9. [DOI: 10.1159/000329573] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
23
|
Santoro A, Guadagni G. Dialysis membrane: from convection to adsorption. Clin Kidney J 2010; 3:i36-i39. [PMID: 27045937 PMCID: PMC4813820 DOI: 10.1093/ndtplus/sfq035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 02/22/2010] [Indexed: 12/02/2022] Open
Abstract
Although patients undergoing dialysis have a complex illness, there are compelling reasons to believe that the inadequate removal of organic waste is an important contributing factor to the illness itself. This paper focuses on the transport phenomena that occur within a dialyser. An attempt is made to clarify how transport phenomena are related to the performance of a dialysis session and how they depend on the membrane characteristics. Our study offers some discussion points on the complex issue of defining what the best parameters could be in comparing the efficiency of different membranes. The new high-flux dialysers have improved larger-molecule clearance and biocompatibility. Membrane performance is a very hard process to evaluate, and different membranes can only be compared by establishing adequate points of comparison. At the same time, the points of comparison themselves may change depending on the type of co-morbidities of the specific patient who is considered for membrane selection. This editorial (together with all the papers presented in this issue) seeks to focus on the membrane's own merits in improving the dialysis therapy.
Collapse
Affiliation(s)
- Antonio Santoro
- Division of Nephrology, Dialysis and Hypertension, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Via Palagio Palagi 9, 40138, Bologna , Italy
| | - Gualtiero Guadagni
- Division of Nephrology, Dialysis and Hypertension, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Via Palagio Palagi 9, 40138, Bologna , Italy
| |
Collapse
|
24
|
Vanholder RC, Glorieux GL, De Smet RV. Back to the future: middle molecules, high flux membranes, and optimal dialysis. Hemodial Int 2009; 7:52-7. [PMID: 19379341 DOI: 10.1046/j.1492-7535.2003.00004.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Middle molecules can be defined as compounds with a molecular weight (MW) above 500 Da. An even broader definition includes those molecules that do not cross the membranes of standard low-flux dialyzers, not only because of molecular weight, but also because of protein binding and/or multicompartmental behavior. Recently, several of these middle molecules have been linked to the increased tendency of uremic patients to develop inflammation, malnutrition, and atheromatosis. Other toxic actions can also be attributed to the middle molecules. In the present publication we will consider whether improved removal of middle molecules by large pore membranes has an impact on clinical conditions related to the uremic syndrome. The clinical benefits of large pore membranes are reduction of uremia-related amyloidosis; maintenance of residual renal function; and reduction of inflammation, malnutrition, anemia, dyslipidemia, and mortality. It is concluded that middle molecules play a role in uremic toxicity and especially in the processes related to inflammation, atherogenesis, and malnutrition. Their removal seems to be related to a better outcome, although better biocompatibility of membranes might be a confounding factor.
Collapse
Affiliation(s)
- Raymond C Vanholder
- Department of Internal Medicine, Nephrology Unit, University Hospital, Ghent, Belgium.
| | | | | |
Collapse
|
25
|
Glorieux G, Schepers E, Schindler R, Lemke HD, Verbeke F, Dhondt A, Lameire N, Vanholder R. A novel bio-assay increases the detection yield of microbiological impurity of dialysis fluid, in comparison to the LAL-test. Nephrol Dial Transplant 2008; 24:548-54. [DOI: 10.1093/ndt/gfn485] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
26
|
Unver S, Ipcioglu OM, Kinalp C, Ozcan O, Atasoyu EM, Evrenkaya TR. Oxidative Stress Potentials of Different Synthetic Hemodialysis Membranes. ACTA ACUST UNITED AC 2008. [DOI: 10.1002/dat.20257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
27
|
Henrie M, Ford C, Andersen M, Stroup E, Diaz-Buxo J, Madsen B, Britt D, Ho CH. In Vitro Assessment of Dialysis Membrane as an Endotoxin Transfer Barrier: Geometry, Morphology, and Permeability. Artif Organs 2008; 32:701-10. [DOI: 10.1111/j.1525-1594.2008.00592.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
28
|
Moreira AC, Gaspar A, Serra MA, Simões J, Lopes da Cruz J, Freitas do Amaral T. Effect of a Sardine Supplement on C-Reactive Protein in Patients Receiving Hemodialysis. J Ren Nutr 2007; 17:205-13. [DOI: 10.1053/j.jrn.2007.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Indexed: 11/11/2022] Open
|
29
|
Abstract
Online hemodiafiltration (HDF) is an extracorporeal technique for solute removal in renal failure, which takes advantage of an enhancement of convective treatment by the large amount of ultrapure nonpyrogen dialysate being used for substitution of the ultrafiltered volume. It offers many advantages aside from its safe inflammatory profile, which is attributable to the use of ultrapure dialysate and highly biocompatible dialysis membranes. Due to an improved convective clearance, significantly increased removal of large or protein-bound uremic retention solutes can be achieved, with a potential benefit on cardiovascular morbidity and mortality. Recent observational data indicate that online HDF offers a survival advantage even after adjustment for comorbidity and dialysis efficiency. Research has been ongoing to maximize further the effectiveness of the technique by new technical innovations such as transmembrane-pressure feedback control or mid-dilution online HDF.
Collapse
Affiliation(s)
- Steven Van Laecke
- Nephrology Section of Department of Internal Medicine, University of Ghent, De Pintelaan 185, Ghent, Belgium
| | | | | |
Collapse
|
30
|
Grooteman MPC, Gritters M, Wauters IMPMJ, Schalkwijk CG, Stam F, Twisk J, Ter Wee PM, Nubé MJ. Patient characteristics rather than the type of dialyser predict the variability of endothelial derived surface molecules in chronic haemodialysis patients. Nephrol Dial Transplant 2005; 20:2751-8. [PMID: 16188898 DOI: 10.1093/ndt/gfi126] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a frequent complication in chronic haemodialysis (HD) patients. Endothelial dysfunction, as measured by soluble cellular adhesion molecules (sCAM) and von Willebrand factor (vWf) in plasma, is an early manifestation of CVD. Today, it is unknown if, and to what extent, their levels are influenced by the type of dialyser. METHODS Four dialysers, low-flux cuprammonium (CU); high-flux and low-flux polysulfone and super-flux polyethersulfone, were compared in 15 chronic HD patients in a randomized cross-over fashion. sCAM and vWf were measured at baseline as well as after 4 weeks, and both intra-dialytical and after 24 h (t24 h). Twenty healthy subjects served as controls. RESULTS Baseline levels were considerably higher in chronic HD patients than in controls (soluble intercellular adhesion molecule-1: sICAM-1 732+/-216 vs 572+/-259 ng/ml, P = 0.06; soluble vascular cell adhesion molecule-1: sVCAM-1 1917+/-492 vs 1126+/-338 ng/ml, P<0.001; vWF: 205+/-55% vs 98+/-52%, P<0.001). After 4 weeks, no changes were observed. During and after HD, sCAM did not change, except in the case of CU (sICAM-1: 719+/-259 to 772+/-261 ng/ml, P = 0.04). CU induced a rise in vWF directly after HD (t4 h; from 188+/-48% to 255+/-92%, P<0.01), whereas all modalities induced a significant increase at t24 h (mean 228+/-54%, P = 0.02). The levels of sCAM and vWf appeared to be dependent on the individual patients rather than on the type of dialyser (explained variance by different patients: 66%-91%, P<0.001; by type of dialyser 0.4-1.2%). CONCLUSIONS Baseline levels of sCAM and vWf were markedly higher in chronic HD patients than in controls and did not change after 4 weeks with any dialyser. All membranes induced a marked rise in vWf at t24 h, whereas sICAM-1 increased only in the case of CU at t4 h. As sCAM showed no marked changes during HD with any other modality, our study suggests activation of blood cells rather than endothelial cells. As pre-dialysis levels of sCAM and vWf varied noticeably between individual patients, endothelial dysfunction seems to be far more dependent on patient-related factors than on the HD treatment itself.
Collapse
Affiliation(s)
- Muriel P C Grooteman
- VU University Medical Center, Dept of Nephrology, De Boelelaan 1117, 1081 HV, Amsterdam; Postbus 7057, 1007 MB Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Thomé FS, Senger M, Garcez C, Garcez J, Chemello C, Manfro RC. Dialysis water treated by reverse osmosis decreases the levels of C-reactive protein in uremic patients. Braz J Med Biol Res 2005; 38:789-94. [PMID: 15917962 DOI: 10.1590/s0100-879x2005000500018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Atherosclerosis is a major complication of chronic renal failure. Microinflammation is involved in atherogenesis and is associated with uremia and dialysis. The role of dialysate water contamination in inducing inflammation has been debated. Our aim was to study inflammatory markers in patients on chronic dialysis, before and 3 to 6 months after switching the water purification system from deionization to reverse osmosis. Patients had demographic, clinical and nutritional information collected and blood drawn for determination of albumin, ferritin, C-reactive protein (CRP), interleukin-6, and tumor necrosis factor-alpha in both situations. Acceptable levels of water purity were less than 200 colony-forming units of bacteria and less than 1 ng/ml of endotoxin. Sixteen patients died. They had higher median CRP (26.6 vs 11.2 mg/dl, P = 0.007) and lower median albumin levels (3.1 vs 3.9 g/l, P < 0.05) compared to the 31 survivors. Eight patients were excluded because of obvious inflammatory conditions. From the 23 remaining patients (mean age +/- SD: 51.3 +/- 13.9 years), 18 had a decrease in CRP after the water treatment system was changed. Overall, median CRP was lower with reverse osmosis than with deionization (13.2 vs 4.5 mg/l, P = 0.022, N = 23). There was no difference in albumin, cytokines, subjective global evaluation, or clinical and biochemical parameters. In conclusion, uremic patients presented a clinically significant reduction in CRP levels when dialysate water purification system switched from deionization to reverse osmosis. It is possible that better water treatments induce less inflammation and eventually less atherosclerosis in hemodialysis patients.
Collapse
Affiliation(s)
- F S Thomé
- Programa de Pós-Graduação em Ciências Médicas: Nefrologia, Faculdade de Medicina, Universidade Federal do Rio Grande do SulSão Paulo, SP, Brasil.
| | | | | | | | | | | |
Collapse
|
32
|
Ledebo I. Ultrapure Dialysis Fluid – Direct and Indirect Benefits in Dialysis Therapy. Blood Purif 2005; 22 Suppl 2:20-5. [PMID: 15655318 DOI: 10.1159/000081869] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The fluid quality description 'ultrapure' means practically free from bacteria and endotoxin. In quantitative terms it is defined as <0.1 CFU/ml and <0.03 EU/ml. The requirements on endotoxin as well as bacteria should be fulfilled, because these two entities are not strictly correlated. Ultrapure dialysis fluid can be prepared from standard quality fluid by a single step of controlled ultrafiltration. Recent clinical studies demonstrate that the use of ultrapure dialysis fluid in hemodialysis is associated with patient benefits indicating a less inflammatory state compared to hemodialysis with standard fluid. By applying one additional step of controlled ultrafiltration, ultrapure dialysis fluid can be further purified to such high microbiological quality that it can be used for infusion. This opens up the possibility for convective therapies, hemodiafiltration and hemofiltration, for which large volumes of sterile infusion solution are needed. With optimal application of these therapies, solute removal is enhanced, qualitatively as well as quantitatively, and fluid management is facilitated through improved hemodynamic stability.
Collapse
|
33
|
Gomila M, Gascó J, Busquets A, Gil J, Bernabeu R, Buades JM, Lalucat J. Identification of culturable bacteria present in haemodialysis water and fluid. FEMS Microbiol Ecol 2004; 52:101-14. [PMID: 16329897 DOI: 10.1016/j.femsec.2004.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2004] [Revised: 10/21/2004] [Accepted: 10/26/2004] [Indexed: 11/25/2022] Open
Abstract
Water used to prepare haemodialysis fluid is not sterile, and its microbiological control is important for the prevention of haemodialysis-associated illness. Bacterial populations inhabiting a distribution system for haemodialysis water were studied over an 18-month period. 203 planktonic bacteria isolated on R2A medium were identified by restriction analysis and sequencing of 16S rRNA gene. A diverse bacterial community was detected, containing predominantly Gram-negative members of the Alphaproteobacteria and Betaproteobacteria, as well as representatives of the genus Mycobacterium. Ecological and clinical consequences are discussed: bacteria from the genera Novosphingobium, Pseudomonas and Sphingomonas have been described in the build-up of biofilms, and others like Acinetobacter, Mycobacterium or Brevibacterium may represent a health risk to patients under haemodialysis treatment.
Collapse
Affiliation(s)
- Margarita Gomila
- Area Microbiologia, Departament de Biologia, Universitat de les Illes Balears, and Institut Mediterrani d'Estudis Avançats (CSIC-UIB), Palma de Mallorca, Spain
| | | | | | | | | | | | | |
Collapse
|
34
|
Amoureux MC. [Pathophysiological role of endotoxins, a common denominator to various diseases]. ACTA ACUST UNITED AC 2004; 52:415-22. [PMID: 15336435 DOI: 10.1016/j.patbio.2004.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Accepted: 04/30/2004] [Indexed: 01/26/2023]
Abstract
A growing number of investigations point to endotoxin or lipopolysaccharide as a central player in many pathophysiological states and diseases. Endotoxins are one of the most toxic biological contaminants continuously shed by both dead and live Gram negative bacteria. Endotoxins induce the primitive form of defense called innate immunity. Endotoxins have been related to inflammatory reactions observed in patients suffering from respiratory distress syndrome, multiorgan failure and septic shock, hepatic diseases, or in subjects affected by graft versus host disease after allogeneic transplantation. As our understanding of the molecular mechanisms underlying pathologies progresses, more diseases involving endotoxins emerge. Although these illnesses are multifactorial, the objective of this article is to review some of the common and distinct processes involving endotoxins in various disease states.
Collapse
Affiliation(s)
- M-C Amoureux
- Clarigen Inc., 5922 Farnsworth-Court, Carlsbad, CA 92008, Etats-Unis.
| |
Collapse
|
35
|
Weber V, Linsberger I, Rossmanith E, Weber C, Falkenhagen D. Pyrogen transfer across high- and low-flux hemodialysis membranes. Artif Organs 2004; 28:210-7. [PMID: 14961961 DOI: 10.1111/j.1525-1594.2004.47227.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The extent to which bacterial products from contaminated dialysate enter a patient's blood depends upon the type and permeability of the hemodialysis membrane in use. This study was performed to assess the transfer of pyrogenic substances across both high- and low-flux membranes (DIAPES, Fresenius Polysulfone, Helixone, Polyamide S). All experiments were carried out in the saline-saline model. The dialysate pool was contaminated either with purified lipopolysaccharide (LPS) (250 and 500 EU/mL) or with sterile bacterial culture filtrates (20 EU/mL), and in vitro dialysis was performed under diffusive and convective conditions. A significant transfer of endotoxin was observed for both low- and high-flux DIAPES challenged with either LPS or with bacterial culture filtrates. Under identical conditions, no transfer of endotoxins was detectable across Fresenius Polysulfone and Helixone upon challenge with purified LPS. With bacterial culture filtrates, endotoxin concentrations for Polyamide S and Fresenius Polysulfone were about 10% and 1%, respectively, of those measured for DIAPES, whereas no transfer of endotoxin was detectable for Helixone. Using an alternative assay (induction of interleukin-1 receptor antagonist, IL-1Ra, in whole blood), only the DIAPES membrane showed the passage of cytokine-inducing substances. Thus, when saline is present in both the blood and dialysate compartments (i.e., the situation during predialysis priming procedures), dialysis membranes differ profoundly with respect to their permeability to endotoxins.
Collapse
Affiliation(s)
- Viktoria Weber
- Center for Biomedical Technology, Danube University Krems, Krems, Austria.
| | | | | | | | | |
Collapse
|
36
|
|
37
|
Lonnemann G, Novick D, Rubinstein M, Passlick-Deetjen J, Lang D, Dinarello CA. A switch to high-flux helixone membranes reverses suppressed interferon-gamma production in patients on low-flux dialysis. Blood Purif 2004; 21:225-31. [PMID: 12784048 DOI: 10.1159/000070694] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2003] [Indexed: 11/19/2022]
Abstract
UNLABELLED Long-term hemodialysis (HD) induces an inflammatory response and is associated with a suppressed cellular immune response manifested, in part, by impaired interferon (IFN-gamma) production. We investigated the effect of high-flux HD using the synthetic Helixone membrane and ultrafiltered dialysate on plasma levels of inflammatory mediators and on the whole blood production of IFN-gamma. METHODS Twelve ESRD patients were dialyzed under low-flux HD (polysulfone F6) and again after 6 weeks of high-flux HD (Helixone FX100). Ultrafiltered bicarbonate dialysate without bacterial growth and no detectable endotoxin was used throughout the study. Plasma levels of urea, albumin, beta(2)-microglobulin (beta(2)-m), interleukin (IL)-6, C-reactive protein (CRP), IL-1 receptor antagonist (IL-1Ra), IL-18, and IL-18-binding protein (IL-18BP) were measured. In addition, the Staphylococcus epidermidis-induced production of IFN-gamma and IL-18 was assessed in whole blood cultures of HD patients as well as in 9 healthy subjects. RESULTS Plasma levels of urea, albumin, IL-6, IL-1Ra and CRP were not significantly different between high-flux and low-flux HD. In contrast, beta(2)-m levels decreased significantly by 31% with high-flux Helixone (p < 0.002). Stimulated whole blood production of IFN-gamma was reduced in low-flux HD but increased to near normal levels after 6 weeks of high-flux HD. Plasma levels of free IL-18 and its specific inhibitor IL-18BP were not different between the two dialyzer membranes. CONCLUSION Compared to low-flux polysulfone HD with ultrafiltered dialysate, high-flux HD with the synthetic Helixone membrane did not result in a significant change in plasma levels of proinflammatory (IL-6, CRP, IL-18) and anti-inflammatory (IL-1Ra, IL-18BP) cytokines. However, high-flux HD restores whole blood IFN-gamma production without significant changes in free IL-18. Therefore, the immune modulation in high-flux HD is likely due to removal of inhibitors of IFN-gamma production other than IL-18BP.
Collapse
|
38
|
Galle J, Seibold S, Wanner C. Inflammation in uremic patients: what is the link? Kidney Blood Press Res 2004; 26:65-75. [PMID: 12771529 DOI: 10.1159/000070986] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Uremic patients suffer to an extremely high degree from cardiovascular disease. Cardiovascular disease results mainly from atherosclerotic remodeling of the arterial system. Inflammation is considered to contribute significantly to development of atherosclerosis, and albeit many different factors may lead to inflammation, generation of enhanced oxidative stress is believed to be an important common feature of pro-inflammatory causes. Studies in the general population without renal disease could clearly show that markers of inflammation, in particular C-reactive protein, predict the cardiovascular risk. In this review article, we discuss the presence and the predictive value of inflammation in patients with end-stage renal disease, and analyze whether uremic patients are exposed to specific pro-inflammatory and pro-oxidative conditions. Particular emphasis is set on oxidative stress induced by oxidatively modified lipoproteins and angiotensin II. Based on pathophysiological considerations valid for uremic patients, we discuss therapeutical options that might help to reduce cardiovascular disease in uremic patients.
Collapse
Affiliation(s)
- Jan Galle
- Department of Medicine, Division of Nephrology, University of Würzburg, Würzburg, Germany.
| | | | | |
Collapse
|
39
|
Szathmary S, Hegyi E, Amoureux MC, Rajapakse N, Chicorka L, Szalai G, Reszegi K, Derbyshire Z, Paluh J, Dodson B, Grandics P. Characterization of the DialGuard TM Device for Endotoxin Removal in Hemodialysis. Blood Purif 2004; 22:409-15. [PMID: 15316195 DOI: 10.1159/000080232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2004] [Indexed: 11/19/2022]
Abstract
Bacterial pyrogens, capable of penetrating dialyzer membranes, are responsible for a systemic inflammatory reaction in hemodialysis patients. Dialyzer reuse, involving rinsing of the dialyzer with pyrogen-containing water, may exacerbate this situation. Studies of the mechanism of action of endotoxin suggest that it irreversibly damages the vascular endothelium. The novel endotoxin removal method described here, is based on affinity-binding of endotoxin by the adsorbent ClarEtox, a USP Class VI-certified resin that is the active component of the medical device DialGuard. Under standard hemodialysis operating conditions, challenge of DialGuard with Pseudomonas maltophilia supernatant-spiked dialysate, containing 35-193 EU/ml endotoxin, resulted in endotoxin levels below 0.05 EU/ml in the treated dialysate. DialGuard was able to decrease endotoxin concentrations in the dialysate from a range of 2.39-8.49 to <0.005 EU/ml. DialGuard supports high fluid velocities at low back pressures and can be sanitized using the heat sanitization cycle of hemodialysis machines. DialGuard offers a simple, user-friendly way to reduce the concentration of endotoxin in dialysate and water for dialysis at a low cost.
Collapse
|
40
|
Abstract
Water used in dialysis requires additional treatment to minimize patient exposure to potential contaminants that may be present in drinking water. Although standards for the chemical purity of water are in existence and have eliminated many of the problems seen in renal units in the 1970s, some problems remain, and the importance of newer contaminants arising from changes in water treatment at the municipal level are being recognized. Despite this, recent surveys have indicated considerable shortcomings in compliance with chemical standards. The water quality used in the preparation of dialysis fluid also requires minimal bacterial content. Staff working in renal units are frequently unaware of the level of microbiologic contamination in their dialysis fluid arising from the presence of biofilm in the dialysis machines and the water distribution network. Bacterial fragments generated by such biofilms are able to cross the dialysis membrane and stimulate an inflammatory response in the patient. Such inflammation has been implicated in the mortality and morbidity associated with dialysis. The desire to improve treatment outcomes has led to the application of more stringent standards for the microbiologic purity of dialysis fluid and to the introduction of ultraclean dialysis fluid into clinical practice.
Collapse
Affiliation(s)
- Nicholas A Hoenich
- School of Clinical Medical Sciences, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom.
| | | |
Collapse
|
41
|
Descamps-Latscha B, Jungers P, Witko-Sarsat V. Immune system dysregulation in uremia: role of oxidative stress. Blood Purif 2003; 20:481-4. [PMID: 12207098 DOI: 10.1159/000063558] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Immune system dysregulation in end-stage renal disease patients is a multifactorial process combining profound immunodeficiency with a state of cellular activation. While at the origin of the deficiency uremic toxins are thought to play a prominent role, the dialysis procedure is the main factor for the genesis of a recurrent cellular activation process leading to a chronic inflammation state dominated by oxidative stress and its related severe complications, e.g. beta(2)-microglobulin amyloid arthropathy and accelerated atherosclerosis. The recent identification of advanced oxidation protein products (AOPPs) in the plasma of uremic patients and the following demonstration that AOPPs act as both potential uremic toxins and proinflammatory mediators, have opened novel areas of research on these novel molecular bases of oxidative stress and on therapeutic strategies aimed at reducing its most deleterious effects in hemodialysis patients.
Collapse
|
42
|
Chauveau P, Level C, Lasseur C, Bonarek H, Peuchant E, Montaudon D, Vendrely B, Combe C. C-reactive protein and procalcitonin as markers of mortality in hemodialysis patients: a 2-year prospective study. J Ren Nutr 2003; 13:137-43. [PMID: 12671838 DOI: 10.1053/jren.2003.50017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE We have previously shown in a transversal study that PCT combined to CRP is associated to an altered nutritional status in hemodialysis patients. In a 2-year prospective study, we have assessed the relationship between markers of inflammation or nutrition and mortality. DESIGN Two-year prospective study, in 61 patients dialyzed in our unit (29 M/32 F, age 63 +/- 15 years, on dialysis for 76 +/- 94 months, 12 hrs/wk, on high-flux (HF) membrane for 25 patients and low-flux (LF) for 36 patients, without reuse). Kt/V was 1.53 +/- 0.30. SETTING Hospital-based dialysis unit. MAIN OUTCOME MEASURE CRP, PCT, ferritin, albumin, and prealbumin, were measured in 04/99 (T0) and every 6 months thereafter. Interleukin-6 (IL6) and fibrinogen were measured at the start of study. The outcome and the causes of death of patients were noted in 58 patients, 3 patients were lost of follow-up. RESULTS The mortality (24 deaths) was 42% at 2 years in this hospital based unit. The main causes of mortality were cardiovascular diseases (71%) and infection (17%). Patients were classified according to their CRP (CRP+ if CRP > or = 5 mg/L; n = 40), and PCT values (PCT + if PCT > or = 0.5 ng/mL; n = 25). IL6 level was > or = 10 pg/mL for 95% of the patients. Mortality was higher in the CRP+ group (Kaplan-Meier test P < .01) but not in the PCT or IL6 positive patients. All patients of the CRP+ group at T0 remained CRP+. Only 56% of patients of PCT+ remained positive at 6 months. When patients were grouped according to CRP quartile the difference on survival remained significant (P = .03), patients who were classified in the third and fourth quartile (upper than 9.9 mg/L), exhibited a higher rate of mortality than the lower quartile. The concomitant presence of a high level of PCT and CRP was associated with a worsened nutritional status at T0 but PCT level had no influence on 2-year mortality. CONCLUSION In this 2-year prospective study in a hospital-based cohort of high-risk hemodialysis patients, elevated CRP, but not raised PCT, was associated with increased mortality. Inflammation remained present throughout a 2-year follow-up in patients with an initial CRP higher than 5 mg/L. An upper value of CRP above 9.9 mg/L is independly predictive of mortality, mainly from cardiovascular causes. The association of high PCT and CRP was no more predictive of mortality than high CRP.
Collapse
Affiliation(s)
- Philippe Chauveau
- Service de Néphrologie et Hémodialyse, Hôpital Saint André, Bordeaux, France
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Wratten ML, Galaris D, Tetta C, Sevanian A. Evolution of oxidative stress and inflammation during hemodialysis and their contribution to cardiovascular disease. Antioxid Redox Signal 2002; 4:935-44. [PMID: 12573142 DOI: 10.1089/152308602762197470] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
End-stage renal disease patients have increased cardiovascular morbidity and mortality. These patients have many unique risk factors, such as an accumulation of uremic toxins, electrolyte imbalances, metabolic disturbances, anemia, chronic inflammation, and thrombogenic disturbances. Oxidative stress has been implicated in many of these disturbances. This review will focus on some of the factors that may accelerate cardiovascular disease in uremic patients, with an emphasis on mechanisms and interactions of various components of oxidative stress and inflammation. Understanding the mechanisms of these pathways may be useful in developing effective prevention and treatment strategies.
Collapse
Affiliation(s)
- Mary Lou Wratten
- Clinical and Laboratory Research Department, Bellco, Mirandola (MO) Italy.
| | | | | | | |
Collapse
|
44
|
|
45
|
Lederer SR, Schiffl H. Ultrapure dialysis fluid lowers the cardiovascular morbidity in patients on maintenance hemodialysis by reducing continuous microinflammation. Nephron Clin Pract 2002; 91:452-5. [PMID: 12119476 DOI: 10.1159/000064286] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The aims of our prospective 3-year investigation were (1) to clarify whether high C-reactive protein (CRP) levels are an intermittent or a continuous phenomenon in individual hemodialysis patients and (2) to evaluate a possible relationship between ultrapure dialysis fluid associated CRP levels and an increased prevalence of atherosclerosis in a group of 60 hemodialysis patients treated either with conventional (n = 38) or on-line-produced ultrapure dialysis fluid (n = 22). Primary end points of the study were angiographically confirmed cerebrovascular, cardiovascular, or peripheral vascular events. Measurements of the CRP levels were done every 3 months using a highly sensitive assay. The CRP levels were normal (<0.5 mg/dl) in 45 patients and raised in 15 patients at the time of recruitment. In 87% of the patients with normal CRP levels, ultrapure dialysis fluid was used. The CRP levels measured at recruitment and at various time points thereafter did not differ significantly within patient groups. However, patients with increased CRP concentrations experienced significantly more vascular events as compared with patients with normal CRP levels (11 events vs. 1 event; p < 0.001). The data indicate that continuous induction of acute-phase proteins represents a nontraditional vascular risk factor contributing to the development and progression of atherosclerosis in dialysis patients. Ultrapure dialysis fluid lowers cardiovascular morbidity by preventing/reducing chronic microinflammation.
Collapse
Affiliation(s)
- S R Lederer
- Kuratorium für Dialyse und Nierentransplantation, Dialysezentrum München-Laim, Elsenheimerstrasse 63, D-80687 Münich, Germany
| | | |
Collapse
|
46
|
Abstract
Recent trends show a progressive increase in the use of modified cellulosic and synthetic dialyzers and a corresponding decrease in the utilization rate of unmodified cellulosic dialyzers. The purpose of this article is to describe current membrane and dialyzer technology, with the focus almost entirely on modified cellulosic and synthetic membranes. A general overview of membrane-related determinants of dialyzer performance is first presented, followed by a discussion of specific characteristics of some of the more commonly used membranes and dialyzers.
Collapse
Affiliation(s)
- William R Clark
- Renal Division, Baxter Healthcare Corp., McGaw Park, Illinois, USA.
| | | |
Collapse
|
47
|
Morena M, Cristol JP, Senécal L, Leray-Moragues H, Krieter D, Canaud B. Oxidative stress in hemodialysis patients: is NADPH oxidase complex the culprit? KIDNEY INTERNATIONAL. SUPPLEMENT 2002:109-14. [PMID: 11982824 DOI: 10.1046/j.1523-1755.61.s80.20.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Oxidative stress results from an imbalance between oxidant production, including reactive oxygen species (ROS), reactive nitrogen species (RNS), chlorinated compounds, and antioxidant defense mechanisms. Most reports prove that oxidative stress is present in ESRD patients. Several studies tend to accreditate the hypothesis by which oxidative stress is a strong co-factor for the development of complications related to long-term HD such as atherosclerosis, amyloidosis, malnutrition, anemia, and infection. In order to evaluate the rationale for curative action against oxidative damage in chronic renal failure patients, we reviewed the putative factors involved in this process. Antioxidant systems are severely impaired in uremic patients and gradually altered with the degree of renal failure. Moreover, the inflammatory state caused by the hemoincompatibility of the dialysis system plays a critical role in the activation of NADPH oxidase, aggravating the pro-oxidant status of uremic patients. Prevention of ROS overproduction by improvement of dialysis biocompatibility, an important component of adequate dialysis, might be completed by antioxidant supplementation.
Collapse
Affiliation(s)
- Marion Morena
- New England Medical Center, Division of Nephrology, Boston, Massachusetts, USA
| | | | | | | | | | | |
Collapse
|
48
|
Abstract
ABSTRACT. Maintenance hemodialysis patients display evidence of elevated interleukin-1 (IL-1) and tumor necrosis factor alpha release after stimulation either by contaminated dialysate, bioincompatible membrane material, or both. This release is followed by the stimulated secretion of a large number of other interleukins, particularly IL-6, the cytokine principally responsible for acute-phase protein synthesis. It has been shown that high levels of the circulating proinflammatory cytokines IL-1, tumor necrosis factor alpha, IL-6, and IL-13 are associated with mortality in hemodialysis patients. Essential functions of polymorphonuclear leukocytes—that is, phagocytosis, oxygen species production, upregulation of specific cell surface receptor proteins, or apoptosis—are disturbed in patients with end-stage renal disease. These are further altered as a result of complement activation by the hemodialysis procedure, particularly if bioincompatible dialyzers are used. Polymorphonuclear leukocyte degranulation occurring during extracorporeal circulation does not depend on complement activation but rather on intracellular calcium and the presence or absence of the degranulation inhibitory proteins angiogenin and complement factor D. Clinical signs and symptoms of end-stage renal disease patients are at least in part related to the accumulation of middle molecules such as β2-microglobulin, parathyroid hormone, advanced glycation end products, advanced lipoxidation end products, advanced oxidation protein products (formed as a result of oxidative stress, carbonyl stress, or both), granulocyte inhibitory proteins, or leptin. Currently available membrane materials do not provide long-lasting, effective reduction of middle molecules in patients who require maintenance hemodialysis.
Collapse
|
49
|
Ledebo I. On-line Preparation of Solutions for Dialysis: Practical Aspects Versus Safety and Regulations. J Am Soc Nephrol 2002. [DOI: 10.1681/asn.v13suppl_1s78] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ABSTRACT. On-line preparation, i.e., continuous mixing and immediate use, was introduced for dialysis fluid in 1964, and it contributed significantly to the expansion of dialysis therapy through simplified handling, improved microbiology, and enhanced efficiency. On-line prepared replacement solution for hemofiltration was shown to be clinically safe as early as 1978, but the implementation was delayed for 20 yr because of regulatory conservatism. On-line preparation of sterile and pyrogen-free solutions for infusion is based on the use of water and concentrates that contribute a minimum of microorganisms and are mixed and distributed in a hygienically designed and maintained flow path. Ultrafilters with known retention capacity are placed in strategic positions and dimensioned to remove bacteria and endotoxins, which gives a sterility assurance level of at least six magnitudes, as required by the Pharmacopoeia for sterile products. Microbiologic testing of the fluid should be applied when designing, validating, and troubleshooting on-line systems but not for routine quality control, because it only gives retrospective information. Quality assurance has to be built into a system and the way it is operated. On-line fluid preparation, when properly performed, is safe, simple, and cost-effective and enhances the efficiency as well as the biocompatibility of dialysis therapy.
Collapse
|
50
|
Borawski J, Naumnik B, Pawlak K, Mysliwiec M. Endothelial dysfunction marker von Willebrand factor antigen in haemodialysis patients: associations with pre-dialysis blood pressure and the acute phase response. Nephrol Dial Transplant 2001; 16:1442-7. [PMID: 11427638 DOI: 10.1093/ndt/16.7.1442] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Increased plasma soluble von Willebrand factor antigen (vWF : Ag) level, a marker of vascular endothelial cell dysfunction, is a strong predictor of atherosclerotic cardiovascular disease (CVD) in the general population. We studied cross-sectional associations between vWF : Ag level, prevalence of CVD, and related factors including pre-dialysis arterial blood pressure (BP) and some markers of inflammation in maintenance haemodialysis (HD) patients. Methods and results. Plasma vWF : Ag level measured by an enzyme-linked immunosorbent assay (ELISA) was higher in 110 HD patients than in 20 controls. On bivariate regression analysis, vWF : Ag level was directly associated with the presence of CVD, age, fibrinogen and the use of enoxaparin (vs unfractionated heparin) during HD procedures, and inversely with albumin and pre-dialysis BP. The patients with prevalent CVD were older, had higher vWF : Ag, white blood cell and platelet counts, fibrinogen and triglycerides, lower albumin levels, and were less frequently on combination antihypertensive therapy. Multivariable analyses identified low pre-dialysis BP, hypoalbuminaemia and hyperfibrinogenaemia (in descending order of significance) as independent predictors of high vWF : Ag level. There were no associations between vWF : Ag levels and gender, ABO blood type, smoking, body mass index, renal failure cause, duration of HD therapy, K(t)/V, normalized protein catabolic rate, dialysate buffers, dialysers, viral hepatitis, erythropoietin treatment, specific antihypertensive drugs, haemoglobin, white blood cell and platelet counts, liver enzymes, phosphorous, total cholesterol, and triglycerides. CONCLUSION Elevated plasma levels of endothelial dysfunction marker vWF : Ag in maintenance HD patients are associated with established cardiovascular mortality risk factors such as low pre-dialysis blood pressure and the activated acute phase response.
Collapse
Affiliation(s)
- J Borawski
- Department of Nephrology and Internal Medicine, Medical Academy, Bialystok, Poland
| | | | | | | |
Collapse
|