1
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Ward RA, Daugirdas JT. Kinetics of β -2-Microglobulin with Hemodiafiltration and High-Flux Hemodialysis. Clin J Am Soc Nephrol 2024:01277230-990000000-00374. [PMID: 38650079 DOI: 10.2215/cjn.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
Key Points
Addition of hemodiafiltration has a relatively small impact on reducing either predialysis or time-averaged serum β-2-microglobulin levels.Residual kidney function has a major impact on the predialysis and time-averaged serum β-2-microglobulin levels.
Background
A kinetic model for β-2-microglobulin removal and generation was used to explore the impact of adding hemodiafiltration on predialysis and time-averaged serum values.
Methods
The model was tested on data from the HEMO study and on a sample of patients undergoing high-flux hemodialysis. The impact of hemodiafiltration on β-2-microglobulin levels was evaluated by modeling four randomized studies of hemodiafiltration versus hemodialysis. The impact of residual kidney function on β-2-microglobulin was tested by comparing results of previously reported measured data with model predictions.
Results
In the low-flux and high-flux arms of the HEMO study, measured median β-2-microglobulin reduction ratios could be matched by dialyzer clearances of 5.9 and 29 ml/min, respectively. Median predialysis serum β-2-microglobulin levels were matched if generation rates of β-2-microglobulin were set to approximately 235 mg/d. In another group of patients treated with dialyzers with increased β-2-microglobulin clearances, measured cross-dialyzer clearances (57±28 ml/min) were used as inputs. In these studies, the kinetic model estimates of intradialysis and early postdialysis serum β-2-microglobulin levels were similar to median measured values. The model was able to estimate the changes in predialysis serum β-2-microglobulin in each of four published randomized comparisons of hemodiafiltration with hemodialysis, although the model predicted a greater decrease in predialysis serum β-2-microglobulin with hemodiafiltration than was reported in two of the studies. The predicted impact of residual kidney clearance on predialysis serum β-2-microglobulin concentrations was similar to that reported in one published observational study. Modeling predicted that postdilution hemodiafiltration using 25 L/4 hours replacement fluid would lower serum time-averaged concentration of β-2-microglobulin by about 18.2%, similar to the effect of 1.50 ml/min residual kidney GFR.
Conclusions
A two-pool kinetic model of β-2-microglobulin yielded values of reduction ratio and predialysis serum concentration that were consistent with measured values with various hemodiafiltration and hemodialysis treatment regimens.
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Affiliation(s)
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois
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2
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Portales-Castillo I, Yee J, Tanaka H, Fenves AZ. Beta-2 Microglobulin Amyloidosis: Past, Present, and Future. KIDNEY360 2020; 1:1447-1455. [PMID: 35372889 DOI: 10.34067/kid.0004922020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022]
Abstract
Almost half a century has elapsed since the first description of dialysis-related amyloidosis (DRA), a disorder caused by excessive accumulation of β-2 microglobulin (B2M). Within that period, substantial advances in RRT occurred. These improvements have led to a decrease in the incidence of DRA. In many countries, DRA is considered a "disappearing act" or complication. Although the prevalence of patients living with RRT increases, not all will have access to kidney transplantation. Consequently, the number of patients requiring interventions for treatment of DRA is postulated to increase. This postulate has been borne out in Japan, where the number of patients with ESKD requiring surgery for carpal tunnel continues to increase. Clinicians treating patients with ESKD have treatment options to improve B2M clearance; however, there is a need to identify ways to translate improved B2M clearance into improved quality of life for patients undergoing long-term dialysis.
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Affiliation(s)
- Ignacio Portales-Castillo
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
| | - Hiroshi Tanaka
- Division of Nephrology, Department of Medicine, Mihara Red Cross Hospital, Mihara, Japan
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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3
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Murakami K, Kokubo K, Hirose M, Kobayashi K, Kobayashi H. Squared frequency-Kt/V: a new index of hemodialysis adequacy—correlation with solute concentrations by computer simulation. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0198-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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4
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Snauwaert E, Van Biesen W, Raes A, Glorieux G, Vande Walle J, Roels S, Vanholder R, Askiti V, Azukaitis K, Bayazit A, Canpolat N, Fischbach M, Saoussen K, Litwin M, Obrycki L, Paglialonga F, Ranchin B, Samaille C, Schaefer F, Schmitt CP, Spasojevic B, Stefanidis CJ, Shroff R, Eloot S. Haemodiafiltration does not lower protein-bound uraemic toxin levels compared with haemodialysis in a paediatric population. Nephrol Dial Transplant 2019; 35:648-656. [DOI: 10.1093/ndt/gfz132] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/20/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Haemodiafiltration (HDF) is accepted to effectively lower plasma levels of middle molecules in the long term, while data are conflicting with respect to the additive effect of convection on lowering protein-bound uraemic toxins (PBUTs). Here we compared pre-dialysis β2-microglobulin (β2M) and PBUT levels and the percentage of protein binding (%PB) in children on post-dilution HDF versus conventional high- (hf) or low-flux (lf) haemodialysis (HD) over 12 months of treatment.
Methods
In a prospective multicentre, non-randomized parallel-arm intervention study, pre-dialysis levels of six PBUTs and β2M were measured in children (5–20 years) on post-HDF (n = 37), hf-HD (n = 42) and lf-HD (n = 18) at baseline and after 12 months. Analysis of variance was used to compare levels and %PB in post-HDF versus conventional hf-HD and lf-HD cross-sectionally at 12 months and longitudinal from baseline to 12 months.
Results
For none of the PBUTs, no difference was found in either total and free plasma levels or %PB between post-HDF versus the hf-HD and lf-HD groups. Children treated with post-HDF had lower pre-dialysis β2M levels [median 23.2 (21.5; 26.6) mg/dL] after 12 months versus children on hf-HD [P<0.01; 35.2 (29.3; 41.2) mg/dL] and children on lf-HD [P<0.001; 47.2 (34.3; 53.0) mg/dL]. While β2M levels remained steady in the hf-HD and lf-HD group, a decrease in β2M was demonstrated for children on post-HDF (P<0.01).
Conclusions
While post-HDF successfully decreased β2M, no additive effect on PBUT over 12 months of treatment was found. PBUT removal is complex and hampered by several factors. In children, these factors might be different from adults and should be explored in future research.
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Affiliation(s)
- Evelien Snauwaert
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
| | - Wim Van Biesen
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
| | - Ann Raes
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
| | - Griet Glorieux
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
| | - Sanne Roels
- Department of Data Analysis, Faculty of Psychology and Pedagogy, Ghent University, Ghent, Belgium
| | - Raymond Vanholder
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
| | | | - Karolis Azukaitis
- Clinic of Pediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Aysun Bayazit
- Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | | | | | - Mieczyslaw Litwin
- Department of Nephrology, Kidney Transplantation and Hypertension, Children's Memorial Health Institute, Warsaw, Poland
| | - Lukasz Obrycki
- Department of Nephrology, Kidney Transplantation and Hypertension, Children's Memorial Health Institute, Warsaw, Poland
| | - Fabio Paglialonga
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Ranchin
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Charlotte Samaille
- Nephrologie pédiatrique, Hôpital Jeanne de Flandre, CHU de Lille, Lille, France
| | - Franz Schaefer
- Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | | | - Brankica Spasojevic
- University Children's Hospital, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sunny Eloot
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
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5
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Gomez M, Maduell F. A unidimensional diffusion model applied to uremic toxin kinetics in haemodiafiltration treatments. MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2019; 36:223-240. [PMID: 29912346 DOI: 10.1093/imammb/dqy008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/21/2018] [Indexed: 11/14/2022]
Abstract
Kinetic modelling in haemodialysis is usually based upon the resolution of volume-defined compartment models. The interaction among these compartments is described by purely diffusive processes. In this paper we present an alternative kinetic model for uremic toxins in post-dilutional haemodiafiltration treatments by means of a unidimensional diffusion equation. A wide range of solutes such as urea, creatinine, $\beta _{2}$-microglobulin, myoglobin and prolactin were studied by imposing appropriate boundary and initial conditions in a virtual [0,1] domain. The diffusivity along the domain and the extraction rate at the dialyser are the kinetic parameters which were fitted by least-squares for every studied solute. The accuracy of the presented volumeless model as well as the behavior of the proposed kinetic parameters could be an alternative to the compartment description for a variety of molecular weight uremic toxins undergoing different treatment configurations.
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Affiliation(s)
- Miquel Gomez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació Clínic per a la Recerca Biomèdica (FCRB), Hospital Clínic de Barcelona, Spain
| | - Francisco Maduell
- Department of Nephrology and Renal Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Hospital Clínic de Barcelona, Villaroel, Barcelona, Spain
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6
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Uremic Toxin Clearance and Cardiovascular Toxicities. Toxins (Basel) 2018; 10:toxins10060226. [PMID: 29865226 PMCID: PMC6024759 DOI: 10.3390/toxins10060226] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 12/31/2022] Open
Abstract
Uremic solutes contribute to cardiovascular disease in renal insufficiency. In this review we describe the clearance of selected uremic solutes, which have been associated with cardiovascular disease. These solutes—indoxyl sulfate (IS), p-cresol sulfate (PCS), phenylacetylglutamine (PAG), trimethylamine-n-oxide (TMAO), and kynurenine—exemplify different mechanisms of clearance. IS and PCS are protein-bound solutes efficiently cleared by the native kidney through tubular secretion. PAG and TMAO are not protein-bound but are also cleared by the native kidney through tubular secretion, while kynurenine is not normally cleared by the kidney. Increases in the plasma levels of the normally secreted solutes IS, PCS, TMAO, and PAG in chronic kidney disease (CKD) are attributable to a reduction in their renal clearances. Levels of each of these potential toxins are even higher in patients on dialysis than in those with advanced chronic kidney disease, which can be accounted for in part by a low ratio of dialytic to native kidney clearance. The rise in plasma kynurenine in CKD and dialysis patients, by contrast, remains to be explained. Our ability to detect lower levels of the potential uremic cardiovascular toxins with renal replacement therapy may be limited by the intermittency of treatment, by increases in solute production, and by the presence of non-renal clearance. Reduction in the levels of uremic cardiovascular toxins may in the future be achieved more effectively by inhibiting their production.
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7
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Abstract
Uremic solutes contribute to cardiovascular disease in renal insufficiency. In this review we describe the clearance of selected uremic solutes, which have been associated with cardiovascular disease. These solutes-indoxyl sulfate (IS), p-cresol sulfate (PCS), phenylacetylglutamine (PAG), trimethylamine-n-oxide (TMAO), and kynurenine-exemplify different mechanisms of clearance. IS and PCS are protein-bound solutes efficiently cleared by the native kidney through tubular secretion. PAG and TMAO are not protein-bound but are also cleared by the native kidney through tubular secretion, while kynurenine is not normally cleared by the kidney. Increases in the plasma levels of the normally secreted solutes IS, PCS, TMAO, and PAG in chronic kidney disease (CKD) are attributable to a reduction in their renal clearances. Levels of each of these potential toxins are even higher in patients on dialysis than in those with advanced chronic kidney disease, which can be accounted for in part by a low ratio of dialytic to native kidney clearance. The rise in plasma kynurenine in CKD and dialysis patients, by contrast, remains to be explained. Our ability to detect lower levels of the potential uremic cardiovascular toxins with renal replacement therapy may be limited by the intermittency of treatment, by increases in solute production, and by the presence of non-renal clearance. Reduction in the levels of uremic cardiovascular toxins may in the future be achieved more effectively by inhibiting their production.
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Affiliation(s)
- Robert D Mair
- The Departments of Medicine, VA Palo Alto Healthcare System, 111R, 3801 Miranda Ave., Palo Alto, CA 94304, USA.
- Division of Nephrology, Stanford University, 777 Welch Road, Suite DE, Palo Alto, CA 94304, USA.
| | - Tammy L Sirich
- The Departments of Medicine, VA Palo Alto Healthcare System, 111R, 3801 Miranda Ave., Palo Alto, CA 94304, USA.
- Division of Nephrology, Stanford University, 777 Welch Road, Suite DE, Palo Alto, CA 94304, USA.
| | - Timothy W Meyer
- The Departments of Medicine, VA Palo Alto Healthcare System, 111R, 3801 Miranda Ave., Palo Alto, CA 94304, USA.
- Division of Nephrology, Stanford University, 777 Welch Road, Suite DE, Palo Alto, CA 94304, USA.
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8
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Leong SC, Sao JN, Taussig A, Plummer NS, Meyer TW, Sirich TL. Residual Function Effectively Controls Plasma Concentrations of Secreted Solutes in Patients on Twice Weekly Hemodialysis. J Am Soc Nephrol 2018; 29:1992-1999. [PMID: 29728422 DOI: 10.1681/asn.2018010081] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/08/2018] [Indexed: 11/03/2022] Open
Abstract
Background Most patients on hemodialysis are treated thrice weekly even if they have residual kidney function, in part because uncertainty remains as to how residual function should be valued and incorporated into the dialysis prescription. Recent guidelines, however, have increased the weight assigned to residual function and thus reduced the treatment time required when it is present. Increasing the weight assigned to residual function may be justified by knowledge that the native kidney performs functions not replicated by dialysis, including solute removal by secretion. This study tested whether plasma concentrations of secreted solutes are as well controlled in patients with residual function on twice weekly hemodialysis as in anuric patients on thrice weekly hemodialysis.Methods We measured the plasma concentration and residual clearance, dialytic clearance, and removal rates for urea and the secreted solutes hippurate, phenylacetylglutamine, indoxyl sulfate, and p-cresol sulfate in nine patients on twice weekly hemodialysis and nine patients on thrice weekly hemodialysis.Results Compared with anuric patients on thrice weekly dialysis with the same standard Kt/Vurea, patients on twice weekly hemodialysis had lower hippurate and phenylacetylglutamine concentrations and similar indoxyl sulfate and p-cresol sulfate concentrations. Mathematical modeling revealed that residual secretory function accounted for the observed pattern of solute concentrations.Conclusions Plasma concentrations of secreted solutes can be well controlled by twice weekly hemodialysis in patients with residual kidney function. This result supports further study of residual kidney function value and the inclusion of this function in dialysis adequacy measures.
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Affiliation(s)
- Sheldon C Leong
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and.,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
| | - Justin N Sao
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
| | - Abigail Taussig
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
| | - Natalie S Plummer
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and.,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
| | - Timothy W Meyer
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and.,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
| | - Tammy L Sirich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and .,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
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9
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Affiliation(s)
- Dominic S.C. Raj
- Department of Medicine, Louisiana State University School of Medicine, Shreveport, LA - USA
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10
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Risler T, Braun N, Hanel K, Kuhlmann U, Skroch D, Müller G. Do Different Dialysis-Membranes Affect Beta 2-Microglobulin Kinetics during Chronic Hemodialysis? Int J Artif Organs 2018. [DOI: 10.1177/039139889401701105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hemodialysis is not an absolute prerequisite for the formation of β2-microglobulin amyloidosis, but it enhances the progression of this complication related to long-standing renal failure. Thus the clearance and turnover of β2-microglobulin seems to play a major role in this disease. In a prospective multicenter study the β2-microglobulin clearance was studied in 87 patients starting hemodialysis. Serum samples were taken prior to and after the first dialysis session and also before and after dialysis at 4, 6, 12, 16, 26 and 52 weeks. Patients were either treated by cuprophane or a polyacrylonitril membrane. At the start, the mean serum β2-microglobulin level was about 18 mg/L in patients treated with a cuprophane membrane, but the levels increased after hemodialysis and reached a plateau, which was always higher than in those treated with polyacrylonitril, which cleared β2-microglobulin from the serum. However, after 12 months the difference was no longer significant. Thus β2-microglobulin excretion during dialysis differs between the two membranes, but seems to lose its significance for the β2-microglobulin serum level in chronic hemodialysis treatment.
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Affiliation(s)
- T. Risler
- Section of Nephrology and Hypertension, Dept. of Medicine, University Hospital Tübingen, Tübingen
| | - N. Braun
- Section of Nephrology and Hypertension, Dept. of Medicine, University Hospital Tübingen, Tübingen
| | - K.D. Hanel
- Division of Nephrology, Klinikum am Eichert, Göppingen
| | - U. Kuhlmann
- Department of Nephrology, Robert-Bosch-Hospital, Stuttgart
| | | | - G.A. Müller
- Section of Nephrology and Hypertension, Dept. of Medicine, University Hospital Tübingen, Tübingen
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11
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Shaldon S, Vienken J. Biocompatibility: Is it a Relevant Consideration for Today's Haemodialysis? Int J Artif Organs 2018. [DOI: 10.1177/039139889601900401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S. Shaldon
- Montpellier, France and Wuppertal - Germany
| | - J. Vienken
- Montpellier, France and Wuppertal - Germany
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12
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Sirich TL. Obstacles to reducing plasma levels of uremic solutes by hemodialysis. Semin Dial 2017; 30:403-408. [DOI: 10.1111/sdi.12609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Tammy L. Sirich
- The Department of Medicine; VA Palo Alto Health Care System and Stanford University; Palo Alto CA USA
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13
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Leypoldt JK, Meijers BKI. Effect of Treatment Duration and Frequency on Uremic Solute Kinetics, Clearances and Concentrations. Semin Dial 2016; 29:463-470. [PMID: 27578429 DOI: 10.1111/sdi.12531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The kinetics of uremic solute clearances are discussed based on two categories of uremic solutes, namely those that are and those that are not derived directly from nutrient intake, particularly dietary protein intake. This review highlights dialysis treatments that are more frequent and longer (high-dose hemodialysis) than conventional thrice weekly therapy. It is proposed that the dialysis dose measures based on urea as a marker uremic solute, such as Kt/V and stdKt/V, be referred to as measures of dialysis inadequacy, not dialysis adequacy. For uremic solutes derived directly from nutrient intake, it is suggested that inorganic phosphorus and protein-bound uremic solutes be considered as markers in the development of alternative measures of dialysis dose for high-dose hemodialysis prescriptions. As the current gap in understanding the detailed kinetics of protein-bound uremic solutes, it is proposed that normalization of serum phosphorus concentration with a minimum (or preferably without a) need for oral-phosphorus binders be targeted as a measure of dialysis adequacy in high-dose hemodialysis. For large uremic solutes not derived directly from nutrient intake (middle molecules), use of extracorporeal clearances for β2 -microglobulin that are higher than currently available during thrice weekly therapy is unlikely to reduce predialysis serum β2 -microglobulin concentrations. High-dose hemodialysis prescriptions will lead to reductions in predialysis serum β2 -microglobulin concentrations, but such reductions are also limited by significant residual kidney clearance. Kinetic data regarding middle molecules larger than β2 -microglobulin are scarce; additional studies on such uremic solutes are of high interest to better understand improved methods for prescribing high-dose hemodialysis prescriptions to improve patient outcomes.
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Affiliation(s)
- John K Leypoldt
- Renal Therapeutic Area and Medical Affairs, Baxter Healthcare Corporation, Deerfield, Illinois.
| | - Björn K I Meijers
- Division of Nephrology, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
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14
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Roumelioti ME, Nolin T, Unruh ML, Argyropoulos C. Revisiting the Middle Molecule Hypothesis of Uremic Toxicity: A Systematic Review of Beta 2 Microglobulin Population Kinetics and Large Scale Modeling of Hemodialysis Trials In Silico. PLoS One 2016; 11:e0153157. [PMID: 27055286 PMCID: PMC4824495 DOI: 10.1371/journal.pone.0153157] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/24/2016] [Indexed: 01/01/2023] Open
Abstract
Background Beta-2 Microglobulin (β2M) is a prototypical “middle molecule” uremic toxin that has been associated with a higher risk of death in hemodialysis patients. A quantitative description of the relative importance of factors determining β2M concentrations among patients with impaired kidney function is currently lacking. Methods Herein we undertook a systematic review of existing studies reporting patient level data concerning generation, elimination and distribution of β2M in order to develop a population model of β2M kinetics. We used this model and previously determined relationships between predialysis β2M concentration and survival, to simulate the population distribution of predialysis β2M and the associated relative risk (RR) of death in patients receiving conventional thrice-weekly hemodialysis with low flux (LF) and high flux (HF) dialyzers, short (SD) and long daily (LD) HF hemodialysis sessions and on-line hemodiafiltration at different levels of residual renal function (RRF). Results We identified 9 studies of 106 individuals and 156 evaluations of or more compartmental kinetic parameters of β2M. These studies used a variety of experimental methods to determine β2M kinetics ranging from isotopic dilution to profiling of intra/inter dialytic concentration changes. Most of the patients (74/106) were on dialysis with minimal RRF, thus facilitating the estimation of non-renal elimination kinetics of β2M. In large scale (N = 10000) simulations of individuals drawn from the population of β2M kinetic parameters, we found that, higher dialytic removal materially affects β2M exposures only when RRF (renal clearance of β2M) was below 2 ml/min. In patients initiating conventional HF hemodialysis, total loss of RRF was predicted to be associated with a RR of death of more than 20%. Hemodiafiltration and daily dialysis may decrease the high risk of death of anuric patients by 10% relative to conventional, thrice weekly HF dialysis. Only daily long sessions of hemodialysis consistently reduced mortality risk between 7–19% across the range of β2M generation rate. Conclusions Preservation of RRF should be considered one of the therapeutic goals of hemodialysis practice. Randomized controlled trials of novel dialysis modalities may require large sample sizes to detect an effect on clinical outcomes even if they enroll anuric patients. The developed population model for β2M may allow personalization of hemodialysis prescription and/or facilitate the design of such studies by identifying patients with higher β2M generation rate.
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Affiliation(s)
- Maria Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico Health Sciences Center, School of Medicine, Albuquerque, NM, United States of America
| | - Thomas Nolin
- Department of Pharmacy and Therapeutics, and Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, United States of America
| | - Mark L. Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico Health Sciences Center, School of Medicine, Albuquerque, NM, United States of America
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico Health Sciences Center, School of Medicine, Albuquerque, NM, United States of America
- * E-mail:
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15
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Protein-Bound Uremic Toxin Profiling as a Tool to Optimize Hemodialysis. PLoS One 2016; 11:e0147159. [PMID: 26799394 PMCID: PMC4723122 DOI: 10.1371/journal.pone.0147159] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/29/2015] [Indexed: 12/20/2022] Open
Abstract
Aim We studied various hemodialysis strategies for the removal of protein-bound solutes, which are associated with cardiovascular damage. Methods This study included 10 patients on standard (3x4h/week) high-flux hemodialysis. Blood was collected at the dialyzer inlet and outlet at several time points during a midweek session. Total and free concentration of several protein-bound solutes was determined as well as urea concentration. Per solute, a two-compartment kinetic model was fitted to the measured concentrations, estimating plasmatic volume (V1), total distribution volume (Vtot) and intercompartment clearance (K21). This calibrated model was then used to calculate which hemodialysis strategy offers optimal removal. Our own in vivo data, with the strategy variables entered into the mathematical simulations, was then validated against independent data from two other clinical studies. Results Dialyzer clearance K, V1 and Vtot correlated inversely with percentage of protein binding. All Ks were different from each other. Of all protein-bound solutes, K21was 2.7–5.3 times lower than that of urea. Longer and/or more frequent dialysis that processed the same amount of blood per week as standard 3x4h dialysis at 300mL/min blood flow showed no difference in removal of strongly bound solutes. However, longer and/or more frequent dialysis strategies that processed more blood per week than standard dialysis were markedly more adequate. These conclusions were successfully validated. Conclusion When blood and dialysate flow per unit of time and type of hemodialyzer are kept the same, increasing the amount of processed blood per week by increasing frequency and/or duration of the sessions distinctly increases removal.
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Plasma Levels of Middle Molecules to Estimate Residual Kidney Function in Haemodialysis without Urine Collection. PLoS One 2015; 10:e0143813. [PMID: 26629900 PMCID: PMC4668015 DOI: 10.1371/journal.pone.0143813] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/10/2015] [Indexed: 01/02/2023] Open
Abstract
Background Residual Kidney Function (RKF) is associated with survival benefits in haemodialysis (HD) but is difficult to measure without urine collection. Middle molecules such as Cystatin C and β2-microglobulin accumulate in renal disease and plasma levels have been used to estimate kidney function early in this condition. We investigated their use to estimate RKF in patients on HD. Design Cystatin C, β2-microglobulin, urea and creatinine levels were studied in patients on incremental high-flux HD or hemodiafiltration(HDF). Over sequential HD sessions, blood was sampled pre- and post-session 1 and pre-session 2, for estimation of these parameters. Urine was collected during the whole interdialytic interval, for estimation of residual GFR (GFRResidual = mean of urea and creatinine clearance). The relationships of plasma Cystatin C and β2-microglobulin levels to GFRResidual and urea clearance were determined. Results Of the 341 patients studied, 64% had urine output>100ml/day, 32.6% were on high-flux HD and 67.4% on HDF. Parameters most closely correlated with GFRResidual were 1/β2-micoglobulin (r2 0.67) and 1/Cystatin C (r2 0.50). Both these relationships were weaker at low GFRResidual. The best regression model for GFRResidual, explaining 67% of the variation, was:
GFRResidual=160.3⋅(1β2m)−4.2
Where β2m is the pre-dialysis β2 microglobulin concentration (mg/L). This model was validated in a separate cohort of 50 patients using Bland-Altman analysis. Areas under the curve in Receiver Operating Characteristic analysis aimed at identifying subjects with urea clearance≥2ml/min/1.73m2 was 0.91 for β2-microglobulin and 0.86 for Cystatin C. A plasma β2-microglobulin cut-off of ≤19.2mg/L allowed identification of patients with urea clearance ≥2ml/min/1.73m2 with 90% specificity and 65% sensitivity. Conclusion Plasma pre-dialysis β2-microglobulin levels can provide estimates of RKF which may have clinical utility and appear superior to cystatin C. Use of cut-off levels to identify patients with RKF may provide a simple way to individualise dialysis dose based on RKF.
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Once upon a time in dialysis: the last days of Kt/V? Kidney Int 2015; 88:460-5. [DOI: 10.1038/ki.2015.155] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/04/2014] [Indexed: 11/09/2022]
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Eloot S, Van Biesen W, Axelsen M, Glorieux G, Pedersen RS, Heaf JG. Protein-bound solute removal during extended multipass versus standard hemodialysis. BMC Nephrol 2015; 16:57. [PMID: 25896788 PMCID: PMC4404563 DOI: 10.1186/s12882-015-0056-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Multipass hemodialysis (MPHD) is a recently described dialysis modality, involving the use of small volumes of dialysate which are repetitively recycled. Dialysis regimes of 8 hours for six days a week using this device result in an increased removal of small water soluble solutes and middle molecules compared to standard hemodialysis (SHD). Since protein-bound solutes (PBS) exert important pathophysiological effects, we investigated whether MPHD results in improved removal of PBS as well. Methods A cross-over study (Clinical Trial NCT01267760) was performed in nine stable HD patients. At midweek a single dialysis session was performed with either 4 hours SHD using a dialysate flow of 500 mL/min or 8 hours MPHD with a dialysate volume of 50% of estimated body water volume. Blood and dialysate samples were taken every hour to determine concentrations of p-cresylglucuronide (PCG), hippuric acid (HA), indole acetic acid (IAA), indoxyl sulfate (IS), and p-cresylsulfate (PCS). Dialyser extraction ratio, reduction ratio, and solute removal were calculated for these solutes. Results Already at 60 min after dialysis start, the extraction ratio in the hemodialyser was a factor 1.4-4 lower with MPHD versus SHD, resulting in significantly smaller reduction ratios and lower solute removal within a single session. Even when extrapolating our findings to 3 times 4 h SHD and 6 times 8 h MPHD per week, the latter modality was at best similar in terms of total solute removal for most protein-bound solutes, and worse for the highly protein-bound solutes IS and PCS. When efficiency was calculated as solute removal/litre of dialysate used, MPHD was found superior to SHD. Conclusion When high water consumption is a concern, a treatment regimen of 6 times/week 8 h MPHD might be an alternative for 3 times/week 4 h SHD, but at the expense of a lower total solute removal of highly protein-bound solutes.
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Affiliation(s)
- Sunny Eloot
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Mette Axelsen
- Institute of Public Health, Aarhus University, Nordre Ringgade 1, 8000, Aarhus C, Denmark.
| | - Griet Glorieux
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | | | - James Goya Heaf
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Keir R, Evans ND, Hutchison CA, Vigano MR, Stella A, Fabbrini P, Storr M, Chappell MJ. Kinetic modelling of haemodialysis removal of myoglobin in rhabdomyolysis patients. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2014; 114:e29-e38. [PMID: 24008249 DOI: 10.1016/j.cmpb.2013.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 07/09/2013] [Accepted: 07/22/2013] [Indexed: 06/02/2023]
Abstract
An extended two compartment model is proposed to describe the dynamics of myoglobin in rhabdomyolysis patients undergoing dialysis. Before using clinical data to estimate the model's unknown parameters, structural identifiability analysis was performed to determine the parameters uniqueness given certain clinical observations. A Taylor series expansion method was implemented which found that the model was structurally globally/uniquely identifiable for both on- and off-dialysis phases. The fitted model was then used in a predictive capacity showing that the use of Theralite high cut-off (HCO) or HCO 1100 dialyser gave a significant reduction in myoglobin renal exposure compared to standard haemodialysis (HD).
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Affiliation(s)
- R Keir
- School of Engineering, University of Warwick, Coventry CV4 7AL, United Kingdom.
| | - N D Evans
- School of Engineering, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - C A Hutchison
- Renal Unit, University Hospital Birmingham, B15 2WB, United Kingdom
| | - M R Vigano
- Clinica Nefrologica, Università degli Studi di Milano Bicocca, AO San Gerardo Monza, Italy
| | - A Stella
- Clinica Nefrologica, Università degli Studi di Milano Bicocca, AO San Gerardo Monza, Italy
| | - P Fabbrini
- Clinica Nefrologica, Università degli Studi di Milano Bicocca, AO San Gerardo Monza, Italy
| | - M Storr
- Gambro Dialysatoren GmbH & Co. KG, Hechinegn, Germany
| | - M J Chappell
- School of Engineering, University of Warwick, Coventry CV4 7AL, United Kingdom
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Eloot S, Ledebo I, Ward RA. Extracorporeal Removal of Uremic Toxins: Can We Still Do Better? Semin Nephrol 2014; 34:209-27. [DOI: 10.1016/j.semnephrol.2014.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tumour markers and kidney function: a systematic review. BIOMED RESEARCH INTERNATIONAL 2014; 2014:647541. [PMID: 24689048 PMCID: PMC3933284 DOI: 10.1155/2014/647541] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/02/2013] [Accepted: 12/06/2013] [Indexed: 01/18/2023]
Abstract
Tumour markers represent useful tools in diagnosis and clinical management of patients with cancer, because they are easy to use, minimally invasive, and easily measured in either blood or urine. Unfortunately, such an ideal marker, as yet, does not exist. Different pathological states may increase the level of a tumour marker in the absence of any neoplasia. Alternatively, low levels of tumour markers could be also found in the presence of neoplasias. We aimed at reviewing studies currently available in the literature examining the association between tumour markers and different renal impairment conditions. Each tumour marker was found to be differently influenced by these criteria; additionally we revealed in many cases a lack of available published data.
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Melo NCV, Moyses RMA, Elias RM, Castro MCM. Reprocessing high-flux polysulfone dialyzers does not negatively impact solute removal in short-daily online hemodiafiltration. Hemodial Int 2014; 18:473-80. [DOI: 10.1111/hdi.12126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Natalia C. V. Melo
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
- HRT-SES/DF; Brasilia Brazil
| | - Rosa M. A. Moyses
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| | - Rosilene M. Elias
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| | - Manuel C. M. Castro
- Nephrology Division; University of Sao Paulo School of Medicine; Sao Paulo Brazil
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Maduell F, Moreso F, Pons M, Ramos R, Mora-Macià J, Carreras J, Soler J, Torres F, Campistol JM, Martinez-Castelao A. High-efficiency postdilution online hemodiafiltration reduces all-cause mortality in hemodialysis patients. J Am Soc Nephrol 2013; 24:487-97. [PMID: 23411788 DOI: 10.1681/asn.2012080875] [Citation(s) in RCA: 417] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Retrospective studies suggest that online hemodiafiltration (OL-HDF) may reduce the risk of mortality compared with standard hemodialysis in patients with ESRD. We conducted a multicenter, open-label, randomized controlled trial in which we assigned 906 chronic hemodialysis patients either to continue hemodialysis (n=450) or to switch to high-efficiency postdilution OL-HDF (n=456). The primary outcome was all-cause mortality, and secondary outcomes included cardiovascular mortality, all-cause hospitalization, treatment tolerability, and laboratory data. Compared with patients who continued on hemodialysis, those assigned to OL-HDF had a 30% lower risk of all-cause mortality (hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.53-0.92; P=0.01), a 33% lower risk of cardiovascular mortality (HR, 0.67; 95% CI, 0.44-1.02; P=0.06), and a 55% lower risk of infection-related mortality (HR, 0.45; 95% CI, 0.21-0.96; P=0.03). The estimated number needed to treat suggested that switching eight patients from hemodialysis to OL-HDF may prevent one annual death. The incidence rates of dialysis sessions complicated by hypotension and of all-cause hospitalization were lower in patients assigned to OL-HDF. In conclusion, high-efficiency postdilution OL-HDF reduces all-cause mortality compared with conventional hemodialysis.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clinic, University of Barcelona, Villarroel, 170 - 08036 Barcelona, Spain.
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Vanholder R, Eloot S, Van Biesen W, Lameire N. Less water for haemodialysis: is multiple pass the future pace to go? Nephrol Dial Transplant 2013; 28:1067-70. [PMID: 23291373 DOI: 10.1093/ndt/gfs546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ok E, Asci G, Toz H, Ok ES, Kircelli F, Yilmaz M, Hur E, Demirci MS, Demirci C, Duman S, Basci A, Adam SM, Isik IO, Zengin M, Suleymanlar G, Yilmaz ME, Ozkahya M. Mortality and cardiovascular events in online haemodiafiltration (OL-HDF) compared with high-flux dialysis: results from the Turkish OL-HDF Study. Nephrol Dial Transplant 2012; 28:192-202. [DOI: 10.1093/ndt/gfs407] [Citation(s) in RCA: 315] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Eloot S, Vanholder R, Van Biesen W. Less water for haemodialysis: is multiple pass the future pace to go? Nephrol Dial Transplant 2012; 27:3975-8. [DOI: 10.1093/ndt/gfs435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Heaf JG, Axelsen M, Pedersen RS. Multipass haemodialysis: a novel dialysis modality. Nephrol Dial Transplant 2012; 28:1255-64. [PMID: 23136214 PMCID: PMC3661003 DOI: 10.1093/ndt/gfs484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Heaf et al. describe the novel multipass system as a most useful application in the setting of daily extended dialysis at home and suggests a number of modifications to our classical dialysis paradigm aimed at reducing water consumption. Their paper shows how continued creative thinking can modify the classical set-up of dialysis to obtain a system which at the same time could be more economical, ecological and simple. Introduction Most home haemodialysis (HD) modalities are limited to home use since they are based on a single-pass (SP) technique, which requires preparation of large amounts of dialysate. We present a new dialysis method, which requires minimal dialysate volumes, continuously recycled during treatment [multipass HD (MPHD)]. Theoretical calculations suggest that MPHD performed six times weekly for 8 h/night, using a dialysate bath containing 50% of the calculated body water, will achieve urea clearances equivalent to conventional HD 4 h thrice weekly, and a substantial clearance of higher middle molecules. Methods Ten stable HD patients were dialyzed for 4 h using standard SPHD (dialysate flow 500 mL/min). Used dialysate was collected. One week later, an 8-h MPHD was performed. The dialysate volume was 50% of the calculated water volume, the dialysate inflow 500 mL/min−0.5 × ultrafiltration/min and the outflow 500 mL/min + 0.5 × ultrafiltration/min. Elimination rates of urea, creatinine, uric acid, phosphate and β2-microglobulin (B2M) and dialysate saturation were determined hourly. Results Three hours of MPHD removed 49, 54, 50, 51 and 57%, respectively, of the amounts of urea, creatinine, uric acid, phosphate and B2M that were removed by 4 h conventional HD. The corresponding figures after 8 h MPHD were 63, 78, 74, 78 and 111%. Conclusions Clearance of small molecules using MPHD 6 × 8 h/week will exceed traditional HD 3 × 4 h/week. Similarly, clearance of large molecules will significantly exceed traditional HD and HD 5 × 2.5 h/week. This modality will increase patients' freedom of movement compared with traditional home HD. The new method can also be used in the intensive care unit and for automated peritoneal dialysis.
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Affiliation(s)
- James Goya Heaf
- Department of Nephrology B, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Eloot S, Van Biesen W, Vanholder R. A Sad but Forgotten Truth: The Story of Slow-Moving Solutes in Fast Hemodialysis. Semin Dial 2012; 25:505-9. [DOI: 10.1111/j.1525-139x.2012.01107.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Eloot S, Schneditz D, Vanholder R. What can the dialysis physician learn from kinetic modelling beyond Kt/V(urea)? Nephrol Dial Transplant 2012; 27:4021-9. [PMID: 22923544 DOI: 10.1093/ndt/gfs367] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Maduell F, Arias M, Duran CE, Vera M, Fontsere N, Azqueta M, Rico N, Perez N, Sentis A, Elena M, Rodriguez N, Arcal C, Bergada E, Cases A, Bedini JL, Campistol JM. Nocturnal, every-other-day, online haemodiafiltration: an effective therapeutic alternative. Nephrol Dial Transplant 2011; 27:1619-31. [DOI: 10.1093/ndt/gfr491] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Lee HC, Choi JS, Lim DH, Jeong JM, Park PK, Jung AD, Nah MY, Kim NH. The Short-term Efficacy and Safety of On-line Hemodiafiltration. Chonnam Med J 2010. [DOI: 10.4068/cmj.2010.46.1.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hyung-Chul Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Joon-Suk Choi
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dae-Hun Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Ji-Min Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Pyung-Kyun Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - An-Doc Jung
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Myong-Yun Nah
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Nam-ho Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
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Eloot S, Dhondt A, Hoste E, Verstraete A, De Waele J, Colpaert K, Hoeksema H, Tromp F, Vanholder R. How to remove accumulated iodine in burn-injured patients. Nephrol Dial Transplant 2009; 25:1614-20. [PMID: 19965987 DOI: 10.1093/ndt/gfp647] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Absorption of large quantities of iodine, as induced by the use of topical antimicrobial povidone-iodine in burn-injured patients, may cause metabolic and electrolyte abnormalities as well as renal failure. To diminish iodine levels, haemodialysis was previously reported to be a suitable therapy. We therefore studied the kinetics of iodine in order to define the most optimal dialysis strategy. METHODS Two patients with elevated iodine levels (93.6 and 81.2 mg/L) underwent continuous dialysis with blood flows Q(B) 150 and 120 mL/min. Blood was sampled from the inlet and outlet dialysis line at several time points during a 7-h and 39-h 10-min period, respectively. Samples were analysed for iodine with the inductively coupled plasma mass spectrometry (ICPMS) method. Kinetic analysis was performed using one and two compartmental models, deriving kinetic parameters: plasmatic volume V(1), extraplasmatic volume V(2) and intercompartmental clearance K(12). The calibrated kinetic model of Patient 2 was further used to simulate different dialysis strategies: 12-h per day with Q(B) 240, 6-h per day with Q(B) 480 and 240, and 12-h every 2 days with Q(B) 240. For each strategy, the mean average plasmatic and extraplasmatic concentration (TAC(p) and TAC(ep)) was calculated during 48 h. RESULTS Iodine seemed to follow one compartmental kinetics when serum sample collections were limited to the first 7 h of dialysis (Patient 1), but iodine appeared to be distributed in two volumes (V(1)=19.4 L, V(2)=38.0 L and K(12)=55 mL/min) when a longer observation period was taken into account (Patient 2). The simulations disclosed that 12-h dialysis per day with Q(B) 240 or continuous dialysis with Q(B) 120 resulted in the lowest TAC(p) (18.2 and 19.0 microg/L) and TAC(ep) (34.4 and 36.1 microg/L). CONCLUSION In patients with elevated iodine levels, especially when associated with renal failure, haemodialysis with a minimum 12-h duration with sufficient blood flow should be the first choice to remove iodine.
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Affiliation(s)
- Sunny Eloot
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Belgium.
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Kohn OF, Coe FL, Ing TS. Solute kinetics with short-daily home hemodialysis using slow dialysate flow rate. Hemodial Int 2009; 14:39-46. [PMID: 19758296 DOI: 10.1111/j.1542-4758.2009.00399.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
"NxStage System One()" is increasingly used for daily home hemodialysis. The ultrapure dialysate volumes are typically between 15 L and 30 L per dialysis, substantially smaller than the volumes used in conventional dialysis. In this study, the impact of the use of low dialysate volumes on the removal rates of solutes of different molecular weights and volumes of distribution was evaluated. Serum measurements before and after dialysis and total dialysate collection were performed over 30 times in 5 functionally anephric patients undergoing short-daily home hemodialysis (6 d/wk) over the course of 8 to 16 months. Measured solutes included beta(2) microglobulin (beta(2)M), phosphorus, urea nitrogen, and potassium. The average spent dialysate volume (dialysate plus ultrafiltrate) was 25.4+/-4.7 L and the dialysis duration was 175+/-15 min. beta(2) microglobulin clearance of the polyethersulfone dialyzer averaged 53+/-14 mL/min. Total beta(2)M recovered in the dialysate was 106+/-42 mg per treatment (n=38). Predialysis serum beta(2)M levels remained stable over the observation period. Phosphorus removal averaged 694+/-343 mg per treatment with a mean predialysis serum phosphorus of 5.2+/-1.8 mg/dL (n=34). Standard Kt/V averaged 2.5+/-0.3 per week and correlated with the dialysate-based weekly Kt/V. Weekly beta(2)M, phosphorus, and urea nitrogen removal in patients dialyzing 6 d/wk with these relatively low dialysate volumes compared favorably with values published for thrice weekly conventional and with short-daily hemodialysis performed with machines using much higher dialysate flow rates. Results of the present study were achieved, however, with an average of 17.5 hours of dialysis per week.
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Affiliation(s)
- Orly F Kohn
- University of Chicago, Chicago, Illinois, USA.
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Haase M, Bellomo R, Baldwin I, Haase-Fielitz A, Fealy N, Morgera S, Goehl H, Storr M, Boyce N, Neumayer HH. Beta2-microglobulin removal and plasma albumin levels with high cut-off hemodialysis. Int J Artif Organs 2007; 30:385-92. [PMID: 17551901 DOI: 10.1177/039139880703000505] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE beta2-microglobulin (beta2MG) is pivotal to the pathogenesis of dialysis-related amyloidosis. We compared the effects of high cut-off hemodialysis (HCO-HD) with those of standard high-flux hemodialysis (HF-HD) regarding the concentration and clearance of beta2MG and albumin. DESIGN We enrolled ten patients with acute renal failure in a double-blind, cross-over, randomized controlled trial. PROCEDURES Each patient received four hours of HCO-HD (estimated in vivo cutoff 50-60 kDa) and four hours of HF-HD (estimated in vivo cutoff 15-20 kDa) in random order. Statistical methods and outcome measures: As data lacked normal distribution, we used nonparametric statistical analysis. Plasma and dialysate concentrations of beta2MG and albumin were measured at baseline and after four hours of each study treatment. MAIN FINDINGS We found significantly greater diffusive beta2MG clearances for HCO-HD compared to HF-HD (at the start: 71.8 ml/min vs. 5.1 ml/min; P=0.008 and at the end: 68.8 ml/min vs. 5.7 ml/min; P=0.008). We found a reduction in plasma beta2MG concentrations of -31.6% during HCO-HD compared to an increase by 25.7% during HF-HD; P=0.008. At baseline (HCO-HD: 26.0 g/L vs. HF-HD: 26.5 g/L), and at the end of both treatments, plasma albumin concentrations were comparable (HCO-HD: 25.5 g/L vs. HF-HD: 26.5 g/L; P=0.25). During HCO-HD, albumin clearance was 1.9 ml/min at the start and decreased significantly to 0.8 ml/min at the end; P=0.008. HF-HD had an albumin clearance of 0.01 ml/min. CONCLUSIONS HCO-HD was more effective in decreasing plasma beta2MG concentrations than standard HF-HD and did not reduce plasma albumin levels. Further studies of HCO-HD in the treatment of dialysis-related beta2MG accumulation appear warranted.
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Affiliation(s)
- M Haase
- Intensive Care Research, Austin Hospital, University of Melbourne, Australia.
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Ward RA, Greene T, Hartmann B, Samtleben W. Resistance to intercompartmental mass transfer limits β2-microglobulin removal by post-dilution hemodiafiltration. Kidney Int 2006; 69:1431-7. [PMID: 16395268 DOI: 10.1038/sj.ki.5000048] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although clearance of beta(2)-microglobulin is greater with hemodiafiltration than with high-flux hemodialysis, beta(2)-microglobulin concentrations after long-term hemodiafiltration are only slightly less than those obtained with high-flux hemodialysis. Resistance to beta(2)-microglobulin transfer between body compartments could explain this observation. beta(2)-Microglobulin kinetics were determined in patients receiving on-line post-dilution hemodiafiltration for 4 h with 18 l of filtration. Plasma beta(2)-microglobulin concentrations were measured during and for 2 h following hemodiafiltration and immediately before the next treatment. The filter clearance of beta(2)-microglobulin was determined from arterial and venous concentrations. The beta(2)-microglobulin generation rate was calculated from the change in the plasma concentration between treatments. The intercompartmental clearance was obtained by fitting the observed concentrations to a two-compartment, variable volume model. The plasma clearance of beta(2)-microglobulin by the filter was 73 +/- 2 ml/min. Plasma beta(2)-microglobulin concentrations decreased by 68 +/- 2% from pre- to post-treatment (27.1 +/- 2.2-8.5 +/- 0.7 mg/l), but rebounded by 32+/-3% over the next 90 min. The generation rate of beta(2)-microglobulin was 0.136 +/- 0.008 mg/min. The model fit yielded an intercompartmental clearance of 82 +/- 7 ml/min and a volume of distribution of 10.2 +/- 0.6 l, corresponding to 14.3 +/- 0.7% of body weight. Hemodiafiltration provides a beta(2)-microglobulin clearance of similar magnitude to the intercompartmental clearance within the body. As a result, intercompartmental mass transfer limits beta(2)-microglobulin removal by hemodiafiltration. This finding suggests that alternative strategies, such as increased treatment times or frequency of treatment, are needed to further reduce plasma beta(2)-microglobulin concentrations.
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Affiliation(s)
- R A Ward
- Department of Medicine, University of Louisville, Kentucky 40202-1718, USA.
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Leypoldt JK. Kinetics of β2-Microglobulin and Phosphate during Hemodialysis: Effects of Treatment Frequency and Duration. Semin Dial 2005; 18:401-8. [PMID: 16191181 DOI: 10.1111/j.1525-139x.2005.00079.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Current understanding of beta2-microglobulin (beta2M) and phosphate (or inorganic phosphorus) kinetics during hemodialysis is reviewed. The postdialysis:predialysis concentration ratio for beta2M is determined by dialyzer clearance for beta2M, treatment time, patient body size (specifically, extracellular fluid volume), and total ultrafiltration volume during the treatment. Evaluation of these treatment parameters can be used to calculate dialyzer clearance for beta2M; however, such calculated values are only approximations, since they neglect intradialytic generation, nonrenal (nondialyzer) clearance, and postdialysis rebound of beta2M. The detailed kinetics of beta2M during hemodialysis are best described using a two-compartment model. Theoretical predictions from such two-compartment models suggest that the product of dialyzer clearance for beta2M and weekly treatment duration, independent of treatment frequency, is the main determinant of plasma beta2M concentrations. The kinetics of phosphate removal during hemodialysis are incompletely understood. Phosphate is removed from both extracellular and intracellular compartments during hemodialysis; the plasma phosphate concentration levels off after the first 1 or 2 hours of treatment and plasma concentrations can rebound even before therapy is complete. Increases in dialyzer clearance of phosphate have been previously achieved only by increasing dialysis membrane surface area or by the use of hemodiafiltration. A four-compartment model of phosphate kinetics proposed recently by Spalding et al. suggests that the major barrier to phosphate removal is limited transfer of phosphate between the intracellular and extracellular compartments, although other complex factors also play important roles. Theoretical predictions using the model of Spalding et al. suggest that increasing either treatment frequency or treatment duration can increase phosphate removal. The kinetics of beta2M are representative of middle molecules whose removal during hemodialysis is governed predominantly by clearance at the dialyzer. In contrast, phosphate removal is limited primarily by its sequestration in the intracellular compartment (and possibly other compartments), not by its clearance at the dialyzer. The kinetics of phosphate may therefore be representative of uremic toxins whose removal is limited by sequestration into compartments or by protein binding. Enhanced removal of both of these uremic toxins using a given therapy will require treatments of increased frequency and longer duration.
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Affiliation(s)
- John K Leypoldt
- Research Service, VA Salt Lake City Health Care System, Departments of Medicine, University of Utah, Salt Lake City, Utah 84112-5350, USA.
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Bammens B, Evenepoel P, Verbeke K, Vanrenterghem Y. Removal of middle molecules and protein-bound solutes by peritoneal dialysis and relation with uremic symptoms. Kidney Int 2004; 64:2238-43. [PMID: 14633148 DOI: 10.1046/j.1523-1755.2003.00310.x] [Citation(s) in RCA: 153] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Current guidelines for peritoneal dialysis adequacy are based on kinetics of small water-soluble molecules and do not consider the role of other compounds such as middle molecules and protein-bound solutes. Information on the elimination characteristics of the latter solutes by peritoneal dialysis is limited. Moreover, their relation with uremic symptoms remains unclear. The aim of the present study was (1) to investigate the relative contribution of residual renal function to the overall clearances of beta2-microglobulin (beta2m), a middle molecule, and p-cresol, a protein-bound solute, in adults on peritoneal dialysis as compared to small water-soluble molecules and (2) to evaluate relations between serum levels and uremic symptoms. METHODS We performed a cross-sectional observational study, including 30 nonanuric peritoneal dialysis patients. Total, peritoneal, and renal clearances were calculated for urea nitrogen (60 D), creatinine (113 D), phosphate (96 D), beta2m (11.8 kD), and p-cresol (108 D). All patients were asked to complete a uremic symptom questionnaire. RESULTS Declining total clearances (L/week/1.73 m2) were measured for urea nitrogen, creatinine, phosphate, beta2m, and p-cresol, respectively: 97.3 +/- 4.6, 98.9 +/- 6.1, 64.0 +/- 3.4, 23.1 +/- 2.6, and 17.5 +/- 2.3 (Friedman test P < 0.001). Conversely, the contribution of residual renal function (%) to the respective solute clearances increased significantly: 31.6 +/- 3.2, 51.0 +/- 4.0, 42.4 +/- 4.0, 68.0 +/- 5.4, 61.9 +/- 4.6 (Friedman test P < 0.001). The serum level of p-cresol, but of none of the other solutes examined, correlated significantly with the symptom score (Pearson r= 0.48, P= 0.008). CONCLUSION During peritoneal dialysis p-cresol behaves like beta2m, probably due to its protein binding. The total clearance of both molecules is significantly lower as compared to water-soluble solutes and mainly depends on residual renal function. Our data further suggest that protein-bound solutes are involved in the pathophysiology of uremic symptoms.
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Affiliation(s)
- Bert Bammens
- Department of Medicine, Division of Nephrology and Laboratory of Radiopharmaceutical Chemistry, University Hospital Gasthuisberg, Leuven, Belgium
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Lee WCR, Uchino S, Fealy N, Baldwin I, Panagiotopoulos S, Goehl H, Morgera S, Neumayer HH, Bellomo R. Beta2-microglobulin clearance with super high flux hemodialysis: an ex vivo study. Int J Artif Organs 2004; 26:723-7. [PMID: 14521169 DOI: 10.1177/039139880302600804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Beta2m accumulation induces disease in patients with end-stage renal failure (ESRF). Thus, its removal from patients with ESRF appears desirable. Current dialysis technology, however, has limited effectiveness. AIMS To measure beta2m clearance with a novel super high flux membrane. DESIGN Ex vivo experimental study. SETTING Intensive Care Laboratory of Tertiary institution. SUBJECTS Six volunteers. MEASUREMENTS AND RESULTS At a blood flow of 300 ml/min, the clearance of beta2-MG increased from 113.5 +/- 38.5 ml/min with a dialysate flow rate of 200 ml/min to 184.8 +/- 61.1 ml/min with a flow rate of 300 ml/min and 195.0 +/- 60.0 ml/min with a 500 ml/min flow rate. The clearance of albumin was 4.5 ml/min with a dialysate flow rate of 200 ml/min, 5.2 ml/min for a flow rate of 300 ml/min and 5.8 ml/min for a flow rate of 500 ml/min. CONCLUSIONS High levels of beta2m clearance can be achieved with a super high flux membrane while albumin losses remain limited.
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Affiliation(s)
- W C R Lee
- Department of Intensive Care, Austin & Repatriation Medical Centre, Melbourne, Australia
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Grovender EA, Kellogg B, Singh J, Blom D, Ploegh H, Wittrup KD, Langer RS, Ameer GA. Single-chain antibody fragment-based adsorbent for the extracorporeal removal of β2-microglobulin. Kidney Int 2004; 65:310-22. [PMID: 14675065 DOI: 10.1111/j.1523-1755.2004.00377.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dialysis-related amyloidosis (DRA) is a frequent complication of end-stage renal disease (ESRD) that has been associated with the accumulation of beta2-microglobulin (beta2-m). Removal of beta2-m results in the loss of important proteins due to the nonspecific nature of current therapies. Although whole antibodies can potentially be used to confer specificity to beta2-m removal from blood, single-chain variable region (scFv) antibody fragments could potentially offer several advantages as immunoadsorption ligands due to their size, genetic definition, ability to be expressed by microbes, and amenability for in vitro evolution. METHODS An antihuman beta2-m scFv was constructed from the BBM.1 hybridoma and expressed by a yeast display vector. The binding affinity of the wild-type scFv fragment was quantified by flow cytometry analysis. Soluble scFv was expressed by a yeast secretion vector, purified, and immobilized onto agarose beads. The binding capacity of the immunoadsorbent was measured by equilibrating samples with saturating quantities of fluorescent beta2-m in serum. RESULTS The displayed scFv possessed a nanomolar affinity (KD= 0.008 +/- 0.004 mg-beta2-m/L). The immunoadsorbent exhibited an adsorption site density of 0.41 +/- 0.01 mg beta2-m/mL settled gel. Under saturating conditions, the mass ratio of adsorbed beta2-m to immobilized antibody is 70% greater than any previous literature report for whole antibodies. Preliminary specificity experiments suggest that the scFv-based immunoadsorbent is specific toward human beta2-m. CONCLUSION Recombinant DNA technology was successfully used to engineer an scFv-based immunoadsorbent. Use of immobilized scFvs during hemodialysis may minimize loss of valuable proteins and facilitate the removal of macromolecules that are significantly larger than the molecular weight cut-off of the membrane.
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Affiliation(s)
- Eric A Grovender
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Abstract
Beta-2 microglobulin is the most widely studied low-molecular-weight protein in end-stage renal disease. It is known to cause dialysis-related amyloidosis (DRA), by virtue of its retention when renal function fails, its deposition in tissues, its aggregation into fibrils, and its ability to become glycosylated. The onset of DRA may be protracted by the use of noncellulosic membranes, especially when high-volume hemodiafiltration is used in the treatment of renal failure. Adsorptive methods have been developed to improve the removal of beta-2 microglobulin. There seems to be a relative risk reduction in mortality when patients are treated with dialysis membranes that have a higher clearance of beta-2 microglobulin.
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Abe T, Uchita K, Orita H, Kamimura M, Oda M, Hasegawa H, Kobata H, Fukunishi M, Shimazaki M, Abe T, Akizawa T, Ahmad S. Effect of beta(2)-microglobulin adsorption column on dialysis-related amyloidosis. Kidney Int 2003; 64:1522-8. [PMID: 12969174 DOI: 10.1046/j.1523-1755.2003.00235.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND beta2-microglobulin (beta2-m) is considered a major pathogenic factor in dialysis-related amyloidosis (DRA), often seen in long-term dialysis patients. No effective therapy for this severely debilitating disease is currently available. Lixelle, an adsorption column, has been developed for the elimination of beta2-m; the efficacy of this column has been evaluated in this study. METHODS Seventeen hemodialysis patients with DRA were first treated with high-flux dialysis for a minimum of 1 year. This was followed by 1-year treatment with Lixelle column connected in series to the high-flux dialyzer. Treatments were used three times a week for both phases of this study. During the study period, beta2-m, pinch strength, motor terminal latency, and activities of daily living were evaluated. RESULTS After 1-year treatment with high-flux dialysis the beta2-m level remained unchanged; however, after 1-year treatment with the addition of the Lixelle column, beta2-m level decreased significantly from 34.5 +/- 8.4 mg/L to 28.8 +/- 7.3 mg/L (P < 0.05). After 1 year of Lixelle column use, the pinch strength increased from 6.8 +/- 4.7 pounds to 9.1 +/- 5.5 pounds (P < 0.01), and the median motor terminal latency was significantly reduced from 5.1 +/- 1.0 mseconds to 4.5 +/- 1.1 mseconds. A significant improvement was also observed in the activities of daily living score of the upper extremities. CONCLUSION These results suggest that the addition of Lixelle to the high-flux dialyzer is associated with a significant clinical improvement in DRA patients.
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Affiliation(s)
- Takaya Abe
- Center of Blood Purification Therapy, Wakayama Medical University, Wakayama, Japan.
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Maduell F, Navarro V, Torregrosa E, Rius A, Dicenta F, Cruz MC, Ferrero JA. Change from three times a week on-line hemodiafiltration to short daily on-line hemodiafiltration. Kidney Int 2003; 64:305-13. [PMID: 12787423 DOI: 10.1046/j.1523-1755.2003.00043.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Daily dialysis has shown excellent clinical results because a higher frequency of dialysis is more physiologic. On-line hemodiafiltration (OL-HDF) is a HDF technique that combines diffusion with high convection in which the dialysis fluid itself is used as a reinfusion solution. The aim of this study was to demonstrate the beneficial effect of the more effective dialysis schedule (daily dialysis) with the dialysis modality that offers the highest uremic toxin removal (on-line HDF). METHODS Eight patients, six males and two females, on standard 4 to 5 hours three times a week OL-HDF (S-OL-HDF) were switched to daily OL-HDF (D-OL-HDF) 2 to 21/2 hours six times per week. Dialysis parameters were identical during both periods and only frequency and dialysis time of each session were changed. Tolerance, uremic toxin removal, urea kinetics, biochemical and anemia profiles, blood pressure, and left ventricular hypertrophy were evaluated. RESULTS D-OL-HDF was well accepted and tolerated. The disappearance of postdialysis fatigue was rapidly reported by patients. Patients mantained the same [time average concentration (TAC) and weekly single-pool Kt/V (spKt/V)] throughout the study. However, equivalent renal urea clearance (EKR), standard Kt/V and weekly urea reduction ratio (URR) were increased during D-OL-HDF. Weekly urea, creatinine, osteocalcin, beta2-microglobulin, myoglobin, and prolactin reduction ratios were improved with D-OL-HDF. There was a significant decrease in predialysis plasma levels of urea, creatinine, acid uric, beta2-microglobulin and homocysteine over 6 months. Phosphate binders were reduced and antihypertensive drugs were stopped. A 30% regression of left ventricular mass was observed. CONCLUSION The change from S-OL-HDF to D-OL-HDF was well tolerated. Disappearance of postdialysis fatigue, better dialysis adequacy, a higher removal of middle and large molecules, a reduction of phosphate binders, improvement of status nutritional, and an important reduction of cardiovascular risk factors were observed.
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Leypoldt JK, Jaber BL, Lysaght MJ, McCarthy JT, Moran J. Kinetics and dosing predictions for daily haemofiltration. Nephrol Dial Transplant 2003; 18:769-76. [PMID: 12637647 DOI: 10.1093/ndt/gfg019] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Thrice-weekly haemofiltration affords excellent outcome when it is used to treat chronic renal failure patients. Daily haemofiltration (DHF) has recently been proposed as a more intensive therapy option, but the total ultrafiltration or exchange volume (replacement volume plus net ultrafiltration volume) requirements for adequate solute clearances during this novel therapy are unknown. METHODS We calculated theoretical solute kinetic profiles during six times per week DHF for comparison with those during thrice-weekly haemodialysis using a high-flux dialyser (HFHD) or during continuous ambulatory peritoneal dialysis (CAPD). HFHD and CAPD were chosen for comparison because K/DOQI guidelines have defined adequate treatment doses for these therapies. Steady-state concentrations were calculated using a two-compartment model of an anuric patient with 35 l of total body water for five solutes: urea, creatinine, vitamin B(12), inulin and beta(2)-microglobulin. Solute distribution volumes and generation rates were taken from the literature, and excess fluid (1 l/day) was assumed to accumulate in and be removed from the extracellular fluid compartment. Theoretical predictions of solute clearance were compared for a 15-l exchange volume/session during DHF, urea Kt/V of 3.6/week during HFHD and urea Kt/V of 2.0/week during CAPD as solute-specific values of the equivalent renal clearance (EKR) and standard Kt/V (stdKt/V) recently defined by Gotch. Additional comparisons of solute clearances were performed between DHF and other daily therapies including six times per week short daily haemodialysis (SDHD) and six times per week nocturnal haemodialysis (NHD). RESULTS The calculated results predict that: (i) urea clearance during DHF with an exchange volume of 90 l/week (6x15 l) is equivalent to those during HFHD and CAPD based on urea stdKt/V; and (ii) middle molecule clearances during DHF exceed those achieved during HFHD and CAPD based on either EKR or stdKt/V. As expected, DHF therapy was inferior regarding the clearance of urea and other small solutes to SDHD and NHD; however, DHF therapy was superior to SDHD regarding the clearance of larger middle molecules, approaching the clearances achieved by NHD. CONCLUSIONS We predict that an exchange volume of approximately 40% of total body water (15/35 l=43%) per session will provide adequate clearance of small solutes and substantial clearance of middle molecules during six times per week DHF therapy. These theoretical predictions require clinical validation.
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Affiliation(s)
- John K Leypoldt
- Research Service, Salt Lake City VA Health Care System, Salt Lake City, UT, USA.
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