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Vernooij RW, Hockham C, Barth C, Canaud B, Cromm K, Davenport A, Hegbrant J, Rose M, Strippoli G, Török M, Woodward M, Bots M, Blankestijn P. High-Target Hemodiafiltration Convective Dose Achieved in Most Patients in a 6-Month Intermediary Analysis of the CONVINCE Randomized Controlled Trial. Kidney Int Rep 2023; 8:2276-2283. [PMID: 38025213 PMCID: PMC10658200 DOI: 10.1016/j.ekir.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/28/2023] [Accepted: 08/07/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction High convection volumes in hemodiafiltration (HDF) result in improved survival; however, it remains unclear whether it is achievable in all patients. Methods CONVINCE, a randomized controlled trial, randomized patients with end-stage kidney disease 1:1 to high-dose HDF versus high-flux hemodialysis (HD) continuation. We evaluated the proportion of patients achieving high-dose HDF target: convection volume per visit of ≥23 l (range ±1 l) at baseline, month 3, and month 6. We compared baseline characteristics in the following 2 ways: (i) patients on target for all 3 visits versus patients who missed target on ≥1 visits and (ii) patients on target for all 3 visits or missing it once versus patients who missed target on ≥2 visits. Results A total of 653 patients were randomized to HDF. Their mean age was 62.2 (SD 13.5) years, 36% were female, 81% had fistula vascular access, and 33% had diabetes. Across the 3 visits, 75 patients (11%), 27 patients (4%), and 11 patients (2%) missed the convection volume target once, twice, and thrice, respectively. Apart from diabetes, there were no apparent differences in patient characteristics between patients who always achieved the high-dose target (83%) and those who missed the target either once or more (17%) or twice or more (6%). Conclusion Achieving high-dose HDF is feasible for nearly all patients in CONVINCE and could be maintained during the 6-month follow-up period. Apart from diabetes, there were no other indications for confounding by indication on multivariable analyses that may explain the potential survival advantage for patients receiving high-dose HDF.
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Affiliation(s)
- Robin W.M. Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - C. Hockham
- George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - C. Barth
- B. Braun Avitum AG, Medical Scientific Affairs, Melsungen, Germany
| | - B. Canaud
- Montpellier University, School of Medicine, Montpellier, France and Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - K. Cromm
- Fresenius Medical Care Deutschland GmbH, Global Medical Office, Bad Homburg, Germany
| | - A. Davenport
- UCL Center for Nephrology, Royal Free Hospital, Division of Medicine, University College London, London, UK
| | - J. Hegbrant
- Division of Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - M. Rose
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center of Internal Medicine and Dermatology, Department of Psychosomatic Medicine, Berlin Institute of Health, Berlin, Germany
| | - G.F.M. Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
- School of Public Health, University of Sydney, Sydney, Australia
| | - M. Török
- Corporate Medical Office Diaverum, Malmö, Sweden
| | - M. Woodward
- George Institute for Global Health, School of Public Health, Imperial College London, London, UK
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - M.L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - P.J. Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Pedreros-Rosales C, Jara A, Lorca E, Mezzano S, Pecoits-Filho R, Herrera P. Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond. Toxins (Basel) 2023; 15:531. [PMID: 37755957 PMCID: PMC10535648 DOI: 10.3390/toxins15090531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.
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Affiliation(s)
- Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción 4070386, Chile
- Nephrology Service, Hospital Las Higueras, Talcahuano 4270918, Chile
| | - Aquiles Jara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Eduardo Lorca
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
| | - Sergio Mezzano
- Instituto de Medicina, Facultad de Medicina, Universidad Austral, Valdivia 5110566, Chile
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI 48108, USA
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Patricia Herrera
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
- Nephrology Service, Hospital del Salvador, Santiago 8320000, Chile
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Hemodiafiltration: Technical and Medical Insights. Bioengineering (Basel) 2023; 10:bioengineering10020145. [PMID: 36829639 PMCID: PMC9952158 DOI: 10.3390/bioengineering10020145] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Despite the significant medical and technical improvements in the field of dialytic renal replacement modalities, morbidity and mortality are excessively high among patients with end-stage kidney disease, and most interventional studies yielded disappointing results. Hemodiafiltration, a dialysis method that was implemented in clinics many years ago and that combines the two main principles of hemodialysis and hemofiltration-diffusion and convection-has had a positive impact on mortality rates, especially when delivered in a high-volume mode as a surrogate for a high convective dose. The achievement of high substitution volumes during dialysis treatments does not only depend on patient characteristics but also on the dialyzer (membrane) and the adequately equipped hemodiafiltration machine. The present review article summarizes the technical aspects of online hemodiafiltration and discusses present and ongoing clinical studies with regards to hard clinical and patient-reported outcomes.
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Caskey FJ, Procter S, MacNeill SJ, Wade J, Taylor J, Rooshenas L, Liu Y, Annaw A, Alloway K, Davenport A, Power A, Farrington K, Mitra S, Wheeler DC, Law K, Lewis-White H, Ben-Shlomo Y, Hollingworth W, Donovan J, Lane JA. The high-volume haemodiafiltration vs high-flux haemodialysis registry trial (H4RT): a multi-centre, unblinded, randomised, parallel-group, superiority study to compare the effectiveness and cost-effectiveness of high-volume haemodiafiltration and high-flux haemodialysis in people with kidney failure on maintenance dialysis using linkage to routine healthcare databases for outcomes. Trials 2022; 23:532. [PMID: 35761367 PMCID: PMC9235280 DOI: 10.1186/s13063-022-06357-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND More than a third of the 65,000 people living with kidney failure in the UK attend a dialysis unit 2-5 times a week to have their blood cleaned for 3-5 h. In haemodialysis (HD), toxins are removed by diffusion, which can be enhanced using a high-flux dialyser. This can be augmented with convection, as occurs in haemodiafiltration (HDF), and improved outcomes have been reported in people who are able to achieve high volumes of convection. This study compares the clinical- and cost-effectiveness of high-volume HDF compared with high-flux HD in the treatment of kidney failure. METHODS This is a UK-based, multi-centre, non-blinded randomised controlled trial. Adult patients already receiving HD or HDF will be randomised 1:1 to high-volume HDF (aiming for 21+ L of substitution fluid adjusted for body surface area) or high-flux HD. Exclusion criteria include lack of capacity to consent, life expectancy less than 3 months, on HD/HDF for less than 4 weeks, planned living kidney donor transplant or home dialysis scheduled within 3 months, prior intolerance of HDF and not suitable for high-volume HDF for other clinical reasons. The primary outcome is a composite of non-cancer mortality or hospital admission with a cardiovascular event or infection during follow-up (minimum 32 months, maximum 91 months) determined from routine data. Secondary outcomes include all-cause mortality, cardiovascular- and infection-related morbidity and mortality, health-related quality of life, cost-effectiveness and environmental impact. Baseline data will be collected by research personnel on-site. Follow-up data will be collected by linkage to routine healthcare databases - Hospital Episode Statistics, Civil Registration, Public Health England and the UK Renal Registry (UKRR) in England, and equivalent databases in Scotland and Wales, as necessary - and centrally administered patient-completed questionnaires. In addition, research personnel on-site will monitor for adverse events and collect data on adherence to the protocol (monthly during recruitment and quarterly during follow-up). DISCUSSION This study will provide evidence of the effectiveness and cost-effectiveness of HD as compared to HDF for adults with kidney failure in-centre HD or HDF. It will inform management for this patient group in the UK and internationally. TRIAL REGISTRATION ISRCTN10997319 . Registered on 10 October 2017.
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Affiliation(s)
- Fergus J Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
- Renal unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
| | - Sunita Procter
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - Stephanie J MacNeill
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Jodi Taylor
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Yumeng Liu
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - Ammar Annaw
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - Karen Alloway
- Research and Innovation, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, England
| | - Albert Power
- Renal unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Coreys Mill Ln, Stevenage, SG1 4AB, UK
| | - Sandip Mitra
- Renal Unit, Manchester University Hospitals NHS Trust, Manchester, UK
| | - David C Wheeler
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, England
- George Institute for Global Health, Sydney, Australia
| | - Kristian Law
- Public and patient involvement representative, Bristol, UK
| | | | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Will Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - Jenny Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - J Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Trials Centre, 1-5 Whiteladies Road, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
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Effets biologiques et cliniques, et résultats au long cours du traitement par ol-HDF des patients adultes insuffisants rénaux chroniques. Nephrol Ther 2022. [DOI: 10.1016/s1769-7255(22)00035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ficociello LH, Busink E, Sawin D, Winter A. Global real-world data on hemodiafiltration: An opportunity to complement clinical trial evidence. Semin Dial 2022; 35:440-445. [PMID: 35439847 PMCID: PMC9790215 DOI: 10.1111/sdi.13085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 12/30/2022]
Abstract
Hemodiafiltration (HDF) is a renal replacement therapy that utilizes both diffusive clearance and convective transport to achieve greater clearance of middle-molecular-weight solutes. Among other factors, important prerequisites for the implementation of HDF include access to high-flux dialyzers, achievement of high blood flow rates, and availability of high volumes of sterile substitution/replacement fluids. Online hemodiafiltration (OL-HDF) is an established kidney replacement therapy, frequently used in many countries. Although in the United States, some prerequisites (e.g., access to high-flux dialyzers and achievement of high blood flow rates) for OL-HDF treatment are readily available; however, a machine capable of generating the online solution for OL-HDF is currently not available. As the clinical experience with HDF accumulates globally, it is worth examining the evidence for this kidney replacement therapy as used in routine clinical care. Such real-world evidence is increasingly recognized as valuable by clinicians and may inform regulatory decisions. In this review, we will focus on emerging global real-world data derived from routine clinical practices and examine how these data may complement those derived from clinical trials.
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Affiliation(s)
| | - Ellen Busink
- Health Economics, Market Access and Political Affairs EMEAFresenius Medical Care Deutschland GmbHBad HomburgGermany
| | | | - Anke Winter
- Global Medical OfficeFresenius Medical CareBad HomburgGermany
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7
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Kashgary A, Khojah A, Bamalan B, Alafari S, Sindi M, Alahmari A, Gasm I, Alkhateeb L, Khojah Y, Abdelsalam M. Effect of Hemodiafiltration Versus Hemodialysis on Cognitive Function Among Patients With End-Stage Renal Disease: A Multicenter Study. Cureus 2021; 13:e19719. [PMID: 34934582 PMCID: PMC8684443 DOI: 10.7759/cureus.19719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Cognitive impairment (CI) and dementia are common in patients with end-stage renal disease (ESRD) undergoing hemodialysis. Their cause is multifactorial. Our study is first to compare the impact of hemodialysis (HD) and online hemodiafiltration (HDF) on patients’ cognitive outcomes. Methods: This was a cross sectional, multicenter cohort study. Adult ESRD patients aged >18 years on regular high flux HD or online HDF were recruited in the study. Clinical, laboratory, daily activities and cognitive functions assessment were assessed in all the involved individuals. Results: A total of 241 patients were successfully recruited into the study: 164 treated with high flux HD and 77 treated with HDF. Hypertension and diabetes were the commonest associated comorbidities. 85.9% of patients were functionally independent with no significant difference between those on HD versus HDF. 81.3% of our patients showed different degrees of CI. HDF has no superiority in the improvement of cognitive functions. Age, vitamin D level and haemoglobin (Hb) were the most independent predictors of cognitive function impairment among HD patients. Conclusions: Cognitive function impairment is a common problem in hemodialysis and is associated with multiple risk factors. HDF showed no beneficial effect over HD. There is no superiority of online HDF versus high flux HD in improving cognitive functions.
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Affiliation(s)
| | - Ahlam Khojah
- Medicine, King Abdulaziz University, Jeddah, SAU
| | | | | | - Marah Sindi
- Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | | | - Ibtisam Gasm
- Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Yazeed Khojah
- Department of Family Medicine, King Abdulaziz University, Jeddah, SAU
| | - Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, EGY
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:S1-S37. [PMID: 34923803 PMCID: PMC8694695 DOI: 10.23876/j.krcp.21.600] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Belova IV, Khrulev AE, Tochilina AG, Khruleva NS, Lobanova NA, Zhirnov VA, Molodtsova SB, Lobanov VN, Solovieva IV. Colon Microbiocenosis and Its Correction in Patients Receiving Programmed Hemodialysis. Sovrem Tekhnologii Med 2021; 12:62-68. [PMID: 34796006 PMCID: PMC8596268 DOI: 10.17691/stm2020.12.5.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 11/14/2022] Open
Abstract
The aim of the investigation was to study the species composition of colon microbiocenosis in patients with chronic kidney disease receiving programmed hemodialysis treatment and to evaluate the efficacy of its correction using a new immobilized synbiotic. Materials and Methods Samples of colon microbiota from 62 patients undergoing programmed hemodialysis were studied before and after a course of diet therapy that included probiotic components, in particular, the immobilized synbiotic LB-complex L. Isolation of microorganisms was carried out according to our original method; for bacteria identification, a MALDI-TOF Autoflex speed mass spectrometer (Bruker Daltonik, Germany) was used in the Biotyper program mode. The results were assessed using the criteria proposed by the authors and based on the OST 91500.11.0004-2003. The efficacy of the immobilized synbiotic was determined based on the clinical data, questionnaires, and bacteriological tests. Results In patients receiving programmed hemodialysis (before the start of the diet therapy), chronic moderate inflammation and azotemia were found. Dysbiotic changes in microbiocenosis were revealed in all the examined patients; in the absence or suppression of lacto- and bifidoflora, the number and diversity of Bacteroides spp., Clostridium spp., Collinsella spp., Eggerthella spp. and other bacteria increased, which was consistent with the theory of functional redundancy of gut microbiota. From the answers to the questionnaires, a decrease in the quality of life was found (up to 70 points out of 100) according to six of the eight scales used. After the combined therapy using the synbiotic LB-complex L in the study group, 56% of the examined patients showed their microbiocenosis restored to normal; no grade III dysbiosis was detected in any patient. There was a significant decrease in CRP and ESR in these patients and an improvement in the quality of life by criteria reflecting physical health. Conclusion In patients receiving programmed hemodialysis, the addition of a probiotic component in the diet therapy restores the evolutionarily determined structure of the microbiocenosis, normalizes its functions, and leads to an overall improvement in health and quality of life.
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Affiliation(s)
- I V Belova
- Leading Researcher, Laboratory of Human Microbiome and Means of Its Correction; Academician I.N. Blokhina Nizhny Novgorod Scientific Research Institute of Epidemiology and Microbiology of Rospotrebnadzor (Russian Federal Consumer Rights Protection and Human Health Control Service), 71 Malaya Yamskaya St., Nizhny Novgorod, 603950, Russia
| | - A E Khrulev
- Associate Professor, Department of Nervous Diseases; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A G Tochilina
- Senior Researcher, Laboratory of Human Microbiome and Means of Its Correction; Academician I.N. Blokhina Nizhny Novgorod Scientific Research Institute of Epidemiology and Microbiology of Rospotrebnadzor (Russian Federal Consumer Rights Protection and Human Health Control Service), 71 Malaya Yamskaya St., Nizhny Novgorod, 603950, Russia
| | - N S Khruleva
- Assistant, Department of Hospital Therapy and General Practice named after V.G. Vogralik; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - N A Lobanova
- Chief Physician; FESFARM NN, 11A Vasenko St., Nizhny Novgorod, 603003, Russia
| | - V A Zhirnov
- Researcher, Laboratory of Human Microbiome and Means of Its Correction; Academician I.N. Blokhina Nizhny Novgorod Scientific Research Institute of Epidemiology and Microbiology of Rospotrebnadzor (Russian Federal Consumer Rights Protection and Human Health Control Service), 71 Malaya Yamskaya St., Nizhny Novgorod, 603950, Russia
| | - S B Molodtsova
- Researcher, Laboratory of Human Microbiome and Means of Its Correction; Academician I.N. Blokhina Nizhny Novgorod Scientific Research Institute of Epidemiology and Microbiology of Rospotrebnadzor (Russian Federal Consumer Rights Protection and Human Health Control Service), 71 Malaya Yamskaya St., Nizhny Novgorod, 603950, Russia
| | - V N Lobanov
- 6-year Student, Medical Faculty; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - I V Solovieva
- Leading Researcher, Head of the Laboratory of Human Microbiome and Means of Its Correction Academician I.N. Blokhina Nizhny Novgorod Scientific Research Institute of Epidemiology and Microbiology of Rospotrebnadzor (Russian Federal Consumer Rights Protection and Human Health Control Service), 71 Malaya Yamskaya St., Nizhny Novgorod, 603950, Russia
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Nagasubramanian S. The future of the artificial kidney. Indian J Urol 2021; 37:310-317. [PMID: 34759521 PMCID: PMC8555564 DOI: 10.4103/iju.iju_273_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/12/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
End-stage renal disease (ESRD) is increasing worldwide. In India, diabetes mellitus and hypertension are the leading causes of chronic kidney disease and ESRD. Hemodialysis is the most prevalent renal replacement therapy (RRT) in India. The ideal RRT must mimic the complex structure of the human kidney while maintaining the patient's quality of life. The quest for finding the ideal RRT, the “artificial kidney”– that can be replicated in the clinical setting and scaled-up across barriers– continues to this date. This review aims to outline the developments, the current status of the artificial kidney and explore its future potential.
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11
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Grooteman M, Nubé M. Reappraisal of Hemodiafiltration for Managing Uremic Complications. Clin J Am Soc Nephrol 2021; 16:1303-1305. [PMID: 34497105 PMCID: PMC8729585 DOI: 10.2215/cjn.07760621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Muriel Grooteman
- Amsterdam UMC, Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Menso Nubé
- Amsterdam UMC, Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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12
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Florens N, Guebre-Egziabher F, Juillard L. Reconsidering adsorption in hemodialysis: is it just an epiphenomenon? A narrative review. J Nephrol 2021; 35:33-41. [PMID: 33837932 DOI: 10.1007/s40620-021-00993-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/04/2021] [Indexed: 01/31/2023]
Abstract
Since the first attempt at extracorporeal renal replacement therapy, renal replacement therapy has been constantly improved. In the field of hemodialysis, substantial efforts have been made to improve toxin removal and biocompatibility. The advent of hemodiafiltration (HDF) and, more recently, of mid cut-off membranes have contributed to management of patients with end-stage renal disease (ESRD). Although several uremic toxins have been discovered, we know little about the clinical impact of their clearance in hemodialysis patients. In addition, a great deal of progress has been made in the areas of filtration and diffusion, but the adsorptive properties of hemodialysis membranes remain under-studied. The mechanism of action of adsorption is based on the attraction between the polymer of the dialysis membrane and the solutes, through hydrophobic interactions, ionic or electrostatic forces, hydrogen bonds or van der Waals forces. Adsorption on the dialysis membrane depends on the membrane surface, pore size, structure and electric load. Its involvement in toxin removal and biocompatibility is significant, and is not just an epiphenomenon. Diffusive and convective properties cannot be improved indefinitely and high permeability membranes, despite their high performance in the clearance of many toxins, have several limitations for long-term use in hemodialysis. This review will discuss why adsorption should be reconsidered and better characterized to improve efficiency and adequacy of dialysis.
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Affiliation(s)
- Nans Florens
- Department of Nephrology, Dialysis and Hypertension, Edouard Herriot Hospital, Hospices Civils de Lyon, 5 Place d'Arsonval, Cedex 03, 6943769003, Lyon, France. .,CarMeN, INSERM U1060, INRA U1397, INSA de Lyon, Université Claude Bernard Lyon 1, University of Lyon, 69500, Bron, France.
| | - Fitsum Guebre-Egziabher
- Department of Nephrology, Dialysis and Hypertension, Edouard Herriot Hospital, Hospices Civils de Lyon, 5 Place d'Arsonval, Cedex 03, 6943769003, Lyon, France.,CarMeN, INSERM U1060, INRA U1397, INSA de Lyon, Université Claude Bernard Lyon 1, University of Lyon, 69500, Bron, France
| | - L Juillard
- Department of Nephrology, Dialysis and Hypertension, Edouard Herriot Hospital, Hospices Civils de Lyon, 5 Place d'Arsonval, Cedex 03, 6943769003, Lyon, France.,CarMeN, INSERM U1060, INRA U1397, INSA de Lyon, Université Claude Bernard Lyon 1, University of Lyon, 69500, Bron, France
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13
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Evans M, Xu H, Rydell H, Prütz KG, Lindholm B, Stendahl M, Segelmark M, Carrero JJ. Association Between Implementation Of Novel Therapies And Improved Survival In Patients Starting Hemodialysis: The Swedish Renal Registry 2006-2015. Nephrol Dial Transplant 2020; 36:gfaa357. [PMID: 33326038 PMCID: PMC8237989 DOI: 10.1093/ndt/gfaa357] [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: 07/19/2020] [Revised: 10/22/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The recent years have witnessed significant therapeutic advances for patients on hemodialysis. We evaluated temporal changes in treatments practices and survival rates among incident hemodialysis patients. METHODS Observational study of patients initiating hemodialysis in Sweden 2006-2015. Trends of hemodialysis-related practices, medications, and routine laboratory biomarkers were evaluated. The incidence of death and major cardiovascular events (MACE) across calendar years were compared against the age-sex-matched general population. Via Cox regression, we explored whether adjustment for implementation of therapeutic advances modified observed survival and MACE risks. RESULTS Among 6,612 patients, age and sex were similar, but the burden of co-morbidities increased over time. The proportion of patients receiving treatment by hemodiafiltration, >3 sessions/week, lower ultrafiltration rate, and working fistulas increased progressively, as did use of non-calcium phosphate binders, cinacalcet, and vitamin D3. The standardized 1-year mortality decreased from 13.2% in 2006/07 to 11.1% in 2014/15. The risk of death decreased by 6% (HR 0.94, 95% CI 0.90-0.99) every two years, and the risk of MACE by 4% (HR 0.96; 0.92-1.00). Adjustment for changes in treatment characteristics abrogated these associations (HR 1.00; 0.92-1.09 for death and 1.00; 0.94-1.06 for MACE). Compared with the general population, the risk of death declined from 6 times higher 2006/2007 [standardized incidence rate ratio, sIRR 6.0 (5.3-6.9)], to 5.6 higher 2014/15 [sIRR 5.57 (4.8-6.4)]. CONCLUSIONS Gradual implementation of therapeutic advances over the last decade was associated with a parallel reduction in short-term risk of death and MACE among hemodialysis patients.
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Affiliation(s)
- Marie Evans
- Division of Renal Medicine, Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Helena Rydell
- Division of Renal Medicine, Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Karl-Göran Prütz
- Swedish Renal Registry, Department of Internal Medicine, Ryhov Regional Hospital, Jönköping, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine, Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Maria Stendahl
- Swedish Renal Registry, Department of Internal Medicine, Ryhov Regional Hospital, Jönköping, Sweden
| | - Mårten Segelmark
- Department of Clinical Sciences, Division of Nephrology, Lund University and Skane University Hospital, Lund, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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14
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Lindgren A, Fjellstedt E, Christensson A. Comparison of Hemodialysis Using a Medium Cutoff Dialyzer versus Hemodiafiltration: A Controlled Cross-Over Study. Int J Nephrol Renovasc Dis 2020; 13:273-280. [PMID: 33149656 PMCID: PMC7602900 DOI: 10.2147/ijnrd.s263110] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/15/2020] [Indexed: 01/29/2023] Open
Abstract
Purpose Conventional hemodialysis (HD) treatment has an acceptable removal of small uremic molecules, but so-called "middle molecules" in the range of 0.5-60 kDa are poorly cleared with HD compared to a native kidney, which may contribute to morbidity in the dialysis population. Hemodiafiltration (HDF) has a better removal of middle molecules compared to HD but is technically demanding and requires well-functioning dialysis access. The newly introduced medium cutoff (MCO) filters have been developed to enhance middle molecule clearance in HD-mode. The aim of this study was to compare reduction ratios (RRs) of molecules with different molecular weights (0.06-150 kDa) during dialysis with MCO dialyzer (used in HD-mode) compared to online-hemodiafiltration (ol-HDF) treatment with a conventional high-flux dialyzer. Patients and Methods This is a prospective controlled single-center cross-over study, including 16 patients in Malmö, Sweden. All patients had ongoing post-dilution ol-HDF treatment before the study. The study compared reduction ratios of small-, middle-, and large-sized molecules during a single 4h dialysis treatment with post-dilution ol-HDF (Polyflux 210H) to a 4h dialysis treatment with MCO dialyzer (Theranova 500) in HD-mode. Between treatments, the patients had a washout period of at least two weeks of their ordinary HDF treatment to reach their ordinary steady state. Results ol-HDF had significantly higher RR for cystatin C (13 kDa), compared to MCO (RR 68.1 vs 65.8, p=0.003), during a 4h dialysis treatment (mean convection volume of 24.5 L for HDF, and mean Qb of 324 mL/min for HDF and 323 mL/min for MCO). There was no significant difference in the RR for other middle molecules, or for smaller or larger molecules. Conclusion Overall, the RRs were comparable for ol-HDF and MCO-HD. There was a slightly higher RR of cystatin C (a small middle molecule) for HDF compared to MCO but no difference in other measured molecules.
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Affiliation(s)
- Anna Lindgren
- Department of Nephrology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Erik Fjellstedt
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Nephrology, Skåne University Hospital, Malmö, Sweden
| | - Anders Christensson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Nephrology, Skåne University Hospital, Malmö, Sweden
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15
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Blankestijn PJ, Fischer KI, Barth C, Cromm K, Canaud B, Davenport A, Grobbee DE, Hegbrant J, Roes KC, Rose M, Strippoli GF, Vernooij RW, Woodward M, de Wit GA, Bots ML. Benefits and harms of high-dose haemodiafiltration versus high-flux haemodialysis: the comparison of high-dose haemodiafiltration with high-flux haemodialysis (CONVINCE) trial protocol. BMJ Open 2020; 10:e033228. [PMID: 32029487 PMCID: PMC7044930 DOI: 10.1136/bmjopen-2019-033228] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/12/2019] [Accepted: 12/31/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION End-stage kidney disease (ESKD) is a major public health problem affecting more than 2 million people worldwide. It is one of the most severe chronic non-communicable diseases. Haemodialysis (HD) is the most common therapeutic option but is also associated with a risk of cardiovascular events, hospitalisation and suboptimal quality of life. Over the past decades, haemodiafiltration (HDF) has become available. Although high-dose HDF has shown some promising survival advantage compared to conventional HD, the evidence remains controversial. A Cochrane systematic review found, in low-quality trials, with various convective forms of dialysis, a reduction in cardiovascular, but not all-cause mortality and the effects on non-fatal cardiovascular events and hospitalisation were uncertain. In contrast, an individual patient data analysis suggested that high-dose HDF reduced both all-cause and cardiovascular mortality compared to HD. In view of these discrepant results, a definitive trial is required to determine whether high-dose HDF is preferable to high-flux HD. The comparison of high-dose HDF with high-flux HD (CONVINCE) study will assess the benefits and harms of high-dose HDF versus a conventional high-flux HD in adults with ESKD. METHODS AND ANALYSIS This international, prospective, open label, randomised controlled trial aims to recruit 1800 ESKD adults treated with HD in nine European countries. Patients will be randomised 1:1 to high-dose HDF versus continuation of conventional high-flux HD. The primary outcome will be all-cause mortality at 3 years' follow-up. Secondary outcomes will include cause-specific mortality, cardiovascular events, all-cause and infection-related hospitalisations, patient-reported outcomes (eg, health-related quality of life) and cost-effectiveness. ETHICS AND DISSEMINATION The CONVINCE study will address the question of benefits and harms of high-dose HDF compared to high-flux HD for kidney replacement therapy in patients with ESKD with a focus on survival, patient perspectives and cost-effectiveness. TRIAL REGISTRATION NUMBER Netherlands National Trial Register (NTR 7138).
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Affiliation(s)
- Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kathrin I Fischer
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center of Internal Medicine and Dermatology, Department of Psychosomatic Medicine, Berlin, Germany
| | - Claudia Barth
- B. Braun Avitum AG, Medical Scientific Affairs, Melsungen, Germany
| | - Krister Cromm
- Fresenius Medical Care Deutschland GmbH, Global Medical Office, Bad Homburg v.d.H, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Global Medical Office, Bad Homburg v.d.H, Germany
- Montpellier University, School of Medicine, Montpellier, France
| | - Andrew Davenport
- Department of Nephrology, University College of London, London, United Kingdom
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Clinical, Academic Clinical Research Organisation, Zeist, The Netherlands
| | - Jörgen Hegbrant
- Department of Nephrology, Clinical Sciences, Lund University, Lund, Sweden
| | - Kit C Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Matthias Rose
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center of Internal Medicine and Dermatology, Department of Psychosomatic Medicine, Berlin, Germany
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
- University of Sydney, School of Public Health, Sydney, New South Wales, Australia
| | - Robin Wm Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
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Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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Lin Y, He S, Gong J, Ding X, Liu Z, Gong J, Zeng Z, Cheng Y. Continuous veno-venous hemofiltration for severe acute pancreatitis. Cochrane Database Syst Rev 2019; 10:CD012959. [PMID: 31618443 PMCID: PMC6953293 DOI: 10.1002/14651858.cd012959.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe acute pancreatitis is associated with high rates of mortality and life-threatening complications. Continuous veno-venous hemofiltration (CVVH) has been used in some centers to reduce mortality and avoid local or systemic complications, however its efficiency and safety is uncertain. OBJECTIVES To assess the benefits and harms of CVVH in patients suffering from severe acute pancreatitis; to compare the effects of different CVVH techniques; and to evaluate the optimal time for delivery of CVVH. SEARCH METHODS We searched the Cochrane Library (2019, Issue 8), MEDLINE (1946 to 13 September 2019), Embase (1974 to 13 September 2019), and Science Citation Index Expanded (1982 to 13 September 2019). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared CVVH versus no CVVH in participants with severe acute pancreatitis. We also included RCTs that compared different types of CVVH and different schedules for CVVH in participants with severe acute pancreatitis. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included two studies, involving a total of 94 participants, in the review.Continuous veno-venous hemofiltration versus no interventionWe included one study in which 64 participants with severe acute pancreatitis were randomized to undergo CVVH (32 participants) or no intervention (32 participants). There were no deaths in either group (very low-quality evidence). Adverse events, length of stay in the intensive care unit (ICU), length of hospital stay, total hospital cost, and quality of life were not reported in the study.One type of continuous veno-venous hemofiltration versus a different type of continuous veno-venous hemofiltrationWe included one study in which 30 participants with severe acute pancreatitis were randomized to undergo high-volume CVVH (15 participants) or standard CVVH (15 participants). High-volume CVVH may lead to little or no difference in in-hospital mortality rates (20.0% in the high-volume CVVH group versus 33.3% in the standard CVVH group; risk ratio (RR) 0.60, 95% confidence interval (CI) 0.17 to 2.07; 30 participants; 1 study; low-quality evidence). We are uncertain whether high-volume hemofiltration reduces rates of adverse events (13.3% in both groups; RR 1.00, 95% CI 0.16 to 6.20; 30 participants; 1 study; very low-quality evidence). Length of ICU stay, length of hospital stay, total hospital cost, and quality of life were not reported in the study. AUTHORS' CONCLUSIONS The quality of the current evidence is very low or low. For both comparisons addressed in this review, data are sparse. It is unclear whether CVVH has any effect on mortality or complications in patients with severe acute pancreatitis. It is also unclear whether high-volume CVVH is superior, equivalent or inferior to standard CVVH in patients with severe acute pancreatitis.
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Affiliation(s)
- Yanjun Lin
- Department of Urology, The Second Affiliated Hospital, Chongqing Medical University, No. 74, Lin Jiang Road, Chongqing, China, 400010
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18
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Choo SZ, Polkinghorne KR, Kerr PG. Biochemical comparison of 8 h haemodialysis and 4 h haemodiafiltration, and two dialysis membranes, in a randomized cross-over trial. Nephrology (Carlton) 2019; 24:542-549. [PMID: 29722110 DOI: 10.1111/nep.13397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 11/28/2022]
Abstract
AIM Extended-hours haemodialysis has long been regarded as the optimal form of dialysis for solute clearance. With emerging benefits of haemodiafiltration, we wanted to compare these two head-to-head. METHODS In this randomized cross-over trial, we recruited existing nocturnal haemodialysis patients, who had not been hospitalized in the prior 3 months. After a baseline 8 h haemodialysis session, subjects were randomized to either 2 weeks of 8 h haemodialysis or 4 h haemodiafiltration with cross-over to the alternative treatment after a 2-week washout period. Subjects were additionally randomized to the Fresenius FX80 or Nipro Elisio in a parallel design. Blood and dialysate samples were collected at baseline and at the end of both study periods. RESULTS Twelve patients completed the study. Mean (SD) age and body mass index were 55.1 ± 11.5 years and 36.4 ± 10.8, respectively. Urea and creatinine reduction ratios were higher with extended-hours haemodialysis compared to haemodiafiltration (difference 14.0%, 95% CI = 10.6, 17.3; P < 0.001 and 9.1%, 95% CI = 11.0, 7.2; P < 0.001). Fibroblast growth factor 23 (FGF23) clearance was superior with haemodiafiltration (difference 20.1%, 95% CI = 8.7, 31.6; P = 0.001). No difference was seen in reduction ratios for phosphate, retinol binding protein, alpha-1-microglobulin, beta-2-microglobulin and fetuin with both modalities. Compared to Nipro Elisio, Fresenius FX80 dialyser achieved higher beta-2-microglobulin clearance (Period 1: difference 7.8%, 95% CI = 1.3, 14.4; P = 0.02, Period 2:7.5%, 95% CI = 1.0, 14.1; P = 0.02). CONCLUSIONS Small solute clearance was superior with extended-hours haemodialysis while haemodiafiltration enhanced FGF23 clearance. Beta-2-microglobulin clearance was improved with Fresenius FX80 dialyser, but this difference is unlikely to be clinically significant.
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Affiliation(s)
- Shi Z Choo
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
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19
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Mac K, Hedley J, Kelly PJ, Lee VW, Agar JWM, Hawley CM, Johnson DW, See EJ, Polkinghorne KR, Rabindranath KS, Sud K, Webster AC. Effect of centre‐ and patient‐related factors on uptake of haemodiafiltration in Australia and New Zealand: A cohort study using ANZDATA. Nephrology (Carlton) 2019; 25:63-72. [DOI: 10.1111/nep.13574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Kathy Mac
- Centre for Transplant and Renal ResearchWestmead Hospital Sydney New South Wales Australia
| | - James Hedley
- Sydney School of Public HealthThe University of Sydney Sydney New South Wales Australia
| | - Patrick J Kelly
- Sydney School of Public HealthThe University of Sydney Sydney New South Wales Australia
| | - Vincent W Lee
- Centre for Transplant and Renal ResearchWestmead Hospital Sydney New South Wales Australia
- Westmead Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - John W M Agar
- Department of NephrologyUniversity Hospital Geelong Geelong Victoria Australia
| | - Carmel M Hawley
- Faculty of MedicineUniversity of Queensland Brisbane Queensland Australia
- Australasian Kidney Trials Network Brisbane Queensland Australia
- Department of NephrologyPrincess Alexandra Hospital Brisbane Queensland Australia
| | - David W Johnson
- Faculty of MedicineUniversity of Queensland Brisbane Queensland Australia
- Australasian Kidney Trials Network Brisbane Queensland Australia
- Department of NephrologyPrincess Alexandra Hospital Brisbane Queensland Australia
| | - Emily J See
- Department of NephrologyMonash Health Melbourne Victoria Australia
| | | | | | - Kamal Sud
- Centre for Transplant and Renal ResearchWestmead Hospital Sydney New South Wales Australia
- Department of Renal MedicineNepean Hospital Sydney New South Wales Australia
- Nepean Clinical SchoolThe University of Sydney Sydney New South Wales Australia
| | - Angela C Webster
- Centre for Transplant and Renal ResearchWestmead Hospital Sydney New South Wales Australia
- Sydney School of Public HealthThe University of Sydney Sydney New South Wales Australia
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Canaud B, Köhler K, Sichart JM, Möller S. Global prevalent use, trends and practices in haemodiafiltration. Nephrol Dial Transplant 2019; 35:398-407. [DOI: 10.1093/ndt/gfz005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022] Open
Abstract
Abstract
Online haemodiafiltration (HDF) represents today the most advanced and innovative form of renal replacement therapy (RRT). Recent controlled trials tend to prove its superiority over conventional haemodialysis on hard clinical end points provided that the right convective dose was delivered. In this article we report on present prevalent use and epidemiologic trends of HDF worldwide as well as on practice patterns in HDF prescription. In addition we analyze factors that may affect HDF clinical acceptance and more widely its implementation. National and international renal registries provide valuable demographic and epidemiologic information on end stage kidney disease patients on RRT. However, the updating and maintenance of such information system is particularly challenging at a country level and even more so on an international basis. Lag time, incompleteness and/or imprecision of data collection may further hamper precision and validity of data reporting. Fresenius Medical Care (FMC), as a large dialysis care provider operating worldwide, maintains an annually updated database addressing international end stage kidney disease data. Over the last decade, FMC has produced series of precise and reliable reports analyzing RRT trends and practices worldwide. The present overview and analysis is based on our consolidated data from market survey as well as national database registries and databases of recent studies. Online HDF acceptance is growing fast in the two leading regions having approved the method, i.e. Europe and Asia Pacific, with a patient average growth rate of 12 to 24%, being far above the total patient HD growth rate of 6.6%. Today online HDF represents a new paradigm shift in RRT with promising clinical results. Further initiatives (e.g., Kidney Health Initiative, NICE) might provide further push for promoting HDF as a new standard of care in end stage kidney disease patients on a global scale.
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Affiliation(s)
- Bernard Canaud
- Medical Office EMEA, Fresenius Medical Care, Bad Homburg, Germany
- Montpellier University, Montpellier, France
| | - Katrin Köhler
- Medical Office EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Jan-Michael Sichart
- International Strategic Development, Fresenius Medical Care, Bad Homburg, Germany
| | - Stefan Möller
- International Strategic Development, Fresenius Medical Care, Bad Homburg, Germany
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21
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Zhang W, Mei C, Chen N, Ding X, Ni Z, Hao C, Zhang J, Zhang J, Wang N, Jiang G, Guo Z, Yu C, Deng Y, Li H, Yao Q, Marshall MR, Wolley MJ, Qian J. Outcomes and practice patterns with hemodiafiltration in Shanghai: a longitudinal cohort study. BMC Nephrol 2019; 20:34. [PMID: 30709342 PMCID: PMC6359843 DOI: 10.1186/s12882-019-1219-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, there is increased clinical interest and uptake of hemodiafiltration (HDF) for increased removal of uremic toxins. To date, there has been no epidemiological analysis of HDF in China. We present HDF practice patterns and associated mortality risk in Shanghai. METHODS This is an observational, prospectively collected, retrospective analysis of 9351 Chinese patients initiating hemodialysis in Shanghai from 2007 to 2014. The primary exposure was hemodialysis sub-modality at inception, classified into hemodiafiltration (HDF) and hemodialysis (HD), with adjustment for concommitant hemoperfusion. The primary outcome was patient mortality. We used Cox proportional hazards regression and Fine and Gray's proportional subhazards regression, with multiple imputation of missing co-variates by the chained equation method, adjusting for demographic and clinical variables. RESULTS Overall, patients in the cohort were younger, with a more males, and with a lower body mass index when compared to corresponding non-Asian cohorts. Mortality rate was low although it doubled over the period of observation. HDF utilization increased from 7% of patients in 2007 to 42% of patients in 2014. The majority of patients received HDF once a week. The adjusted hazard ratio of death (95% confidence intervals) for HDF versus HD was 0.85 (0.71-1.03), and corresponding sub-hazard ratio 0.86 (0.71-1.03). There was strong effect modification by age. In those aged 40-60 years, the hazard ratio (95% confidence intervals) was 0.65 (0.45-0.94), and sub-hazard ratio also 0.65 (0.45-0.95). CONCLUSIONS Our study has certain limitations resulting from the limited number of co-variates available for modelling, missing data for some co-variates, and the lack of verification of data against source documentation. Notwithstanding, there is evidence of clinical benefit from HDF in China, and potential to improve patient outcomes through the greater removal of middle and larger uremic solutes.
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Affiliation(s)
- Weiming Zhang
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Changlin Mei
- Department of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Chuanming Hao
- Division of Nephrology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
| | - Jinghong Zhang
- Department of Nephrology, 85 Hospital of People's Liberation Army, Shanghai, 200052, China
| | - Jinyuan Zhang
- Department of Nephrology, 455 Hospital of People's Liberation Army, Shanghai, 200052, China
| | - Niansong Wang
- Department of Nephrology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Gengru Jiang
- Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 202150, China
| | - Zhiyong Guo
- Department of Nephrology, Changhai Hospital, Second Military Medical University, Shanghai, Shanghai, 200433, China
| | - Chen Yu
- Department of Nephrology, Tongji Hospital, Tongji University, Shanghai, 200092, China
| | - Yueyi Deng
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Haiming Li
- Baxter China Investment Co Ltd, Medical Affairs, Shanghai, 200031, China
| | - Qiang Yao
- Baxter China Investment Co Ltd, Medical Affairs, Shanghai, 200031, China
| | - Mark R Marshall
- Baxter Healthcare (Asia) Pte Ltd, Medical Affairs, Singapore, 189673, Singapore. .,School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1142, New Zealand. .,Department of Renal Medicine, Counties Manukau Health, Auckland, 1640, New Zealand.
| | - Martin J Wolley
- Department of Renal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, 4029, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Jiaqi Qian
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
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22
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Suwabe T, Barrera-Flores FJ, Rodriguez-Gutierrez R, Ubara Y, Takaichi K. Effect of online hemodiafiltration compared with hemodialysis on quality of life in patients with ESRD: A systematic review and meta-analysis of randomized trials. PLoS One 2018; 13:e0205037. [PMID: 30335792 PMCID: PMC6193628 DOI: 10.1371/journal.pone.0205037] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/18/2018] [Indexed: 11/30/2022] Open
Abstract
Background End-stage renal disease (ESRD) is related to high morbidity, mortality, and impaired health-related quality of life. While hemodialysis (HD) is the current life-saving standard of treatment for patients with ESRD, their quality of life (QoL) remains far from desirable. Online HDF (OL-HDF), due to its convenience, could improve the QoL of patients with ESRD, however, this remains uncertain. Objective We aimed to assess the body of evidence of OL-HDF compared to HD regarding QoL in patients with ESRD. Methods We comprehensively searched in multiple data bases from their inception to February 2018. Reviewers working independently and in duplicate appraised the quality and included randomized controlled trials (RCTs) that evaluated, in patients with ESRD and HD or OL-HDF, QoL (Short Form Health Survey with 36 questions (SF-36) with physical component score (PCS) and mental component score (MCS) as well as scores about social activity, fatigue, and emotion). A meta-analysis of each outcome of interest was performed using a random-effects model. Results Six moderate quality RCTs met the inclusion criteria. Meta-analysis of 4 RCTs including a total of 1,209 patients showed that OL-HDF was associated with a lower yet non-significant score of PCS: MD (mean difference) -0.77 (95% CI -1.94 to 0.41, p = 0.20), and MCS: MD -1.25 (95% CI -3.10 to 0.59, p = 0.18); indicating a poorer QoL in patients on OL-HDF. Meta-analysis of 4 RCTs including a total of 845 patients showed OL-HDF was associated with a significant increase in the score of social activity compared to HD: SMD (standardized mean difference): 1.95 (95% CI 0.05 to 3.86, p = 0.04), indicating a better QoL in patients on OL-HDF; but regarding fatigue and emotion, there was no significant improvement when compared to HD by meta-analysis of 3 RCTs (133 patients). Conclusions The body of evidence suggests that OL-HDF does not improve QoL in patients with ESRD when compared to HD.
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Affiliation(s)
- Tatsuya Suwabe
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Nephrology, Toranomon Hospital, Tokyo, Japan
- * E-mail:
| | - Francisco J. Barrera-Flores
- Division of Endocrinology, Medical School and University Hospital “Dr. Jose E. Gonzalez”, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Plataforma INVEST Medicina UANL KER Unit Mayo Clinic, Medical School and University Hospital “Dr. Jose E. Gonzalez”, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Medical School and University Hospital “Dr. Jose E. Gonzalez”, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Plataforma INVEST Medicina UANL KER Unit Mayo Clinic, Medical School and University Hospital “Dr. Jose E. Gonzalez”, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
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23
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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24
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Piccoli GB, Cabiddu G, Moio MR, Fois A, Cao R, Molfino I, Kaniassi A, Lippi F, Froger L, Pani A, Biolcati M. Efficiency and nutritional parameters in an elderly high risk population on hemodialysis and hemodiafiltration in Italy and France: different treatments with similar names? BMC Nephrol 2018; 19:171. [PMID: 29986663 PMCID: PMC6038182 DOI: 10.1186/s12882-018-0948-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/14/2018] [Indexed: 12/29/2022] Open
Abstract
Background Choice of dialysis is context sensitive, explored for PD and extracorporeal dialysis, but less studied for haemodialysis (HD) and hemodiafiltration (HDF), both widely employed in Italy and France; reasons of choice and differences in prescriptions may impact on dialysis-related variables, particularly relevant in elderly, high-comorbidity patients. Methods The study involved two high-comorbidity in-hospital cohorts, treated in Centers with similar characteristics, in Italy (Cagliari) and France (Le Mans). All patients (204) agreed to participate. Stable cases on thrice-weekly dialysis, with at least 2 months follow-up were selected (180 patients, Males 59.4%, median age 71 years, vintage 4.3 years, Charlson index 9). Univariate and multivariate correlations between baseline data, HD-HDF, dialysis efficiency and nutritional markers were assessed. Results In Le Mans HDF was mainly chosen to increase efficiency (large surface dialysers, high convective volume; 76.3% of the patients), in Cagliari to improve tolerance (smaller surfaces, lower convective volume; 59% of patients). Kt/V was similar in HD and HDF, and in both settings(median Kt/V Daugirdas 2: 1.6); in the setting of high efficiency no correlation was found between Kt/V, BMI, urea, creatinine, n-PCR and phosphate. The relationship between Kt/V and albumin was divergent: a weak consensual increase was present in Cagliari, a decrease in Le Mans, suggesting a role of albumin losses with high convective volumes. In the multivariate analysis, after adjustment for other covariates (including comorbidity and type of treatment) low albumin level < 3.5 g/dl was highly correlated with setting of study: Le Mans (OR: 7.155 (2.955–17.324)). The multivariate analysis confirmed a role of type of treatment, with higher risk of low albumin levels in HDF (OR: 3.592 (1.466–8.801)), and of comorbidity (Charlson index> = 7 (OR: 3.153 (1.311–7.582)), MIS index> = 7 (OR: 5.916 (2.457–14.241)). Conclusions The different prescriptions of HD and HDF may have similar effects on dialysis efficiency, but diverging effects on crucial nutritional markers, such as albumin levels, probably more evident in high-comorbidity populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy. .,Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.
| | | | - Maria Rita Moio
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France
| | | | | | - Ida Molfino
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.,University of Naples, Naples, Italy
| | - Ana Kaniassi
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | - Francoise Lippi
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | - Ludivine Froger
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | | | - Marilisa Biolcati
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
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25
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Cheng Y, Gong J, Ding X, Liu Z, Gong J, Zeng Z. Continuous veno‐venous hemofiltration for severe acute pancreatitis. Cochrane Database Syst Rev 2018; 2018:CD012959. [PMCID: PMC6491106 DOI: 10.1002/14651858.cd012959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of CVVH in people suffering from severe acute pancreatitis, compare the effects of different CVVH techniques, and evaluate the optimal time for delivery of CVVH.
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Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
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26
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Klouche K, Amigues L, Morena M, Brunot V, Dupuy AM, Jaussent A, Picot MC, Besnard N, Daubin D, Cristol JP. On-line hemodiafiltration did not induce an overproduction of oxidative stress and inflammatory cytokines in intensive care unit-acute kidney injury. BMC Nephrol 2017; 18:371. [PMID: 29273022 PMCID: PMC5741969 DOI: 10.1186/s12882-017-0785-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 12/08/2017] [Indexed: 12/18/2022] Open
Abstract
Background Though on-line intermittent hemodiafiltration (OL-IHDF) is a routine therapy for chronic dialysis patients, it is not yet widespread used in critically ill patients. This study was undergone to evaluate efficiency and tolerance of OL-IHDF and to appreciate inflammatory consequences of its use in intensive care unit (ICU)-acute kidney injury (AKI) patients. Methods In this prospective cohort study conducted in a medical academic ICU in France, 30 AKI patients who underwent OL-IHDF were included. OL-HDF used an ultrapure water production: AQ 1250 line with double reverse osmosis, a generator 5008 with a 1.8m2 dialyzer with Polysulfone membrane (Fresenius Medical Care). Tolerance and efficiency of OL-IHDF were evaluated as well as its inflammatory risk by the measurement of plasma concentrations of proinflammatory (Interleukin 6, IL1β, IL8, Interferon γ) and anti-inflammatory (IL4, IL10) cytokines, Epidermal growth factor (EGF), Vascular Endothelial growth factor (VEGF) and Macrophage Chemoattractive Protein-1 (MCP-1) before and after sessions. Results Intradialytic hypotensive events were observed during 27/203 OL-IHDF sessions accounting for a mal-tolerated session’s rate at 13.3%. Mean delivered urea Kt/V per session was 1.12 ± 0.27 with a percentage of reduction for urea, creatinine, β2-microglobulin and cystatine C at 61.6 ± 8.8%, 55.3 ± 6.7%, 51.5 ± 8.7% and 44.5 ± 9.8% respectively. Production of superoxide anion by leukocytes, mean levels of pro- and anti-inflammatory cytokines and plasmatic concentrations of EGF, VEGF and MCP-1 did not differ before and after OL-IHDF sessions. We observed however a significant decrease of mean TNFα plasmatic concentrations from 8.2 ± 5.8 to 4.8 ± 3.5 pg/ml at the end of OL-IHDF. Conclusions OL-IHDF was not associated with an increase in pro and anti-inflammatory cytokines, oxidative stress or EGF, VEGF and MCP-1 in AKI patients and seems therefore a secure and feasible modality in ICUs.
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Affiliation(s)
- Kada Klouche
- Intensive Care Medicine Department, University of Montpellier Lapeyronie Hospital, 371, Av Doyen Gaston Giraud, 34295, Montpellier, France. .,Lapeyronie University Hospital. PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France.
| | - Laurent Amigues
- Intensive Care Medicine Department, University of Montpellier Lapeyronie Hospital, 371, Av Doyen Gaston Giraud, 34295, Montpellier, France
| | - Marion Morena
- Departments of Biochemistry, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France.,Lapeyronie University Hospital. PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France
| | - Vincent Brunot
- Intensive Care Medicine Department, University of Montpellier Lapeyronie Hospital, 371, Av Doyen Gaston Giraud, 34295, Montpellier, France
| | - Anne Marie Dupuy
- Departments of Biochemistry, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France
| | - Audrey Jaussent
- Departments of Medical statistics, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France
| | - Marie Christine Picot
- Departments of Medical statistics, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France
| | - Noémie Besnard
- Intensive Care Medicine Department, University of Montpellier Lapeyronie Hospital, 371, Av Doyen Gaston Giraud, 34295, Montpellier, France
| | - Delphine Daubin
- Intensive Care Medicine Department, University of Montpellier Lapeyronie Hospital, 371, Av Doyen Gaston Giraud, 34295, Montpellier, France
| | - Jean Paul Cristol
- Departments of Biochemistry, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France.,Lapeyronie University Hospital. PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier cedex 5, France
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27
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Roumelioti ME, Trietley G, Nolin TD, Ng YH, Xu Z, Alaini A, Figueroa R, Unruh ML, Argyropoulos CP. Beta-2 microglobulin clearance in high-flux dialysis and convective dialysis modalities: a meta-analysis of published studies. Nephrol Dial Transplant 2017; 33:1025-1039. [DOI: 10.1093/ndt/gfx311] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 10/04/2017] [Indexed: 01/01/2023] Open
Affiliation(s)
- Maria-Eleni Roumelioti
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Gregory Trietley
- Department of Pharmacy and Therapeutics, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Yue-Harn Ng
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Zhi Xu
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Ahmed Alaini
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Rocio Figueroa
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Mark L Unruh
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
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28
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Argyropoulos CP, Chen SS, Ng YH, Roumelioti ME, Shaffi K, Singh PP, Tzamaloukas AH. Rediscovering Beta-2 Microglobulin As a Biomarker across the Spectrum of Kidney Diseases. Front Med (Lausanne) 2017; 4:73. [PMID: 28664159 PMCID: PMC5471312 DOI: 10.3389/fmed.2017.00073] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/26/2017] [Indexed: 12/28/2022] Open
Abstract
There is currently an unmet need for better biomarkers across the spectrum of renal diseases. In this paper, we revisit the role of beta-2 microglobulin (β2M) as a biomarker in patients with chronic kidney disease and end-stage renal disease. Prior to reviewing the numerous clinical studies in the area, we describe the basic biology of β2M, focusing in particular on its role in maintaining the serum albumin levels and reclaiming the albumin in tubular fluid through the actions of the neonatal Fc receptor. Disorders of abnormal β2M function arise as a result of altered binding of β2M to its protein cofactors and the clinical manifestations are exemplified by rare human genetic conditions and mice knockouts. We highlight the utility of β2M as a predictor of renal function and clinical outcomes in recent large database studies against predictions made by recently developed whole body population kinetic models. Furthermore, we discuss recent animal data suggesting that contrary to textbook dogma urinary β2M may be a marker for glomerular rather than tubular pathology. We review the existing literature about β2M as a biomarker in patients receiving renal replacement therapy, with particular emphasis on large outcome trials. We note emerging proteomic data suggesting that β2M is a promising marker of chronic allograft nephropathy. Finally, we present data about the role of β2M as a biomarker in a number of non-renal diseases. The goal of this comprehensive review is to direct attention to the multifaceted role of β2M as a biomarker, and its exciting biology in order to propose the next steps required to bring this recently rediscovered biomarker into the twenty-first century.
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Affiliation(s)
- Christos P Argyropoulos
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Shan Shan Chen
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Yue-Harn Ng
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Maria-Eleni Roumelioti
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Kamran Shaffi
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Pooja P Singh
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States.,Raymond G. Murphy VA Medical Center Albuquerque, Albuquerque, NM, United States
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Ermer T, Kopp C, Asplin JR, Granja I, Perazella MA, Reichel M, Nolin TD, Eckardt KU, Aronson PS, Finkelstein FO, Knauf F. Impact of Regular or Extended Hemodialysis and Hemodialfiltration on Plasma Oxalate Concentrations in Patients With End-Stage Renal Disease. Kidney Int Rep 2017; 2:1050-1058. [PMID: 29270514 PMCID: PMC5733827 DOI: 10.1016/j.ekir.2017.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/20/2017] [Accepted: 06/01/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Calcium oxalate supersaturation is regularly exceeded in the plasma of patients with end-stage renal disease (ESRD). Previous reports have indicated that hemodialfiltration (HDF) lowers elevated plasma oxalate (POx) concentrations more effectively compared with hemodialysis (HD). We reevaluate the therapeutic strategy for optimized POx reduction with advanced dialysis equipment and provide data on the effect of extended treatment time on dialytic oxalate kinetics. Methods Fourteen patients with ESRD who underwent HDF 3 times a week for 4 to 4.5 hours (regular HDF; n = 8) or 7 to 7.5 hours (extended HDF; n = 6) were changed to HD for 2 weeks and then back to HDF for another 2 weeks. POx was measured at baseline, pre-, mid-, and postdialysis, and 2 hours after completion of the treatment session. Results Baseline POx for all patients averaged 28.0 ± 7.0 μmol/l. Intradialytic POx reduction was approximately 90% and was not significantly different between groups or treatment modes [F(1) = 0.63; P = 0.44]. Mean postdialysis POx concentrations were 3.3 ± 1.8 μmol/l. A rebound of 2.1 ± 1.9 μmol/l was observed within 2 hours after dialysis. After receiving 2 weeks of the respective treatment, predialysis POx concentrations on HD did not differ significantly from those on HDF [F(1) = 0.21; P = 0.66]. Extended treatment time did not provide any added benefit [F(1) = 0.76; P = 0.40]. Discussion In contrast to earlier observations, our data did not support a benefit of HDF over HD for POx reduction. With new technologies evolving, our results emphasized the need to carefully reevaluate and update traditional therapeutic regimens for optimized uremic toxin removal, including those used for oxalate.
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Affiliation(s)
- Theresa Ermer
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christoph Kopp
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - John R Asplin
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, Illinois, USA
| | - Ignacio Granja
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, Illinois, USA
| | - Mark A Perazella
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Martin Reichel
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Peter S Aronson
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Fredric O Finkelstein
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Felix Knauf
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
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30
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Cernaro V, Lucisano S, Canale V, Bruzzese A, Caccamo D, Costantino G, Buemi M, Santoro D. Acetate-free biofiltration to remove fibroblast growth factor 23 in hemodialysis patients: a pilot study. J Nephrol 2017; 31:429-433. [PMID: 28401422 DOI: 10.1007/s40620-017-0393-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
Abstract
AIM Serum levels of 32 kDa-phosphaturic hormone fibroblast growth factor 23 (FGF23) rise early in renal failure in order to keep phosphatemia within the normal range; however, this compensatory mechanism itself contributes to chronic kidney disease-mineral bone disorder. High FGF23 is also associated to left ventricular hypertrophy, vascular calcifications and thus increased cardiovascular risk. The aim of this pilot pre-post study was to evaluate the effects of a single hemodiafiltration session with acetate-free biofiltration (AFB) on FGF23 serum levels. METHODS Nine hemodialysis patients were enrolled; sessions were performed using the Integra® monitor (Hospal, Bologna, Italy) and a polyacrylonitrile membrane. Peripheral venous blood samples were taken before (pre-HD), at mid- and after treatment (post-HD); dialysate samples were collected by the Quantiscan™ monitoring system. FGF23 was measured by a human FGF-23 ELISA kit. Mid- and post-HD values were corrected for hemoconcentration. RESULTS Pre-HD FGF23 levels positively correlated with dialysis vintage (r = 0.7192; p = 0.0443). They were significantly reduced by the hemodialysis session (from 2.38 ± 1.80 to 1.15 ± 1.21 ng/ml, p = 0.0171) with a reduction ratio of 52.55 ± 28.76%. FGF23 was detected in the dialysate samples. CONCLUSION FGF23 underwent a significant reduction during AFB. Such removal was greater than that induced by conventional hemodialysis as reported in the literature (19%-decrease using modified cellulosic membranes). This difference may be attributed to the ability of AFB hemodiafiltration to efficiently remove middle molecules by convection. Whether a better clearance of FGF23 during hemodialysis may result in improved cardiovascular outcomes in the long term needs to be confirmed by randomized controlled trials.
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Affiliation(s)
- Valeria Cernaro
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Silvia Lucisano
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Valeria Canale
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Annamaria Bruzzese
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Daniela Caccamo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Giuseppe Costantino
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy.
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31
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Piccoli GB, Moio MR, Fois A, Sofronie A, Gendrot L, Cabiddu G, D'Alessandro C, Cupisti A. The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach. Nutrients 2017; 9:E372. [PMID: 28394304 PMCID: PMC5409711 DOI: 10.3390/nu9040372] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/25/2022] Open
Abstract
The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Maria Rita Moio
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Antioco Fois
- Nefrologia, Ospedale Brotzu, 09100 Cagliari, Italy.
| | - Andreea Sofronie
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
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32
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Rama I, Llaudó I, Fontova P, Cerezo G, Soto C, Javierre C, Hueso M, Montero N, Martínez-Castelao A, Torras J, Grinyó JM, Cruzado JM, Lloberas N. Online Haemodiafiltration Improves Inflammatory State in Dialysis Patients: A Longitudinal Study. PLoS One 2016; 11:e0164969. [PMID: 27783636 PMCID: PMC5082664 DOI: 10.1371/journal.pone.0164969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 10/04/2016] [Indexed: 12/23/2022] Open
Abstract
Background Patients undergoing conventional hemodialysis (C-HD) present a greater immuno-inflammatory state probably related to uremia, sympathetic nervous system (SNS) activation and /or membrane bioincompatibility, which could improve with a technique-switching to online hemodiafiltration (OL-HD). The antigen-independent pathway activation of this modified immunologic state turns dendritic cells (DC) into an accurate cell model to study these patients. The aim of this study is to further evaluate the immune-inflammatory state of patients in C-HD assessed by DC maturation. Methods 31 patients were submitted to C-HD and after 4 months switched to the OL-HD technique. Monocytes-derived DCs from HD patients were cultured in the presence of IL-4/GM-CSF. DC-maturation was evaluated by assessing the maturation phenotype by flow cytometry (FACs). DCs-functional capacity to elicit T-cell alloresponse was studied by mixed leucocyte reaction. Cytokine release was assessed by FACs and SNS was evaluated measuring renalase levels by ELISA. Results An up-regulation of maturation markers was observed in C-HD DCs which induced two fold more T cells proliferation than OL-HD DCs. Also, C-HD-mDCs presented with over-production of pro-inflammatory cytokines (IL-6, IL-1β, IL-8, IL-10 and TNF-α) compared with OL-HD-mDC (P<0·05). Results were correlated with clinical data. When SNS was evaluated, hypotension events and blood pressure were significantly lower and renalase levels were significantly higher after conversion to OL-HD. Diabetes mellitus type 2 patients also found beneficial reduction of mDC when converted to OL-HD compared to non-diabetics. Conclusions OL-HD could interfere with immuno-inflammatory state in HD patients with an improvement of renalase levels as potential key mediators in the mechanistic pathway of down-regulation of DC maturation.
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Affiliation(s)
- Ines Rama
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Ines Llaudó
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Pere Fontova
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Gema Cerezo
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Carlos Soto
- Consorci Sanitari del Garraf. Sant Antoni Abad Hospital, Vilanova i la Geltrú, Barcelona, Spain
| | - Casimiro Javierre
- Department of Physiological Sciences II, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Miguel Hueso
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Nuria Montero
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | | | - Juan Torras
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Josep M. Grinyó
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Josep M. Cruzado
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
| | - Nuria Lloberas
- Nephrology Department, Bellvitge University Hospital, IDIBELL. Barcelona, Spain
- * E-mail:
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33
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Palleschi S, Ghezzi PM, Palladino G, Rossi B, Ganadu M, Casu D, Cossu M, Mattana G, Pinna AM, Contu B, Ghisu T, Monni A, Gazzanelli L, Mereu MC, Logias F, Passaghe M, Amore A, Bolasco P. Vitamins (A, C and E) and oxidative status of hemodialysis patients treated with HFR and HFR-Supra. BMC Nephrol 2016; 17:120. [PMID: 27566671 PMCID: PMC5002141 DOI: 10.1186/s12882-016-0315-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 07/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodiafiltration with on-line endogenous reinfusion (HFR) is an extracorporeal dialytic method that combines diffusion, convection and adsorption. HFR-Supra (HFR-S) is a second-generation system with increased convective permeability and adsorption capability. Previous studies suggested that HFR reduces oxidative stress compared to standard haemodialysis. The principal aim of the present study was to compare antioxidant vitamins behavior and oxidative status of hemodialysis patients treated with HFR and HFR-S. METHODS The study was designed as a multicenter, randomized, crossover trial. Forty-one patients were recruited from 19 dialysis centers and after a 4-month washout stabilization period in on-line hemodiafiltration (ol-HDF), each patient was randomized to a sequence of treatments (HFR-S followed by HFR or viceversa) with each treatment applied over 6 months. Plasma levels of Advanced Oxidation Protein Products, Total Antioxidant Status, vitamins C, A and E and their ligands (Retinol Binding Protein and total lipids) were measured at baseline and at the end of each treatment period. RESULTS Results show that the higher convective permeability of HFR-S with respect to HFR did not produce additional beneficial effects on the patients' oxidative status, a slight decrease of both Vitamin A and Retinol Binding Protein being the only difference registered in the long-term. However, as compared to ol-HDF, both the re-infusive techniques allowed to reduce the intradialytic loss of Vitamin C and, in the long-term, improve the patients' oxidative status and increase Retinol Binding Protein plasma values. No significant differences were found between the Vitamin C concentration of pre- and post cartridge UF neither in HFR-S nor in HFR showing that the sorbent resin does not adsorb Vitamin C. CONCLUSION HFR-S and HFR are almost equivalent in term of impact on antioxidant vitamins and oxidative status of hemodialysis patients. Nonetheless, as compared to ol-HDF, both treatments produced a sensible sparing of Vitamin C and may represent a new approach for reducing oxidative stress and related complications in dialysis patients. Long-term effects of re-infusive treatments on patients' cardiovascular morbidity and mortality need to be evaluated. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01492491 , retrospectively registered in 10 December 2011.
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Affiliation(s)
- Simonetta Palleschi
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Paolo M. Ghezzi
- Medical Scientific Consultant of Bellco s.r.l. Company, Mirandola, Italy
| | | | - Barbara Rossi
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Piergiorgio Bolasco
- Territorial Unit of Nephrology and Dialysis , ASL 8 of Cagliari, Cagliari, Italy
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Regenerative pharmacology for the treatment of acute kidney injury: Skeletal muscle stem/progenitor cells for renal regeneration? Pharmacol Res 2016; 113:802-807. [PMID: 27001227 DOI: 10.1016/j.phrs.2016.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 02/25/2016] [Accepted: 03/13/2016] [Indexed: 01/01/2023]
Abstract
Regenerative pharmacology and advanced therapy medicinal products is a relatively new and challenging field in drug development. Acute kidney injury (AKI) is a common clinical condition in nephrology with increasing incidence and high mortality rate. During the last few decades, researchers have been eagerly trying to find novel therapeutic strategies for AKI treatment, including advanced pharmacological therapies using mesenchymal stem cells (MSCs). Several types of MSCs have been thoroughly investigated, including bone marrow, adipose derived and umbilical cord blood MSCs and shown promising results in kidney repair. Research has demonstrated, that MSCs exert their effect through reduction of apoptosis, increased production of growth factors, suppression of oxidative stress and inflammatory processes, promotion of renal tubular cell proliferation, as well as by migration and direct incorporation into the renal tissue. Skeletal muscle-derived stem/progenitor cells (MDSPCs) are mesenchymal stem cell lineage of multipotent cells, demonstrating long-term proliferation, high self-renewal capacities, and ability to enhance endogenous tissue repair. The capacity of MDSPCs to regenerate a variety of different tissues following acute injury or destructive tissue diseases have been demonstrated in preclinical and clinical studies. MDSPCs were also reported to promote endogenous tissue repair via paracrine pathway. Considering advantageous properties of MDSPCs, the administration of these cells might be considered as a potential strategy for the treatment of AKI. However, to date, the therapeutic effect of MDSPCs for renal regeneration has not been investigated. This review reflects the current development in AKI treatment using different types of MSCs and the pilot results of the experimental study in vivo using a novel type of stem cells - MDSPCs for the treatment of gentamicin-induced AKI.
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35
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Rousseau-Gagnon M, Agharazii M, De Serres SA, Desmeules S. Effectiveness of Haemodiafiltration with Heat Sterilized High-Flux Polyphenylene HF Dialyzer in Reducing Free Light Chains in Patients with Myeloma Cast Nephropathy. PLoS One 2015; 10:e0140463. [PMID: 26466100 PMCID: PMC4605760 DOI: 10.1371/journal.pone.0140463] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/25/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In cases of myeloma cast nephropathy in need of haemodialysis (HD), reduction of free light chains using HD with High-Cut-Off filters (HCO-HD), in combination with chemotherapy, may be associated with better renal recovery. The aim of the present study is to evaluate the effectiveness of haemodiafiltration (HDF) in reducing free light chain levels using a less expensive heat sterilized high-flux polyphenylene HF dialyzer (HF-HDF). METHODS In a single-centre prospective cohort study, 327 dialysis sessions were performed using a 2.2 m2 heat sterilized high-flux polyphenylene HF dialyzer (Phylther HF22SD), a small (1.1m2) or large (2.1 m2) high-cut-off (HCO) dialyzer (HCOS and HCOL) in a cohort of 16 patients presenting with dialysis-dependent acute cast nephropathy and elevated free light chains (10 kappa, 6 lambda). The outcomes of the study were the mean reduction ratio (RR) of kappa and lambda, the proportion of treatments with an RR of at least 0.65, albumin loss and the description of patient outcomes. Statistical analysis was performed using linear and logistic regression through generalized estimating equation analysis so as to take into account repeated observation within subjects and adjust for session duration. RESULTS There were no significant differences in the estimated marginal mean of kappa RR, which were respectively 0.67, 0.69 and 0.70 with HCOL-HD, HCOS-HDF and HF-HDF (P = 0.950). The estimated marginal mean of the proportions of treatments with a kappa RR ≥0.65 were 68%, 63% and 71% with HCOL-HD, HCOS-HDF and HF-HDF, respectively (P = 0.913). The estimated marginal mean of lambda RR were higher with HCOL-HDF (0.78), compared to HCOL-HD and HF-HDF (0.62, and 0.61 respectively). The estimated marginal mean proportion of treatments with a lambda RR ≥0.65 were higher with HCOL-HDF (81%), compared to 57% in HF-HDF (P = 0.042). The median albumin loss were 7, 21 and 63 g/session with HF-HDF, HCOL-HD and HCOL-HDF respectively (P = 0.044). Among survivors, 9 out of 10 episodes of acute kidney injuries became dialysis-independent following a median time of renal replacement therapy of 40 days (range 7-181). CONCLUSION Therefore, in patients with acute dialysis-dependent myeloma cast nephropathy, in addition to chemotherapy, HDF with a heat sterilized high-flux polyphenylene HF dialyzer could offer an alternative to HCO dialysis for extracorporeal kappa reduction with lower albumin loss.
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Affiliation(s)
- Mathieu Rousseau-Gagnon
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | - Mohsen Agharazii
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
- * E-mail: (SD); (MA)
| | - Sacha A. De Serres
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | - Simon Desmeules
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
- * E-mail: (SD); (MA)
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