1
|
Aterini L, Aterini S, Vadalà B, Ravaglia F, Balboni F, Gallo M. Expanded Hemodialysis Enhancement in Middle Molecule Clearance for Patients With Low Blood Flow Rates of Tunneled Dialysis Catheters. Cureus 2024; 16:e64323. [PMID: 39130834 PMCID: PMC11316456 DOI: 10.7759/cureus.64323] [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] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
INTRODUCTION Expanded hemodialysis (HDx), being based on medium cut-off (MCO) membranes, improves the removal of medium molecule uremic toxins. HDx efficacy has been proven with blood flow rates (Qb) of 350-400 ml/min, while low Qb have only been assessed in single sessions. We evaluated the effectiveness of HDx in patients with tunneled central venous catheters (CVCs) and low Qb over six months, comparing it with high-flux hemodialysis (HF-HD). METHODS The study included 10 patients with a mean age of 79±12 years and mean Qb of 237 ± 12 ml/min. Reduction ratios (RRs) and predialysis serum levels were measured for β2-microglobulin (B2M), free κ and λ light chains (FLC), prolactin (PRL), interleukin-6 (IL-6), albumin, and urea after HF-HD and at one, three, and six months of HDx. Erythropoiesis-stimulating agent (ESA) resistance index (ERI) was also evaluated. RESULTS B2M, κ-FLC, λ-FLC, and PRL RRs were significantly higher with HDx. IL-6, albumin, and urea RRs did not show a statistical difference between the two treatments. Predialysis B2M concentrations were significantly lower after three and six months of HDx, matching up to increased B2M clearance (spKt/V). A decrease in albumin concentrations was observed, with median levels significantly reduced at months seven and eight (35.3 and 35.5 g/L, respectively) but recovering afterwards. ERI was significantly lower during HDx, reaching a 30% reduction at month six. CONCLUSIONS HDx was feasible, safe, and superior to HF-HD in patients with low Qb rates of tunneled dialysis catheters. The present data expand options for HDx prescription, with particular regard for patients who cannot achieve high convective volumes due to inadequate vascular access.
Collapse
Affiliation(s)
- Lorenzo Aterini
- Nephrology, School of Human Health Sciences, Azienda Ospedaliera Universitaria (AOU) Meyer Children Hospital, University of Florence, Florence, ITA
| | - Stefano Aterini
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, ITA
| | - Barbara Vadalà
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, ITA
| | - Francesco Ravaglia
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, ITA
| | - Fiamma Balboni
- Laboratory Service, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, ITA
| | - Marco Gallo
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, ITA
| |
Collapse
|
2
|
Sardarabadi H, Darvishi MH, Zohrab F, Javadi H. Nanophytomedicine: A promising practical approach in phytotherapy. Phytother Res 2024; 38:3607-3644. [PMID: 38725270 DOI: 10.1002/ptr.8230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 07/12/2024]
Abstract
The long and rich history of herbal therapeutic nutrients is fascinating. It is incredible to think about how ancient civilizations used plants and herbs to treat various ailments and diseases. One group of bioactive phytochemicals that has gained significant attention recently is dietary polyphenols. These compounds are commonly found in a variety of fruits, vegetables, spices, nuts, drinks, legumes, and grains. Despite their incredible therapeutic properties, one challenge with polyphenols is their poor water solubility, stability, and bioavailability. This means that they are not easily absorbed by the body when consumed in essential diets. Because of structural complexity, polyphenols with high molecular weight cannot be absorbed in the small intestine and after arriving in the colon, they are metabolized by gut microbiota. However, researchers are constantly working on finding solutions to enhance the bioavailability and absorption of these compounds. This study aims to address this issue by applying nanotechnology approaches to overcome the challenges of the therapeutic application of dietary polyphenols. This combination of nanotechnology and phytochemicals could cause a completely new field called nanophytomedicine or herbal nanomedicine.
Collapse
Affiliation(s)
- Hadi Sardarabadi
- Department of Physiology and Pharmacology, School of Medicine, Qom University of Medical Sciences, Qom, Iran
| | - Mohammad Hasan Darvishi
- Nanobiotechnology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Fatemeh Zohrab
- Department of Medical Science, Qom Branch, Islamic Azad University, Qom, Iran
| | - Hamidreza Javadi
- Nanobiotechnology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| |
Collapse
|
3
|
Sahutoglu T, Erinc O, Avsar FN. Theranova versus FX80: The impact on anemia management in hemodialysis. Int J Artif Organs 2024; 47:260-268. [PMID: 38456311 DOI: 10.1177/03913988241236736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Middle uremic toxins (MUTs) can cause anemia and erythropoietin hyporesponsiveness. Theranova dialyzers may improve anemia management by removing MUTs. Hence, the impact of Theranova dialyzers on erythropoietin responsiveness was studied. METHODS This exploratory single-center prospective observational study, encompassing 50 patients undergoing dialysis with either the Theranova-400 or FX80 membrane for 6 months, involved monthly tracking of hemoglobin levels, weight-adjusted erythropoiesis-stimulating agent (w-ESA) dosing, and erythropoietin resistance index (ERI), with ESA treatment decisions guided by a proprietary algorithm. RESULTS The groups were similar in terms of demographics and baseline laboratory test results. The median hemoglobin levels, w-ESA and ERI, were found to be similar between FX80 and Theranova-400 groups at both baseline (11.06 vs 10.57, p = 0.808; 92.3 vs 105.2, p = 0.838; 8.1 vs 10.48, p = 0.876) and the end of the study (11.43 vs 11.03, p = 0.076; 48.7 vs 71.5; 4.48 vs 6.41, p = 0.310), respectively. There was a trend toward lower w-ESA and ERI at the end of the study compared to baseline in both groups, but the difference was non-significant. CONCLUSIONS Based on this study of 50 patients undergoing high-flux dialysis with near-target hemoglobin levels, switching to Theranova 400 dialyzers compared to FX80 dialyzers did not show statistically significant differences in maintaining hemoglobin levels, reducing ESA dose, or lowering ERI. The non-randomized design and small sample size limit the study's power to detect true differences. Larger, randomized trials are needed to confirm findings and definitively assess Theranova 400's benefits.
Collapse
Affiliation(s)
- Tuncay Sahutoglu
- Department of Nephrology, Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
| | - Osman Erinc
- Department of Internal Medicine, Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
| | - Fevzi Necati Avsar
- Department of Internal Medicine, Mehmet Akif Inan Education and Research Hospital, Sanliurfa, Turkey
| |
Collapse
|
4
|
Meijers B, Vega A, Juillard L, Kawanishi H, Kirsch AH, Maduell F, Massy ZA, Mitra S, Vanholder R, Ronco C, Cozzolino M. Extracorporeal Techniques in Kidney Failure. Blood Purif 2023; 53:343-357. [PMID: 38109873 DOI: 10.1159/000533258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 12/20/2023]
Abstract
During the last decades, various strategies have been optimized to enhance clearance of a variable spectrum of retained molecules to ensure hemodynamic tolerance to fluid removal and improve long-term survival in patients affected by kidney failure. Treatment effects are the result of the interaction of individual patient characteristics with device characteristics and treatment prescription. Historically, the nephrology community aimed to provide adequate treatment, along with the best possible quality of life and outcomes. In this article, we analyzed blood purification techniques that have been developed with their different characteristics.
Collapse
Affiliation(s)
- Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology, UZ Leuven, Leuven, Belgium
| | - Almudena Vega
- Nephrology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Laurent Juillard
- Medical School, Claude Bernard University (Lyon 1), Villeurbanne, France
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Hideki Kawanishi
- Department of Kidney Diseases and Blood Purification Therapy, Tsuchiya General Hospital, Hiroshima, Japan
| | | | - Francisco Maduell
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Ziad A Massy
- Service de Néphrologie, CHU Ambroise Paré, Assistance Publique - Hôpitaux de Paris et Université Paris-Saclay (Versailles-Saint-Quentin-en-Yvelines), Boulogne Billancourt, France
- Inserm U-1018 Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Villejuif, France
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre, Manchester University Hospitals, Manchester, UK
| | - Raymond Vanholder
- Department of Internal Medicine and Pediatrics, Nephrology Section, University Hospital, Ghent, Belgium
- European Kidney Health Alliance, Brussels, Belgium
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| |
Collapse
|
5
|
Lee HY, Suh SW, Hwang JH, Shin J. Responsiveness to an erythropoiesis-stimulating agent is correlated with body composition in patients undergoing chronic hemodialysis. Front Nutr 2022; 9:1044895. [PMID: 36532527 PMCID: PMC9755720 DOI: 10.3389/fnut.2022.1044895] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/18/2022] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Resistance to erythropoiesis-stimulating agents (ESA) is associated with adverse outcomes in patients undergoing chronic hemodialysis. However, the impact of body composition on ESA response remains uncertain. This study retrospectively investigated whether there is an association between the ESA resistance index (ERI) and body composition in patients undergoing chronic hemodialysis. METHODS Multifrequency bioelectrical impedance analysis was used to measure body composition every six months. The ERI was calculated by dividing the weekly body weight-adjusted erythropoietin dose by the hemoglobin concentration. The ERI values were recorded every three months. RESULTS A total of 123 patients were followed up for 24 (interquartile range 5, 75) months. The ERI was negatively correlated with body mass index, arm circumference, arm muscle circumference, body fat percentage, and visceral fat area (P = 0.057, 0.001, 0.017, 0.063, and 0.041, respectively). Patients with a higher mean ERI during the study period had an increased risk of all-cause mortality, cardiovascular events, and infection requiring hospitalization than those with a lower mean ERI (P = 0.027, 0.021, and 0.037, respectively). We also evaluated the association between the slope of body composition parameters and the ERI trend over time and found that the ERI increased over time in patients who had an increased ratio of extracellular water to total body water (P = 0.002) as well as decreased arm circumference, arm muscle circumference, visceral fat area, and phase angle (P = 0.001, P < 0.001, P = 0.036, and 0.002). CONCLUSION ESA responsiveness appears to be associated with body composition in patients undergoing chronic hemodialysis. Therefore, measures improving body composition, such as nutrition and exercise, may have a favorable effect on the response to ESA.
Collapse
Affiliation(s)
- Hyang Yun Lee
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Suk-Won Suh
- Department of Surgery, Chung-Ang University Hospital, Seoul, South Korea
| | - Jin Ho Hwang
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Jungho Shin
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea
| |
Collapse
|
6
|
Zhao Y, Gan L, Niu Q, Ni M, Zuo L. Efficacy and safety of expanded hemodialysis in hemodialysis patients: a meta-analysis and systematic review. Ren Fail 2022; 44:541-550. [PMID: 35343378 PMCID: PMC8967190 DOI: 10.1080/0886022x.2022.2048855] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Expanded hemodialysis (HDx) is a new dialysis modality, but a systematic review of the clinical effects of using HDx is lacking. This systematic review and meta-analysis aimed to assess the efficacy and safety of HDx for hemodialysis (HD) patients. Methods PubMed, the Cochrane library, and EMBASE databases were systematically searched for prospective interventional studies comparing the efficacy and safety of HDx with those of high flux HD or HDF in HD patients. Results Eighteen trials including a total of 853 HD patients were enrolled. HDx increased the reduction ratio (RR) of β2-microglobulin (SMD 6.28%, 95% CI 0.83, 1.73, p = .02), κFLC (SMD 15.86%, 95% CI 6.96, 24.76, p = .0005), and λFLC (SMD 22.42%, 95% CI, 17.95, 26.88, p < .0001) compared with high flux HD. The RR of β2-microglobulin in the HDx group was lower than that in the HDF group (SMD −3.53%, 95% CI −1.16, −1.9, p < .0001). HDx increased the RRs of κFLC (SMD 1.34%, 95% CI 0.52, 2.16, p = .001) and λFLC (SMD 7.28%, 95% CI 1.08, 13.48, p = .02) compared to HDF. There was no significant difference in albumin loss into the dialysate between the HDx and HDF groups (SMD 0.35 g/session, 95% CI −2.38, 3.09, p = .8). Conclusions This meta-analysis indicated that compared with high-flux HD and HDF, HDx can increase the clearance of medium and large-molecular-weight uremic toxins. And it does not increase the loss of albumin compared with HDF.
Collapse
Affiliation(s)
- Yuchao Zhao
- Department of Nephrology, Peking University People's Hospital, Beijing, P. R. China
| | - Liangying Gan
- Department of Nephrology, Peking University People's Hospital, Beijing, P. R. China
| | - Qingyu Niu
- Department of Nephrology, Peking University People's Hospital, Beijing, P. R. China
| | - Mengfan Ni
- Department of Nephrology, Peking University People's Hospital, Beijing, P. R. China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, P. R. China
| |
Collapse
|
7
|
Ferraro R, Ascione F, Dogra P, Cristini V, Guido S, Caserta S. Diffusion‐induced anisotropic cancer invasion: a novel experimental method based on tumour spheroids. AIChE J 2022. [DOI: 10.1002/aic.17678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Rosalia Ferraro
- Università degli Studi di Napoli Federico II Dipartimento di Ingegneria Chimica, dei Materiali e della Produzione Industriale Naples Italy
- CEINGE Advanced Biotechnologies Naples Italy
| | - Flora Ascione
- Università degli Studi di Napoli Federico II Dipartimento di Ingegneria Chimica, dei Materiali e della Produzione Industriale Naples Italy
| | - Prashant Dogra
- Mathematics in Medicine Program Houston Methodist Research Institute Houston Texas USA
- Department of Physiology and Biophysics Weill Cornell Medical College New York New York USA
| | - Vittorio Cristini
- Mathematics in Medicine Program Houston Methodist Research Institute Houston Texas USA
- Department of Imaging Physics University of Texas MD Anderson Cancer Center Houston Texas USA
- Physiology, Biophysics, and Systems Biology Program, Graduate School of Medical Sciences Weill Cornell Medicine New York New York USA
| | - Stefano Guido
- Università degli Studi di Napoli Federico II Dipartimento di Ingegneria Chimica, dei Materiali e della Produzione Industriale Naples Italy
- CEINGE Advanced Biotechnologies Naples Italy
| | - Sergio Caserta
- Università degli Studi di Napoli Federico II Dipartimento di Ingegneria Chimica, dei Materiali e della Produzione Industriale Naples Italy
- CEINGE Advanced Biotechnologies Naples Italy
| |
Collapse
|
8
|
Effects of Expanded Hemodialysis with Medium Cut-Off Membranes on Maintenance Hemodialysis Patients: A Review. MEMBRANES 2022; 12:membranes12030253. [PMID: 35323729 PMCID: PMC8953230 DOI: 10.3390/membranes12030253] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 02/04/2023]
Abstract
Kidney failure is associated with high morbidity and mortality. Hemodialysis, the most prevalent modality of renal replacement therapy, uses the principle of semipermeable membranes to remove solutes and water in the plasma of patients with kidney failure. With the evolution of hemodialysis technology over the last half century, the clearance of small water-soluble molecules in such patients is adequate. However, middle molecules uremic toxins are still retained in the plasma and cause cardiovascular events, anemia, and malnutrition, which significantly contribute to poor quality of life and high mortality in maintenance hemodialysis patients. A new class of membrane, defined as a medium cut-off (MCO) membrane, has emerged in recent years. Expanded hemodialysis with MCO membranes is now recognized as the artificial kidney model closest to natural kidney physiology. This review summarizes the unique morphological characteristics and internal filtration–backfiltration mechanism of MCO membranes, and describes their effects on removing uremic toxins, alleviating inflammation and cardiovascular risk, and improving quality of life in maintenance hemodialysis patients.
Collapse
|
9
|
Kandi M, Brignardello-Petersen R, Couban R, Wu C, Nesrallah G. Clinical Outcomes With Medium Cut-Off Versus High-Flux Hemodialysis Membranes: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2022; 9:20543581211067087. [PMID: 35083060 PMCID: PMC8785433 DOI: 10.1177/20543581211067087] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A novel medium cut-off (MCO) dialyzer (Theranova, Baxter Healthcare, Deerfield, IL, USA) enhances large middle molecule clearance while retaining selectivity for molecules >45 000 Da. OBJECTIVE We undertook a systematic review and meta-analysis evaluating clinical outcomes with MCO vs high-flux membranes. METHODS We searched MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science through July 2020, and gray literature sources from 2017. We included randomized (RS) and nonrandomized studies (NRS) comparing MCO and high-flux membranes in adults receiving maintenance hemodialysis. Pairs of reviewers performed study selection, data extraction, and risk of bias assessment in duplicate. We conducted random-effects pairwise meta-analyses to pool results across studies and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess evidence certainty. RESULTS We identified 22 eligible studies (6 RS, 16 NRS; N = 1811 patients; patient-years = 1546). The MCO dialyzer improved (estimate; 95% confidence interval [CI]; certainty rating) quality of life (mean difference [MD] = 16.7/100 points; 6.9 to 26.4; moderate), Kidney Disease Quality of Life Instrument (KDQOL) subscales-burden (MD = 4.0; 1.1 to 6.9; moderate) and effects (MD = 5.4; 3.2 to 7.6; moderate), pruritus (MD = -4.4; -7.1 to -1.7; moderate), recovery time (MD = -420 minutes; -541 to -299; high), and restless legs syndrome (odds ratio = 0.39; 0.29 to 0.53; moderate). There was little to no difference in all-cause mortality (risk difference = -0.4%; -2.8 to 2.1; moderate) and serious adverse events (rate ratio = 0.63; 0.38 to 1.04; low). MCO dialysis reduced hospitalization (rate ratio = 0.48; 0.27 to 0.84; low), infection (rate ratio = 0.38; 0.17 to 0.85; moderate), hospitalization days (MD = -1.5 days; 95% CI, -2.22 to -0.78; moderate), erythropoiesis resistance index (MD = -2.92 U/kg/week/g/L; 95% CI, -4.25 to -1.6; moderate) and cumulative iron use over 12 weeks (MD = -293 mg; 95% CI, -368 to -218; moderate). We found with low certainty that MCO dialysis had little to no effect on KDQOL symptoms/problem list, pain, and physical health and moderate certainty that MCO dialysis likely has no effect on the KDQOL mental health composite. CONCLUSIONS We found with predominantly moderate certainty that the MCO dialyzer improves several patient-important outcomes with no apparent risks or harms. More definitive studies are needed to better quantify the effects of MCO membranes on mortality, hospitalization, and other rare events.
Collapse
Affiliation(s)
- Maryam Kandi
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | | | - Rachel Couban
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | | | - Gihad Nesrallah
- University of Toronto, ON, Canada
- Nephrology Program, Humber River Hospital, Toronto, ON, Canada
| |
Collapse
|
10
|
Kandi M, Brignardello-Petersen R, Couban R, Wu C, Nesrallah G. Effects of Medium Cut-Off Versus High-Flux Hemodialysis Membranes on Biomarkers: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2022; 9:20543581211067090. [PMID: 35070336 PMCID: PMC8777328 DOI: 10.1177/20543581211067090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Medium cut-off (MCO) membranes enhance large middle-molecule clearance while selectively retaining molecules >45 000 Da. OBJECTIVES We undertook a systematic review and meta-analysis comparing the effects of MCO versus high-flux membranes on biomarkers. METHODS We searched MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science from January 2015 to July 2020, and gray literature sources from 2017. We included randomized (RS) and nonrandomized studies (NRS) comparing MCO and high-flux membranes in adults (>18 years) receiving maintenance hemodialysis. We performed study selection, data extraction, and quality appraisals in duplicate and used the Grading of Recommendations Assessment, Development, and Evaluation framework. Outcomes included solute removal (plasma clearance or dialysate quantitation), reduction ratios, and predialysis serum concentrations for a range of prespecified large middle molecules. RESULTS We identified 26 eligible studies (10 RS and 16 NRS; N = 1883 patients; patient-years = 1366.3). The mean difference (MD) for albumin removal was 2.31 g per session (95% confidence interval [CI], 2.79 to 1.83; high certainty), with a reduction in predialysis albumin of -0.12 g/dl (95% CI, -0.16 to -0.07; I 2 = 0%; high certainty) in the first 24 weeks, returning to normal (MD = -0.02 g/dl, 95% CI, -0.07 to -0.03; I 2 = 56%; high certainty) after 24 weeks. We also found with high certainty that MCO dialysis resulted in a large increase (standardized mean difference [SMD]> 2.0 for all) in β2-microglobulin, κ- and λ-free light chains, and myoglobin removal, resulting in moderate (SMD > 0.5) to large (SMD > 0.8) reductions in predialysis concentrations for all of these solutes. Medium cut-off dialysis increased the reduction ratio for tumor necrosis factor-alpha (TNF-α) by 7.7% (95% CI, 4.7 to 10.6; moderate certainty), and reduced predialysis TNF-α by SMD -0.48 (95% CI, -0.91 to -0.04; moderate certainty). We found with moderate certainty that MCO dialysis had little to no effect on predialysis interleukin-6 (IL-6) plasma concentrations. Medium cut-off dialysis reduced mRNA expression of TNF-α and IL-6 in peripheral leukocytes by MD -15% (95% CI, -19.6 to -10.4; moderate certainty) and -8.8% (95% CI, -10.2 to -7.4; moderate certainty), respectively. CONCLUSION Medium cut-off dialysis increases the clearance of a wide range of large middle molecules and likely reduces inflammatory mediators with a concomitant transient reduction in serum albumin concentration. The net effect of MCO dialysis on large middle molecules could translate into important clinical effects.
Collapse
Affiliation(s)
- Maryam Kandi
- Department of Health Research Methods,
Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | | | - Rachel Couban
- Department of Health Research Methods,
Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | | | - Gihad Nesrallah
- University of Toronto, ON, Canada
- Nephrology Program, Humber River
Hospital, Toronto, ON, Canada
| |
Collapse
|
11
|
Penny JD, Jarosz P, Salerno FR, Lemoine S, McIntyre CW. Impact of Expanded Hemodialysis Using Medium Cut-off Dialyzer on Quality of Life: Application of Dynamic Patient-Reported Outcome Measurement Tool. Kidney Med 2021; 3:992-1002.e1. [PMID: 34939008 PMCID: PMC8664707 DOI: 10.1016/j.xkme.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale & Objective Current hemodialysis (HD) treatments have limited ability to clear larger-molecular-weight uremic toxins. Retention is associated with increased symptom burden, low health-related quality of life (HRQoL), and high mortality. Improved clearance, using novel medium cut-off dialyzers, termed expanded HD (HDx), may be associated with improved subjective experience. We have previously developed a dynamic patient-reported outcome measure (PROM) instrument to allow iterative recording to better appreciate the overall burden of disease and assess the impact of therapy changes. Study Design Single-center interventional pilot study. Setting & Participants 28 patients established on maintenance HD, London, Ontario, Canada. Intervention Initial study consisting of 2-week observation (baseline-conventional high-flux HD) followed by 12 weeks of HDx. HRQoL was assessed using the dynamic PROM instrument thrice weekly (enabled in a dedicated app as the London Evaluation of Illness [LEVIL]). Extension phase; 2-week baseline with 24 weeks of HDx and 8-week washout. Outcomes Principal aim was to establish whether HDx therapy was associated with improved HRQoL, evidence of dose-dependant response, and whether effects were durable over time, using LEVIL. Results Patients with lower LEVIL scores (<70/100) at baseline showed improvement in overall HRQoL after 8 weeks of therapy with similar carryover effect. General well-being, energy, and sleep quality were improved significantly as a consequence of HDx therapy. There were no detrimental effects of HDx detected in patients with higher baseline HRQoL. Limitations Small nonrandomized sample size. The coronavirus disease 2019 pandemic interfered with the extension phase. Conclusions Dynamic PROM assessment effectively identified patients with lower HRQoL and higher symptom burden, demonstrating durable time/dose-dependent improvements across a range of symptom domains. The use of this instrument may allow targeted selection of patients most likely to benefit from HDx therapy and assist in monitoring response and defining effect size and treatment duration to allow optimal design of further definitive randomized controlled trials of this newly introduced technology. Funding Baxter Healthcare Canada. Trial Registration ClinicalTrials.gov ID: NCT03640858.
Collapse
Affiliation(s)
- Jarrin D. Penny
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Patricia Jarosz
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
| | - Fabio R. Salerno
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Sandrine Lemoine
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
| | - Christopher W. McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Address for Correspondence: Christopher W. McIntyre, MD, PhD, The Lilibeth Caberto Kidney Clinical Research Unit, Victoria Hospital, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario, Canada N6A 5W9.
| |
Collapse
|
12
|
Yang J, Ke G, Liao Y, Guo Y, Gao X. Efficacy of medium cut-off dialyzers and comparison with high-flux dialyzers in patients on maintenance hemodialysis: A systematic review and meta-analysis. Ther Apher Dial 2021; 26:756-768. [PMID: 34773675 PMCID: PMC9545768 DOI: 10.1111/1744-9987.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/24/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022]
Abstract
Medium cut‐off (MCO) dialyzers were designed to provide better clearance of uremic toxins. We conducted a meta‐analysis comparing MCO with high‐flux (HF) dialyzers for the effect on uremic toxins in maintenance hemodialysis (HD) patients. Five databases were systematically searched for relevant studies and nine studies were identified finally. Reduction ratio (RR) of urea, urea, creatinine, β2‐macroglobulin (β2‐MG), kappa free light chain (κFLC), and lambda FLC (λFLC) levels were not significantly different between MCO and HF dialyzers. But RR of β2‐MG, κFLC, and λFLC were greater for MCO than HF dialyzers. MCO dialyzers could better reduce tumor necrosis factor‐α (TNF‐α) levels. Subgroup analysis stratified by study design indicated that in randomized controlled trial (RCT) studies, albumin levels was lower in MCO than HF dialyzers group, but the two dialyzers treatments were equivalent in non‐RCT subgroup. Compared with HF dialyzers, MCO dialyzers provided higher middle‐molecules uremic toxins clearance and obviously reduced TNF‐α levels.
Collapse
Affiliation(s)
- Jia Yang
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| | - Guibao Ke
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuanjiang Liao
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| | - Yong Guo
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| | - Xiaoling Gao
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| |
Collapse
|
13
|
Lanot A, Kottler D, Béchade C. [Pruritus associated chronic kidney disease]. Nephrol Ther 2021; 17:488-495. [PMID: 34654672 DOI: 10.1016/j.nephro.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Pruritus associated with chronic kidney disease is a frequent and disabling symptom in patients with severe chronic kidney disease treated by dialysis. It is associated with a poor quality of life, an increased risk of comorbidities and even mortality. Nevertheless, its prevalence is underestimated by nephrologists. The pathophysiology of pruritus associated with chronic kidney disease is not well understood, but several mechanisms seem to contribute to its occurrence: accumulation and skin deposition of uremic toxins, peripheral neuropathy causing an activation of the pruritogenic cowhage pathway, chronic microinflammation, opioid imbalance, and kidney disease-related skin xerosis. Optimization of the treatment of chronic kidney disease treatment, of dialysis parameters, and general skin care measures should always be performed prior to the introduction of systemic therapy targeting one or more of these mechanisms. The available therapeutic trials remain mostly at high risk of bias, with small patient numbers. Gabapentinoids are the molecules recommended as first-line therapy. Peripheral opioid agonists could find a place of choice in the treatment of pruritus associated with chronic kidney disease and will soon be available in France. The low level of evidence for the other molecules does not currently allow us to specify a second-line treatment for this condition.
Collapse
Affiliation(s)
- Antoine Lanot
- UNICAEN, néphrologie, Normandie université, CHU de Caen Normandie, 14000 Caen, France; UNICAEN, UFR de médecine, Normandie Université, 2, rue des Rochambelles, 14032 Caen cedex, France; ANTICIPE U1086 Inserm-UCN, centre François-Baclesse, 14000 Caen, France.
| | - Diane Kottler
- UNICAEN, dermatologie, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - Clémence Béchade
- UNICAEN, néphrologie, Normandie université, CHU de Caen Normandie, 14000 Caen, France; UNICAEN, UFR de médecine, Normandie Université, 2, rue des Rochambelles, 14032 Caen cedex, France; ANTICIPE U1086 Inserm-UCN, centre François-Baclesse, 14000 Caen, France
| |
Collapse
|
14
|
Pelayo-Alonso R, Cobo-Sánchez JL, Patricia Martínez-Álvarez P, Portilla-Sánchez M, Ibarguren-Rodríguez E. Hemodiálisis extendida frente a convencional o hemodiafiltración en línea. Estudio comparativo de necesidad de heparina y coagulación del sistema. ENFERMERÍA NEFROLÓGICA 2021. [DOI: 10.37551/s2254-28842021024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción: La reciente aparición de membranas de corte medio ofrece una alternativa para la eliminación de moléculas medianas y nueva terapia dialítica, la hemodiálisis expandida. Estas membranas se caracterizan por un mayor tamaño de poro que podría afectar a la eliminación de la heparina utilizada durante las sesiones de hemodiálisis. Objetivo: Determinar si existen diferencias en la necesidad de heparina y el estado de coagulación del sistema y dializador según técnica dialítica empleada. Material y Método: Estudio cuasiexperimental en pacientes en hemodiálisis con dos periodos de estudio, en el primero, el paciente realizó hemodiálisis convencional o hemodiafiltración y en el segundo, hemodiálisis expandida con membranas de corte medio. Resultados: El dializador quedó parcialmente coagulado en el 10,3% de las sesiones de hemodiálisis expandida frente al 19,1% de las sesiones de hemodiálisis y el 11,4% de hemodiafiltración (p=0,011). Conclusiones: La hemodiálisis expandida ofrece mejor estado de coagulación final del sistema y dializador que otras membranas.
Collapse
Affiliation(s)
- Raquel Pelayo-Alonso
- UC Nefrología-Unidad de Hemodiálisis. Hospital Universitario Marqués de Valdecilla. Santander. España
| | - José Luis Cobo-Sánchez
- Subdirección de Cuidados. Servicio Cántabro de Salud. Santander. España. Escuela Universitaria de Enfermería Clínica Mompía. Universidad Católica de Ávila. Mompía. España
| | | | - Marta Portilla-Sánchez
- UC Nefrología-Unidad de Hemodiálisis. Hospital Universitario Marqués de Valdecilla. Santander. España
| | | |
Collapse
|
15
|
Reis T, Anwar S, Neves FDADR, Ronco C. Disruptive technologies for hemodialysis: medium and high cutoff membranes. Is the future now? ACTA ACUST UNITED AC 2021; 43:410-416. [PMID: 33836041 PMCID: PMC8428648 DOI: 10.1590/21758239-jbn-2020-0273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 01/19/2023]
Abstract
In the past decade, a new class of hemodialysis (HD) membranes (high retention
onset class) became available for clinical use. The high cutoff (HCO) and the
medium cutoff (MCO) membranes have wider pores and more uniformity in pore size,
allowing an increased clearance of uremic toxins. Owing to the mechanism of
backfiltration/internal filtration, middle molecules are dragged by the
convective forces, and no substitution solution is needed. The HCO dialyzer is
applied in septic patients with acute kidney injury requiring continuous kidney
replacement therapy. The immune response is modulated thanks to the removal of
inflammatory mediators. Another current application for the HCO dialyzer is in
hematology, for patients on HD secondary to myeloma-kidney, since free light
chains are more efficiently removed with the HCO membrane, reducing their
deleterious effect on the renal tubules. In its turn, the MCO dialyzer is used
for maintenance HD patients. A myriad of clinical trials published in the last
three years consistently demonstrates the ability of this membrane to remove
uremic toxins more efficiently than the high-flux membrane, an evolutionary
disruption in the HD standard of care. Safety concerns regarding albumin loss as
well as blood contamination from pyrogens in the dialysate have been overcome.
In this update article, we explore the rise of new dialysis membranes in the
light of the scientific evidence that supports their use in clinical
practice.
Collapse
Affiliation(s)
- Thiago Reis
- Universidade de Brasília, Faculdade de Ciências da Saúde, Laboratório de Farmacologia Molecular, Brasília, DF, Brasil.,San Bortolo Hospital, International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy.,Clínica de Doenças Renais de Brasília, Departamento de Nefrologia, Brasília, DF, Brasil.,Academia Nacional de Medicina, Programa Jovens Lideranças Médicas, Rio de Janeiro, RJ, Brasil
| | - Siddiq Anwar
- Abu Dhabi Health Services (SEHA) Company, Department of Nephrology, Abu Dhabi, United Arab Emirates
| | | | - Claudio Ronco
- San Bortolo Hospital, International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, Vicenza, Italy.,University of Padova, Department of Medicine, Padova, Italy
| |
Collapse
|
16
|
Hadad-Arrascue F, Nilsson LG, Rivera AS, Bernardo AA, Cabezuelo Romero JB. Expanded hemodialysis as effective alternative to on-line hemodiafiltration: A randomized mid-term clinical trial. Ther Apher Dial 2021; 26:37-44. [PMID: 34125503 PMCID: PMC9290668 DOI: 10.1111/1744-9987.13700] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
Expanded hemodialysis (HDx), using medium cut-off membrane, is a novel therapy that effectively clears middle molecules (MMs). We aimed to compare HDx to hemodiafiltration (HDF) in an open randomized clinical study. Patients currently on HDF (age 18-80 years; on HDF >3 months) were randomized to switch to HDx (N = 21) or continue HDF (N = 22) with a 24-week follow-up. Pre- to post-dialysis reduction ratios (RR) and changes in pre-dialysis levels over time were evaluated for MMs and clinical biomarkers. Use of erythropoiesis-stimulating agents (ESAs) was assessed. HDx showed greater RR for YKL-40 while RR appeared similar between groups for beta2 -microglobulin, FGF-23, and free light chains. Intradialytic changes in inflammatory biomarkers (IL-6, CRP, PTX3) did not differ between therapies. Changes from baseline to 12 and 24 weeks did not differ between groups for MMs, inflammatory markers, albumin, fibrinogen, hemoglobin, PTH, and phosphorus. Use of ESAs tended to decrease in HDx arm while remaining stable in HDF arm. HDx appeared safe with similar clinical effectiveness as HDF. With fewer requirements and resource needs, HDx provides an attractive alternative to HDF.
Collapse
Affiliation(s)
- Fernando Hadad-Arrascue
- Renal Therapy Services, Murcia, Spain.,Department of Nephrology, Reina Sofía University Hospital, Murcia, Spain
| | | | | | | | | |
Collapse
|
17
|
Ciceri P, Cozzolino M. Expanded Haemodialysis as a Current Strategy to Remove Uremic Toxins. Toxins (Basel) 2021; 13:toxins13060380. [PMID: 34073439 PMCID: PMC8226798 DOI: 10.3390/toxins13060380] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 01/04/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by the retention of solutes named uremic toxins, which strongly associate with high morbidity and mortality. Mounting evidence suggests that targeting uremic toxins and/or their pathways may decrease the risk of cardiovascular disease in CKD patients. Dialysis therapies have been developed to improve removal of uremic toxins. Advances in our understanding of uremic retention solutes as well as improvements in dialysis membranes and techniques (HDx, Expanded Hemodialysis) will offer the opportunity to ameliorate clinical symptoms and outcomes, facilitate personalized and targeted dialysis treatment, and improve quality of life, morbidity and mortality.
Collapse
Affiliation(s)
- Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione Ca’ Granda IRCCS, Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy
- Correspondence: ; Tel.: +39-02-81844215
| |
Collapse
|
18
|
Sanabria RM, Hutchison CA, Vesga JI, Ariza JG, Sanchez R, Suarez AM. Expanded Hemodialysis and Its Effects on Hospitalizations and Medication Usage: A Cohort Study. Nephron Clin Pract 2021; 145:179-187. [PMID: 33596561 DOI: 10.1159/000513328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Expanded hemodialysis (HDx) effectively removes large middle molecular uremic toxins (>25 kDa) while still retaining albumin, potentially reducing their adverse effects. We compare the clinical laboratory parameters, hospitalization rates, and medication use in a cohort of patients switched from high-flux HD to HDx. METHODS This is a multicenter, observational cohort study of 81 adult patients, across 3 clinics, with end-stage kidney disease (ESKD) on chronic hemodialysis (HD). Patients received high-flux HD for at least 1 year and then switched to HDx and were followed up for 1 year. Patients were excluded if they discontinued therapy, changed provider, underwent kidney transplant, recovered kidney function, or changed to peritoneal dialysis, another dialyzer, or renal clinic. RESULTS Twelve months after switching to HDx, the rate of hospitalization events per patient-year decreased from 0.77 (95% CI: 0.60-0.98, 61 events) to 0.71 (95% CI: 0.55-0.92, 57 events) (p = 0.6987). The hospital day rate per patient-year was significantly reduced from 5.94 days in the year prior to switching compared with 4.41 days after switching (p = 0.0001). The mean dose of erythropoiesis-stimulating agent (SC epoetin-α) and intravenous iron also significantly decreased (p = 0.0361 and p = 0.0003, respectively). CONCLUSION Switching to HDx was associated with reductions in hospital day rate and medication use, suggesting HDx has the potential to reduce the burden of ESKD on patients and healthcare systems.
Collapse
Affiliation(s)
| | - Colin A Hutchison
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | | | | | - Ricardo Sanchez
- Clinical Research Institute, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | | |
Collapse
|