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Zakrzewska A, Biedunkiewicz J, Komorniczak M, Jankowska M, Jasiulewicz K, Płonka N, Biedunkiewicz B, Małgorzewicz S, Tarasewicz A, Puchalska-Reglińska E, Siebert J, Dębska-Ślizień A, Tylicki L. Intradialytic Tolerance and Recovery Time in Different High-Efficiency Hemodialysis Modalities. J Clin Med 2024; 13:326. [PMID: 38256460 PMCID: PMC10816973 DOI: 10.3390/jcm13020326] [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: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
There are several forms of maintenance high-efficiency hemodialysis (HD), including hemodiafiltrations (HDF) in different technical modes and expanded HD, using dialyzers with medium cut-off membranes. The aim of the study was to assess the intradialytic tolerance and length of dialysis recovery time (DRT) in these modalities. This is an exploratory, crossover study in maintenance HD patients with low comorbidity and no clinical indications for the use of high-efficiency HD, who were exposed to five intermittent dialyses in random order: high-flux hemodialysis (S-HD), expanded HD (HDx), pre-dilution HDF (PRE-HDF), mix-dilution HDF (MIX-HDF) and post-dilution HDF (POST-HDF). Twenty-four dialysis sessions of each method were included in the analysis. Dialysis parameters, including blood flow rate, dialysis fluid flow rate and temperature, and pharmacological treatment were constant. Average total convection volume for post-HDF, pre-HDF and mix-HDF were 25.6 (3.8), 61.5 (7.2) and 47.1 (11.4) L, respectively. During all therapies, patients were monitored for the similarity of their hydration statuses using bioimpedance spectroscopy, and for similar variability over time in systemic blood pressure and cardiac output, while peripheral resistance was monitored using impedance cardiography. The lowest frequency of all intradialytic adverse events were observed during HDx. Delayed DRT was the shortest during PRE-HDF. Patients were also more likely to report immediate recovery while receiving PRE-HDF. These differences did not reach statistical significance; however, the study results suggest that intradialytic tolerance and DRT may depend on the dialysis method used. This supports the need of taking into account patient preferences and quality of life while individualizing high-efficiency therapy in HD patients.
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Affiliation(s)
- Agnieszka Zakrzewska
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Jan Biedunkiewicz
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Michał Komorniczak
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Magdalena Jankowska
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Katarzyna Jasiulewicz
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Natalia Płonka
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Bogdan Biedunkiewicz
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Sylwia Małgorzewicz
- Department of Clinical Nutrition, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
| | - Agnieszka Tarasewicz
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | | | - Janusz Siebert
- Department of Family Medicine, University Center for Cardiology, Medical University of Gdansk, 80-211 Gdansk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Leszek Tylicki
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
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Fiorentino M, La Fergola F, De Rosa S. Medium cut-off dialyzer for middle molecular uremic toxins in AKI and chronic dialysis. J Nephrol 2024; 37:23-37. [PMID: 37843731 PMCID: PMC10920419 DOI: 10.1007/s40620-023-01771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/18/2023] [Indexed: 10/17/2023]
Abstract
Uremic toxins accumulate in patients affected by renal failure and can deposit in different organs, including the kidneys and heart. Given their physicochemical characteristics, uremic toxins can contribute to organ dysfunction due to several pathobiological actions at cellular and molecular levels. Several uremic compounds have been described in serum and plasma from patients with acute kidney injury (AKI) and kidney failure; they are usually classified based on their molecular size and protein-binding properties. In this scenario, new dialytic approaches have been proposed in the last few years with the aim of improving uremic toxin removal. Recent studies which focused on the use of medium cut-off membranes in patients on chronic hemodialysis have shown a discrete ability to remove β2-microglobulin and other middle molecules, such as kappa and lambda free light chains, complement factor D and α1-microglobulin. However, current evidence is mainly based on the impact on short-term outcomes and, consequently, longer observational studies are necessary to confirm the efficacy and safety of the medium cut-off dialyzer. Here we present the state-of-the-art on the clinical application of medium cut-off membranes in AKI and chronic dialysis patients.
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Affiliation(s)
- Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", Bari, Italy
| | - Francesco La Fergola
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", Bari, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy.
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Affiliation(s)
- Thomas A Golper
- From Robert Larner College of Medicine, University of Vermont, Burlington, and Vanderbilt University Medical Center, Nashville (professor emeritus)
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Vega-Vega O, Caballero-Islas AE, Del Toro-Cisneros N, Hernandez-Ordoñez SÓ, Arvizu-Hernández M, Martínez-Rueda A, Camacho-Colin D, Gómez-Correa LL, Correa-Rotter R. Improved β2-Microglobulin and Phosphorous Removal with Expanded Hemodialysis and Online Hemodiafiltration versus High-Flux Hemodialysis: A Cross-Over Randomized Clinical Trial. Blood Purif 2023; 52:712-720. [PMID: 37473747 DOI: 10.1159/000531355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/26/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Expanded hemodialysis (HDx) is expected to provide enhanced permeability of medium-sized molecules, selective solute retention, and better internal retrofiltration. The primary objective of this study was to compare the efficiency for removal of β2-microglobulin with 3 different extracorporeal therapies (ETs): high-flux hemodialysis (HF), online hemodiafiltration (OL-HDF), and HDx. The secondary objective was to evaluate the efficiency of removal of other uremic toxins, including urea, phosphate, CRP, IL-6, IL-10, TNF-⍺, indoxyl sulfate, and p-cresol. METHODS This single-center, randomized, and cross-over study was performed. Patients were randomized to determine the initial modality of treatment, each period lasted 4 weeks and between one modality and another, there was a washout period of 1 week. Reduction ratios (RRs) of different-size molecules and albumin were calculated for the different ET. RESULTS Twenty-two patients were included, β2-microglobulin RR was greater during both OL-HDF and HDx as compared to HF (RR 62% vs. 73% vs. 27%, respectively, p = <0.0001), and there was no significant difference between HDx and OL-HDF (p = 0.09). A decrease in serum phosphate levels was observed in the HDx and OL-HDF periods, contrary to an increase in HF (-0.79 mg/dL vs. -1.02 mg/dL vs. + 0.11 mg/dL, respectively, p = <0.0001). There was no difference in RRs of other molecules (BUN, CRP, IL-6, IL-10, TNF-⍺, indoxyl sulfate, and p-Cresol). There was no decrease in serum albumin in any ET. CONCLUSION HDx provides enhanced removal of β2-microglobulin and phosphate as compared to HF, and similar efficacy as with OL-HDF. HDx should be considered an alternative to chronic convective therapies.
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Affiliation(s)
- Olynka Vega-Vega
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Adrián E Caballero-Islas
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico,
| | - Noemí Del Toro-Cisneros
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sergio Óscar Hernandez-Ordoñez
- Postgraduate Division, Faculty of Superior Studies of Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla de Baz, Mexico
| | - Mauricio Arvizu-Hernández
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Armando Martínez-Rueda
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diana Camacho-Colin
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Leidi Laura Gómez-Correa
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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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: 9] [Impact Index Per Article: 9.0] [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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Jonny J, Teressa M. Expanded hemodialysis: a new concept of renal replacement therapy. J Investig Med 2023; 71:38-41. [PMID: 36316065 DOI: 10.1136/jim-2022-002431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 01/06/2023]
Abstract
Expanded hemodialysis (HDx) is an innovation that can increase the effectiveness of hemodialysis. The dialysis process is expected to promote more uremic toxins removal without causing significant hypoalbuminemia using the medium cut-off (MCO) membrane or also known as the high retention onset membrane. Compared with conventional membranes such as those of low-flux hemodialysis, high-flux hemodialysis, and hemodiafiltration, the MCO membrane in HDx is considered to be the closest to the physiology of the glomerular membrane. Several studies have shown the use of the MCO membrane in HDx provides clinical benefits and better outcome although further studies are needed to assess the long-term effect and greater impact for dialysis patients.
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Affiliation(s)
- Jonny Jonny
- Division of Nephrology, Department of Internal Medicine, Gatot Soebroto Army Hospital, Jakarta, Indonesia
| | - Maria Teressa
- Division of Nephrology, Department of Internal Medicine, Gatot Soebroto Army Hospital, Jakarta, Indonesia
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Immune System Dysfunction and Inflammation in Hemodialysis Patients: Two Sides of the Same Coin. J Clin Med 2022; 11:jcm11133759. [PMID: 35807042 PMCID: PMC9267256 DOI: 10.3390/jcm11133759] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 01/27/2023] Open
Abstract
Biocompatibility in hemodialysis (HD) has considerably improved in recent decades, but remains an open issue to be solved, appearing essential to reduce systemic inflammation and enhance patients’ clinical outcomes. Clotting prevention, reduction in complement and leukocyte activation, and improvement of antioxidant effect represent the main goals. This review aims to analyze the different pathways involved in HD patients, leading to immune system dysfunction and inflammation. In particular, we mostly review the evidence about thrombogenicity, which probably represents the most important characteristic of bio-incompatibility. Platelet activation is one of the first steps occurring in HD patients, determining several events causing chronic sub-clinical inflammation and immune dysfunction involvement. Moreover, oxidative stress processes, resulting from a loss of balance between pro-oxidant factors and antioxidant mechanisms, have been described, highlighting the link with inflammation. We updated both innate and acquired immune system dysfunctions and their close link with uremic toxins occurring in HD patients, with several consequences leading to increased mortality. The elucidation of the role of immune dysfunction and inflammation in HD patients would enhance not only the understanding of disease physiopathology, but also has the potential to provide new insights into the development of therapeutic strategies.
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Effects of Expanded Hemodialysis with Medium Cut-Off Membranes on Maintenance Hemodialysis Patients: A Review. MEMBRANES 2022; 12:membranes12030253. [PMID: 35323729 PMCID: PMC8953230 DOI: 10.3390/membranes12030253] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 02/04/2023]
Abstract
Kidney failure is associated with high morbidity and mortality. Hemodialysis, the most prevalent modality of renal replacement therapy, uses the principle of semipermeable membranes to remove solutes and water in the plasma of patients with kidney failure. With the evolution of hemodialysis technology over the last half century, the clearance of small water-soluble molecules in such patients is adequate. However, middle molecules uremic toxins are still retained in the plasma and cause cardiovascular events, anemia, and malnutrition, which significantly contribute to poor quality of life and high mortality in maintenance hemodialysis patients. A new class of membrane, defined as a medium cut-off (MCO) membrane, has emerged in recent years. Expanded hemodialysis with MCO membranes is now recognized as the artificial kidney model closest to natural kidney physiology. This review summarizes the unique morphological characteristics and internal filtration–backfiltration mechanism of MCO membranes, and describes their effects on removing uremic toxins, alleviating inflammation and cardiovascular risk, and improving quality of life in maintenance hemodialysis patients.
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Chen YA, Ou SM, Lin CC. Influence of Dialysis Membranes on Clinical Outcomes: From History to Innovation. MEMBRANES 2022; 12:membranes12020152. [PMID: 35207074 PMCID: PMC8876340 DOI: 10.3390/membranes12020152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 12/18/2022]
Abstract
Dialysis membranes were traditionally classified according to their material compositions (i.e., as cellulosic or synthetic) and on the basis of the new concept of the sieving coefficient (determined by the molecular weight retention onset and molecular weight cut-off). The advantages of synthetic polymer membranes over cellulose membranes are also described on the basis of their physical, chemical, and structural properties. Innovations of dialysis membrane in recent years include the development of medium cutoff membranes; graphene oxide membranes; mixed-matrix membranes; bioartificial kidneys; and membranes modified with vitamin E, lipoic acid, and neutrophil elastase inhibitors. The current state of research on these membranes, their effects on clinical outcomes, the advantages and disadvantages of their use, and their potential for clinical use are outlined and described.
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Affiliation(s)
- Yee-An Chen
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Shuo-Ming Ou
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Correspondence: (S.-M.O.); (C.-C.L.); Tel.: +886-2-2875-3103 (C.-C.L.); +886-2-2871-2121 (S.-M.O.); Fax: +886-2-2875-7858 (C.-C.L.)
| | - Chih-Ching Lin
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Correspondence: (S.-M.O.); (C.-C.L.); Tel.: +886-2-2875-3103 (C.-C.L.); +886-2-2871-2121 (S.-M.O.); Fax: +886-2-2875-7858 (C.-C.L.)
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Locatelli F, Del Vecchio L. Dialysis dose and mortality: where is the limit? Nephrol Dial Transplant 2021; 36:2170-2172. [PMID: 34791439 DOI: 10.1093/ndt/gfab265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
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