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Maduell F, Rodríguez-Espinosa D, Rodas LM, Gómez M, Arias-Guillén M, Fontseré N, Vera M, Del Carmen Salgado M, Rico N, Broseta JJ. Most recently developed polyester polymer alloy dialyzer: A new medium cut-off membrane? Artif Organs 2024; 48:753-762. [PMID: 38404240 DOI: 10.1111/aor.14726] [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: 11/28/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND New versions of the polyester polymer alloy (PEPA) membrane have appeared over the years, with increases in both the pore size and the amount of polyvinylpyrrolidone (PVP) to optimize hydrophilicity performance. This study aimed to assess the efficacy of the most recently developed PEPA dialyzer, the FDY series, in hemodialysis (HD) modality in terms of uremic toxin removal and albumin loss and to compare it with that of several high-flux dialyzers currently used in HD and post-dilution hemodiafiltration (HDF) treatments. METHODS A prospective study was carried out in 21 patients. All patients underwent six dialysis sessions with the same routine dialysis parameters; only the dialyzer and/or the dialysis modality varied: FX80 in HD, FDY 180 in HD, Clearum HS17 in HDF, Elisio 19H in HDF, Vitapes 180 in HDF, and FX80 in post-dilution HDF. The reduction ratios (RR) of urea, creatinine, ß2-microglobulin, myoglobin, κFLC, prolactin, α1-microglobulin, α1-acid glycoprotein, λFLC, and albumin were compared intraindividually. Dialysate albumin loss was also measured. RESULTS Both membranes FDY and FX80 are high-flux dialyzers and are applied here in high-flux HD. The average RR of β2-microglobulin was slightly lower in the two HD treatments than in the HDF treatments. Comparison of dialysis treatments revealed that the PEPA FDY dialyzer in the HD modality was more effective than the FX80 dialyzer in high-flux HD and was as effective as post-dilution HDF, especially in terms of myoglobin, κFLC, prolactin, α1-microglobulin, and λFLC RRs. The FDY treatments obtained similar albumin RR in blood and slightly higher dialysate albumin loss, although the values were clinically acceptable. CONCLUSIONS The most recently developed PEPA dialyzers in the HD modality were as effective as all treatments in the HDF modality and were clearly superior to high-flux helixone HD treatment. These results confirm that this dialyzer should be categorized within the medium cut-off (MCO) membrane classification.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Lida María Rodas
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Miquel Gómez
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Néstor Fontseré
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Manel Vera
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Nayra Rico
- Department of Biochemistry, Hospital Clínic Barcelona, Barcelona, Spain
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Koç NS, Yeter H, Yıldırım T, Erdem Y, Yılmaz R. Effect of medium cut-off membranes on Pentosidine and N-(carboxymethyl) lysine levels in uncontrolled diabetic hemodialysis patients. Ther Apher Dial 2024. [PMID: 38572624 DOI: 10.1111/1744-9987.14126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/24/2024] [Accepted: 02/29/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Patients on hemodialysis, especially with diabetes, face elevated cardiovascular events. A major contributor to complications associated with diabetes is advanced glycation end products (AGEs). Removing these compounds is challenging in traditional hemodialysis. Medium-cut-off (MCO) membranes potentially remove toxins without significant albumin loss. This study explored how MCO membranes impact AGEs levels in uncontrolled diabetic patients undergoing hemodialysis. METHODS Sixteen patients received MCO membrane dialysis, while others used high-flux (HF) membranes. After 12 sessions, the dialyzers were switched, totaling 24 sessions. Blood samples at trial initiation (T0), session 12 (T1) and session 24 (T2) tested for CML, Pentosidine, laboratory parameters. RESULTS Switching dialyzers showed increased albumin with MCO-to-HF and decreased with HF-to-MCO, albeit nonsignificant (p = 0.5/p = 0.1). Patients on MCO had lower albumin levels than HF (p = 0.03/p = 0.6, respectively). Hemodialysis with MCO demonstrated lower levels of CML/Pentosidine compared to HF (p = 0.09/p = 0.9 for CML; p = 0.04/p = 0.3 for Pentosidine). Transitioning to HF led to elevated levels (p = 0.4/p = 0.09 for CML; p = 0.3/p = 0.07 for Pentosidine). CONCLUSION MCO dialysis in diabetic individuals notably reduces AGE levels.
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Affiliation(s)
- Neriman Sıla Koç
- Faculty of Medicine, Department of Internal Medicine, Division of Nephrology, Harran University, Şanlıurfa, Turkey
| | - Hasan Yeter
- Faculty of Medicine, Department of Internal Medicine, Division of Nephrology, Hacettepe University, Ankara, Turkey
| | - Tolga Yıldırım
- Faculty of Medicine, Department of Internal Medicine, Division of Nephrology, Hacettepe University, Ankara, Turkey
| | - Yunus Erdem
- Faculty of Medicine, Department of Internal Medicine, Division of Nephrology, Hacettepe University, Ankara, Turkey
| | - Rahmi Yılmaz
- Faculty of Medicine, Department of Internal Medicine, Division of Nephrology, Hacettepe University, Ankara, Turkey
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Zawada AM, Emal K, Förster E, Saremi S, Delinski D, Theis L, Küng F, Xie W, Werner J, Stauss-Grabo M, Faust M, Boyington S, Kennedy JP. Hydrophilic Modification of Dialysis Membranes Sustains Middle Molecule Removal and Filtration Characteristics. MEMBRANES 2024; 14:83. [PMID: 38668111 PMCID: PMC11052066 DOI: 10.3390/membranes14040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024]
Abstract
While efficient removal of uremic toxins and accumulated water is pivotal for the well-being of dialysis patients, protein adsorption to the dialyzer membrane reduces the performance of a dialyzer. Hydrophilic membrane modification with polyvinylpyrrolidone (PVP) has been shown to reduce protein adsorption and to stabilize membrane permeability. In this study we compared middle molecule clearance and filtration performance of nine polysulfone-, polyethersulfone-, and cellulose-based dialyzers over time. Protein adsorption was simulated in recirculation experiments, while β2-microglobulin clearance as well as transmembrane pressure (TMP) and filtrate flow were determined over time. The results of this study showed that β2-microglobulin clearance (-7.2 mL/min/m2) and filtrate flow (-54.4 mL/min) decreased strongly during the first 30 min and slowly afterwards (-0.7 mL/min/m2 and -6.8 mL/min, respectively, for the next 30 min); the TMP increase (+37.2 mmHg and +8.6 mmHg, respectively) showed comparable kinetics. Across all tested dialyzers, the dialyzer with a hydrophilic modified membrane (FX CorAL) had the highest β2-microglobulin clearance after protein fouling and the most stable filtration characteristics. In conclusion, hydrophilic membrane modification with PVP stabilizes the removal capacity of middle molecules and filtration performance over time. Such dialyzers may have benefits during hemodiafiltration treatments which aim to achieve high exchange volumes.
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Affiliation(s)
- Adam M. Zawada
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Karlee Emal
- Applications Laboratory, Fresenius Medical Care, Ogden, UT 84404, USA; (K.E.); (S.B.)
| | - Eva Förster
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Saeedeh Saremi
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
- Institute for Physical Process Technology, Saarland University of Applied Sciences, 66117 Saarbrücken, Germany;
| | - Dirk Delinski
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Lukas Theis
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Florian Küng
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Wenhao Xie
- Product Development, Fresenius Medical Care, Shanghai 200233, China;
| | - Joanie Werner
- Clinical Marketing & Innovations, Fresenius Medical Care, Waltham, MA 02451, USA;
| | - Manuela Stauss-Grabo
- Global Biomedical Evidence Generation, Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany;
| | - Matthias Faust
- Institute for Physical Process Technology, Saarland University of Applied Sciences, 66117 Saarbrücken, Germany;
| | - Skyler Boyington
- Applications Laboratory, Fresenius Medical Care, Ogden, UT 84404, USA; (K.E.); (S.B.)
| | - James P. Kennedy
- Product Development, Fresenius Medical Care, Ogden, UT 84404, USA;
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Jo YI. Removal of uremic toxin by dialysis, what is the issue? Kidney Res Clin Pract 2023; 42:672-675. [PMID: 37559226 DOI: 10.23876/j.krcp.23.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 06/11/2023] [Indexed: 08/11/2023] Open
Affiliation(s)
- Young-Il Jo
- Division of Nephrology, Department of Internal Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
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de Sequera P, Pérez-García R, Vega A, Martínez-Vaquera S, Acosta JG, Pérez Del Valle K, Fernández-Lucas M, García-Rubiales MA, García-Herrera AL, Coll E, Mérida E, Martínez-Miguel P, Castaño I, Gil-Casares B, Garro J, Maduell F. Trial design of the MOTheR HDx study: a multicenter, open-label, prospective, randomized study to explore the morbidity and mortality in patients dialyzed with the Theranova HDx in comparison with online hemodiafiltration. Clin Kidney J 2023; 16:2254-2261. [PMID: 37915938 PMCID: PMC10616438 DOI: 10.1093/ckj/sfad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Indexed: 11/03/2023] Open
Abstract
Background Dialysis patients have been maintaining a high rate of cardiovascular morbidity and mortality. For this reason, it is to introduce necessary new technical advances in clinical practice. There is a relation between toxins retention and inflammation, mortality and morbidity. Medium cut-off (MCO) membranes are a new generation of membranes that allow the removal of a greater number of medium-sized molecules compared with high-flux hemodialysis (HF-HD), but retaining albumin. MCO membranes have an increased permeability and the presence of internal filtration. Because of these special properties, MCO generated a new concept of therapy called expanded HD (HDx). Until now, online hemodiafiltration (OL-HDF) has demonstrated its superiority, in terms of survival, compared with HF-HD. However, the comparison between OL-HDF and HDx remains an unsolved question. Methods The MOTheR HDx study trial (NCT03714386) is an open-label, multicenter, prospective, 1:1 randomized, parallel-group trial designed to evaluate the efficacy and safety of HDx compared with OL-HDF in patients treated for dialysis in Spain for up to 36 months. The main endpoint is to determinate whether HDx is non inferior to OL-HDF at reducing the combined outcome of all-cause death and stroke (ischemic or hemorrhagic), acute coronary syndrome (angina and myocardial infarction), peripheral arterial disease (amputation or revascularization) and ischemic colitis (mesenteric thrombosis). Results The trial has already started.
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Affiliation(s)
| | | | - Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | | | | | | | | - Elisabeth Coll
- Nephrology Department, Fundación Puigvert, Barcelona, Spain
| | - Evangelina Mérida
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Itziar Castaño
- Nephrology Department, Complejo Hospitalario de Navarra, Navarra, Spain
| | | | - Julia Garro
- Nephrology Department, Hospital Universitario Joan XXIII, Tarragona, Spain
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Kim CS, Joo SY, Choi HS, Bae EH, Ma SK, Kim SW. Comparison of the medium cutoff dialyzer and postdilution hemodiafiltration on the removal of small and middle molecule uremic toxins. Kidney Res Clin Pract 2023; 42:712-722. [PMID: 37448285 DOI: 10.23876/j.krcp.21.287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 07/04/2022] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The medium cutoff (MCO) dialyzer increases the removal of several middle molecules more effectively than high-flux hemodialysis (HD). However, comparative data addressing the efficacy and safety of MCO dialyzers vs. postdilution hemodiafiltration (HDF) in Korean patients are lacking. METHODS Nine patients with chronic HD were included in this pre-post study. Patients underwent HD with an MCO dialyzer for 4 weeks, followed by a 2-week washout period using a high-flux dialyzer to minimize carryover effects, and then turned over to postdilution HDF for 4 weeks. Reduction ratios and differences in the uremic toxins before and after dialysis were calculated from the MCO dialysis, postdilution HDF, and high-flux HD. In the in vitro study, EA.hy926 cells were incubated with dialyzed serum. RESULTS Compared to postdilution HDF, the MCO dialyzer achieved significantly higher reduction ratios for larger middle molecules (myoglobin, kappa free light chain [κFLC], and lambda FLC [λFLC]). Similarly, the differences in myoglobin, κFLC, and λFLC concentrations before and after the last dialysis session were significantly greater in MCO dialysis than in postdilution HDF. The expression of Bax and nuclear factor κB was decreased in the serum after dialysis with the MCO dialyzer than with HDF. CONCLUSION Compared with high-volume postdilution HDF, MCO dialysis did not provide greater removal of molecules below 12,000 Da, whereas it was superior in the removal of larger uremic middle molecule toxins in patients with kidney failure. Moreover, these results may be expected to have an anti-apoptotic effect on the human endothelium.
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Affiliation(s)
- Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Soo Yeon Joo
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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7
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Schaaf CW, Braunisch MC, Holzmann-Littig C, Pfister F, Hannemann L, Hausinger RI, Verbeek M, Schmaderer C, Renders L, Heemann U, Küchle C. Extracorporeal light-chain elimination in myeloma with simple medium cutoff membrane hemodialysis: a retrospective cohort study. Front Oncol 2023; 13:1193504. [PMID: 37746285 PMCID: PMC10514899 DOI: 10.3389/fonc.2023.1193504] [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: 03/30/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Background We determined the efficacy of free light chain (FLC) removal by regular dialysis equipment (high-flux filtration) with medium cutoff (MCO) membrane hemodialysis (HD) as an adjuvant treatment to standard chemotherapy for patients with acute kidney injury complicating multiple myeloma (MM) and its impact on further dialysis dependency. Methods Sixty patients with acute dialysis-dependent renal failure secondary to MM were treated with MCO-HD (55 patients) or HCO (high cutoff)-HD (5 patients) as a control. FLC serum concentration, total protein, immunoglobulins, and LDH were measured throughout the dialysis therapy. The kidney function of the patients was followed up for 1 year. Results The median age was 69 years; 25 female and 35 male patients were enrolled. HD significantly reduced FLC kappa levels in the MCO/HCO group by 58%/84% (MCO/HCO group; p < 0.05) and FLC lambda by 39%/33% (MCO/HCO group; p < 0.05). Single HD data (MCO) showed a relative reduction of 70% in kappa and 37% in lambda FLC concentration, as expected by the different sizes of the light chains. Renal function improved significantly and continuously from starting creatinine 5.7/3.8 mg/dl (MCO/HCO group) before HD to 1.4/2.0 mg/dl (MCO/HCO group; p < 0.001) after 1 year. No significant alteration of total protein, immunoglobulins, and LDH concentrations by HD (HCO and MCO group) was observed. After 1 year, 37 of 60 patients were alive and 34 of them were off dialysis. Conclusion FLC elimination with MCO-HD is effective, technically easy, and less cost-intensive as compared with HCO-HD. Kidney function recovery in MM patients is achievable.
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Affiliation(s)
- Christian W. Schaaf
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Matthias C. Braunisch
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Frederick Pfister
- Department of Nephropathology of the Institute of Pathology, School of Medicine, University of Erlangen, Erlangen, Germany
| | - Liya Hannemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Renate I. Hausinger
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Mareike Verbeek
- Department of Hematology and Oncology, Klinikum rechts der Isar, III. Medical Clinic, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Claudius Küchle
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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Hestekin CN, Pakkaner E, Hestekin JA, De Souza LS, Chowdhury PP, Marçal JL, Moore J, Hesse SA, Takacs CJ, Tassone CJ, Dachavaram SS, Crooks PA, Williams K, Kurtz I. High flux novel polymeric membrane for renal applications. Sci Rep 2023; 13:11703. [PMID: 37474512 PMCID: PMC10359412 DOI: 10.1038/s41598-023-37765-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 06/27/2023] [Indexed: 07/22/2023] Open
Abstract
Biocompatibility and the ability to mediate the appropriate flux of ions, urea, and uremic toxins between blood and dialysate components are key parameters for membranes used in dialysis. Oxone-mediated TEMPO-oxidized cellulose nanomaterials have been demonstrated to be excellent additives in the production and tunability of ultrafiltration and dialysis membranes. In the present study, nanocellulose ionic liquid membranes (NC-ILMs) were tested in vitro and ex vivo. An increase in flux of up to two orders of magnitude was observed with increased rejection (about 99.6%) of key proteins compared to that of polysulfone (PSf) and other commercial membranes. NC-ILMs have a sharper molecular weight cut-off than other phase inversion polymeric membranes, allowing for high throughput of urea and a uremic toxin surrogate and limited passage of proteins in dialysis applications. Superior anti-fouling properties were also observed for the NC-ILMs, including a > 5-h operation time with no systemic anticoagulation in blood samples. Finally, NC-ILMs were found to be biocompatible in rat ultrafiltration and dialysis experiments, indicating their potential clinical utility in dialysis and other blood filtration applications. These superior properties may allow for a new class of membranes for use in a wide variety of industrial applications, including the treatment of patients suffering from renal disease.
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Affiliation(s)
- Christa N Hestekin
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA.
| | - Efecan Pakkaner
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA
| | - Jamie A Hestekin
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA
| | - Leticia Santos De Souza
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA
| | - Partha Pratim Chowdhury
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA
| | - Juliana Louzada Marçal
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA
| | - John Moore
- Ralph E. Martin Department of Chemical Engineering, University of Arkansas, 3202 Bell Engineering Center, Fayetteville, AR, 72701, USA
| | - Sarah A Hesse
- Stanford Synchrotron Radiation Lightsource, SLAC National Accelerator Laboratory, Menlo Park, CA, 94025, USA
| | - Christopher J Takacs
- Stanford Synchrotron Radiation Lightsource, SLAC National Accelerator Laboratory, Menlo Park, CA, 94025, USA
| | - Christopher J Tassone
- Stanford Synchrotron Radiation Lightsource, SLAC National Accelerator Laboratory, Menlo Park, CA, 94025, USA
| | - Soma Shekar Dachavaram
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Peter A Crooks
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Kate Williams
- St. Francis Animal Hospital, 121 Virginia Street, Springdale, AR, 72764, USA
| | - Ira Kurtz
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
- Brain Research Institute, University of California, Los Angeles, CA, 90095, USA
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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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Pongsittisak W, Satpanich P, Jaturapisanukul S, Keawvichit R, Prommool S, Trakranvanich T, Ngamvichukorn T, Kurathong S. Medium Cut-Off versus Low-Flux Dialyzers in Hemodialysis Patients with COVID-19: Clinical Outcomes and Reduction in Interleukin-6. Blood Purif 2023; 52:591-599. [PMID: 37231799 DOI: 10.1159/000530162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/09/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic has caused extensive morbidity and mortality worldwide. Hemodialysis (HD) patients are both vulnerable to COVID-19 infection and tend to suffer greater disease severity and mortality. This retrospective study aimed to compare medium cut-off (MCO) and low-flux (LF) membrane dialyzers in terms of interleukin-6 (IL-6) reduction, change in inflammatory state, intradialytic complications, and mortality in chronic HD patients with COVID-19. METHOD HD patients with a confirmed COVID-19 infection were admitted to the hospital for 10-14 days and underwent HD at the COVID-HD unit. Choice of dialyzer membrane used (MCO vs. LF) depended on the primary nephrologist(s). We collected data on demographics, baseline characteristics, laboratory results, diagnosis, treatments, HD prescription, hemodynamic status during HD, and mortality at 14 and 28 days after. RESULTS IL-6 reduction ratio (RR) in the MCO group was 9.7 (interquartile range, 71.1) percent, which was significantly higher than that of the LF group (RR, -45.7 [interquartile range, 70.2] percent). The incidence rate of intradialytic hypotension in the MCO group was 3.846 events per 100 dialysis hours (95% confidence interval [CI], 1.954-6.856), which was significantly lower than that of the LF group (9.057; 95% CI, 5.592-13.170). Overall, mortality was not significantly different between the two groups. CONCLUSION The MCO membrane was more effective in removing IL-6 and was better tolerated than the LF membrane. Large, randomized controlled trials are required to confirm the relative benefits of the MCO membrane, especially mortality. However, due to the COVID-19 pandemic, our results suggest that the MCO membrane may be beneficial in chronic HD patients with COVID-19.
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Affiliation(s)
- Wanjak Pongsittisak
- Nephrology and Renal Replacement Therapy Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Panchalee Satpanich
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Solos Jaturapisanukul
- Nephrology and Renal Replacement Therapy Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Rassamon Keawvichit
- Department of Clinical Pathology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Surazee Prommool
- Nephrology and Renal Replacement Therapy Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Thananda Trakranvanich
- Nephrology and Renal Replacement Therapy Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Tanun Ngamvichukorn
- Nephrology and Renal Replacement Therapy Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Sathit Kurathong
- Nephrology and Renal Replacement Therapy Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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11
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Krieter DH, Rüth M, Lemke HD, Wanner C. Clinical performance comparison of two medium cut-off dialyzers. Ther Apher Dial 2023; 27:284-292. [PMID: 36858049 DOI: 10.1111/1744-9987.13919] [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: 04/25/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Medium-cut-off (MCO) dialyzers may beneficially impact outcomes in patients on hemodialysis. METHODS In a randomized, controlled trial in maintenance hemodialysis patients, the new Nipro ELISIO-17HX MCO dialyzer was compared to the Baxter Theranova 400 filter regarding middle molecule removal. Furthermore, the suitability of two assays for free lambda-light chain (λFLC) detection (Freelite vs. N-Latex) was verified. RESULTS ELISIO-HX achieved slightly lower reduction ratios for β2 -microglobulin (71.8 ± 6.0 vs. 75.3 ± 5.8%; p = 0.001), myoglobin (54.7 ± 8.6 vs. 64.9 ± 8.7%; p < 0.001), and kappa-FLC (62.1 ± 8.8 vs. 56.3 ± 7.7%; p = 0.021). λFLC reduction ratios were more conclusive with the Freelite assay and not different between ELISIO-HX and Theranova (28.4 ± 3.9 vs. 38.7 ± 13.4%; p = 0.069). The albumin loss of Theranova was considerably higher (2.14 ± 0.45 vs. 0.77 ± 0.25 g; p = 0.001) and the Global Removal ScoreLoss alb largely inferior (30.6 ± 7.4 vs. 82.4 ± 29.2%/g; p = 0.006) to ELISIO-HX. CONCLUSIONS The new ELISIO-HX expands the choice of dialyzers for MCO hemodialysis.
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Affiliation(s)
- Detlef H Krieter
- Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | | | | | - Christoph Wanner
- Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
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12
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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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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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14
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Koniman R, Teo SH, Kaushik M, Nagarajan C, Tan MSY, Tan HK, Ramirez MEG, Lim CC. The use of medium cutoff dialyzers in patients with multiple myeloma and acute kidney injury requiring hemodialysis: A systematic review. Semin Dial 2023; 36:12-17. [PMID: 35840146 DOI: 10.1111/sdi.13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with multiple myeloma and high serum levels of circulating free light chains (FLC) have increased risk of acute kidney injury (AKI) secondary to cast nephropathy and is associated with poor survival. Despite removal of FLC by medium cutoff (MCO) dialyzer, the role of MCO hemodialysis (HD) in the treatment of cast nephropathy and its clinical benefits remain unknown. METHODS A systematic review was conducted to establish the effectiveness of MCO dialyzer and clinical outcomes, compared to other forms of dialyzers in the removal of FLC, in myeloma patients with AKI. The primary outcome was effectiveness of MCO-HD in reducing serum FLC. The secondary outcomes were HD independence, estimated glomerular filtrate rate, mortality rates, length of hospitalization, rebound of serum FLC before the next dialysis, removal of other molecules during dialysis, and adverse events. RESULTS We identified three case series, with a total of 17 patients. There were no randomized controlled trials (RCTs) or cohort studies. These case series showed that MCO dialyzer was effective in the removal of FLC and led to a reduction in FLC concentration post-dialysis. The majority of the case series did not have comparator arm and renal and/or other clinical outcomes. CONCLUSION MCO dialyzer appeared to be effective in the removal of FLC based on the existing limited data. However, more data, particularly large-scale RCTs, are needed to assess the use of MCO dialyzer in reducing serum FLC and its effect on clinical outcomes in patients with multiple myeloma and AKI.
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Affiliation(s)
- Riece Koniman
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Su Hooi Teo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Melinda Si Yun Tan
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Cynthia Ciwei Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Maduell F, Broseta JJ, Rodríguez-Espinosa D, Del Risco-Zevallos J, Gómez M, Rodas LM, Arias-Guillén M, Vera M, Fontseré N, Salgado MDC, Rico N. Efficacy and Safety of the Medium Cut-Off Elisio HX Dialyzer. Blood Purif 2023; 52:68-74. [PMID: 35551384 PMCID: PMC9909626 DOI: 10.1159/000524644] [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: 02/23/2022] [Accepted: 04/19/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The medium cut-off Elisio HX dialyzer by Nipro became commercially available in Europe in 2021, but there are still no reports of in vivo data. This study aimed to evaluate the safety and efficacy of it compared with previously evaluated hemodialysis (HD), expanded HD (HDx), and postdilution hemodiafiltration (HDF) treatments. METHODS A prospective study was carried out on 18 patients who underwent 5 dialysis sessions: FX80 Cordiax in HD, Elisio H19 in HD, Elisio HX19 in HDx, Theranova 400 in HDx, and FX80 Cordiax in HDF. The reduction ratios of urea, creatinine, ß2-microglobulin, myoglobin, kappa FLC, prolactin, α1-microglobulin, α1-acid glycoprotein, lambda FLC, and albumin were compared. Dialysate albumin loss was measured. RESULTS The comparison between the different dialysis modalities revealed no difference for small molecules, but HDx and HDF were significantly more efficient than HD for medium and large molecule removal. The efficacy of Elisio HX19 dialyzer in HDx was similar to the Theranova 400, superior to both dialyzers in HD, and slightly lower than HDF. Albumin losses in dialysate with HD dialyzers were less than 1 g, but between 1.5 and 2.5 g in HDx and HDF. The global removal score (GRS) values with HDx treatments were statistically significantly higher than those with HD. The highest GRS was obtained with the helixone dialyzer in HDF. CONCLUSIONS The new MCO dialyzer, Elisio HX, performs with excellent behavior and tolerance. It represents an upgrade compared to their predecessor and is very close to the removal capacity of HDF treatment.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain,Department of Medicine, University of Barcelona, Barcelona, Spain,*Francisco Maduell,
| | | | | | | | - Miquel Gómez
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Lida M. Rodas
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Manel Vera
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Néstor Fontseré
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Nayra Rico
- Department of Biochemistry, Hospital Clínic Barcelona, Barcelona, Spain
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16
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Maduell F, Broseta JJ, Rodríguez-Espinosa D, del Risco J, Rodas LM, Arias-Guillén M, Vera M, Fontseré N, Salgado MDC, Rico N. Comparison of four medium cut-off dialyzers. Clin Kidney J 2022; 15:2292-2299. [PMID: 36381368 PMCID: PMC9664569 DOI: 10.1093/ckj/sfac167] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Recently, several pharmaceutical companies have developed new medium cut-off (MCO) dialyzers for expanded hemodialysis (HDx). This study aimed to compare the safety and efficacy of four MCO dialyzers, against each other and versus high-flux hemodialysis (HD) and post-dilution hemodiafiltration (HDF). METHODS A prospective study was carried out on 23 patients who underwent six dialysis sessions: two sessions with the FX80 Cordiax in HD and HDF, and four HDx sessions with the Phylther 17-SD, Vie-18X, Elisio HX19 and Theranova 400 dialyzers. The reduction ratios (RRs) of urea, creatinine, β2-microglobulin, myoglobin, kappa free immunoglobulin light chain (κFLC), prolactin, α1-microglobulin, α1-acid glycoprotein, lambda (λFLC) and albumin were compared. Dialysate albumin loss was also measured. RESULTS The differences in efficacy between the evaluated dialyzers were minimal in small molecules and even up to the size of β2-microglobulin. The main differences were found between myoglobin, κFLC, prolactin, α1-microglobulin and λFLC RRs, in which all four MCO dialyzers, with similar efficacy, were clearly superior to HD and slightly inferior to HDF treatment. Albumin losses in the dialysate with HD dialyzers were <1 g and between 1.5 and 2.5 g in HDx and HDF. The global removal score values were similar in all four HDx treatments, and again significantly higher than those with HD. CONCLUSIONS The results of the four MCO dialyzers evaluated in this study showed good efficiency, with no significant performance differences between them while being completely safe in terms of albumin loss. Likewise, the study confirms the superiority of HDx over high-flux HD with an efficacy close to that of post-dilution HDF.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | | | - Jimena del Risco
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Lida María Rodas
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Manel Vera
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Néstor Fontseré
- Department of Nephrology, Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Nayra Rico
- Department of Biochemistry, Hospital Clínic Barcelona, Barcelona, Spain
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Jang K, Nguyen TT, Yi E, Kim CS, Kim SW, Kim IS. Open Pore Ultrafiltration Hollow Fiber Membrane Fabrication Method via Dual Pore Former with Dual Dope Solution Phase. MEMBRANES 2022; 12:1140. [PMID: 36422132 PMCID: PMC9697471 DOI: 10.3390/membranes12111140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 06/16/2023]
Abstract
Hollow-fiber membranes are widely used in various fields of membrane processes because of their numerous properties, e.g., large surface area, high packing density, mass production with uniform quality, obvious end-of-life indicators, and so on. However, it is difficult to control the pores and internal properties of hollow-fiber membranes due to their inherent structure: a hollow inside surrounded by a wall membrane. Herein, we aimed to control pores and the internal structure of hollow-fiber membranes by fabricating a dual layer using a dual nozzle. Two different pore formers, polyethylene glycol (PEG) and polyvinyl pyrrolidone (PVP), were separately prepared in the dope solutions and used for spinning the dual layer. Our results show that nanoscale pores could be formed on the lumen side (26.8-33.2 nm), and the open pores continuously increased in size toward the shell side. Due to robust pore structure, our fabricated membrane exhibited a remarkable water permeability of 296.2 ± 5.7 L/m2·h·bar and an extremely low BSA loss rate of 0.06 ± 0.02%, i.e., a high BSA retention of 99.94%. In consideration of these properties, the studied membranes are well-suited for use in either water treatment or hemodialysis. Overall, our membranes could be considered for the latter application with a high urea clearance of 257.6 mL/min, which is comparable with commercial membranes.
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Affiliation(s)
- Kyunghoon Jang
- School of Earth Sciences and Environmental Engineering, Gwangju Institute of Science and Technology, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
- Inosep Inc., E3 BLDG-408, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
| | - Thanh-Tin Nguyen
- Inosep Inc., E3 BLDG-408, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
| | - Eunsung Yi
- Inosep Inc., E3 BLDG-408, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, 160 Baekseo-ro, Dong-gu, Gwangju 61469, Korea
| | - Soo Wan Kim
- Inosep Inc., E3 BLDG-408, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
- Department of Internal Medicine, Chonnam National University Medical School, 160 Baekseo-ro, Dong-gu, Gwangju 61469, Korea
| | - In S. Kim
- School of Earth Sciences and Environmental Engineering, Gwangju Institute of Science and Technology, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
- Inosep Inc., E3 BLDG-408, 123 Cheomdangwagi-ro, Buk-gu, Gwangju 61005, Korea
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A randomized prospective cross over study on the effects of medium cut-off membranes on T cellular and serologic immune phenotypes in hemodialysis. Sci Rep 2022; 12:16419. [PMID: 36180564 PMCID: PMC9524345 DOI: 10.1038/s41598-022-20818-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/19/2022] [Indexed: 11/08/2022] Open
Abstract
Extended cut-off filtration by medium cut-off membranes (MCO) has been shown to be safe in maintenance hemodialysis (HD). The notion of using them for the control of chronic low-grade inflammation and positively influencing cellular immune aberrations seems tempting. We conducted an open label, multicenter, randomized, 90 day 2-phase cross over clinical trial (MCO- vs. high flux-HD). 46 patients underwent randomization of which 34 completed the study. Dialysate- or pre- and post-dialysis serum inflammatory mediators were assayed for each study visit. Ex vivo T cell activation was assessed from cryopreserved leucocytes by flow cytometry. Linear mixed models were used to compare treatment modalities, with difference in pre-dialysis serum MCP-1 levels after 3 months as the predefined primary endpoint. Filtration/dialysate concentrations of most mediators, including MCP-1 (mean ± SD: 10.5 ± 5.9 vs. 5.1 ± 3.8 pg/ml, P < 0.001) were significantly increased during MCO- versus high flux-HD. However, except for the largest mediator studied, i.e., YKL-40, this did not confer any advantages for single session elimination kinetics (post-HD mean ± SD: 360 ± 334 vs. 564 ± 422 pg/ml, P < 0.001). No sustained reduction of any of the studied mediators was found neither. Still, the long-term reduction of CD69+ (P = 0.01) and PD1+ (P = 0.02) activated CD4+ T cells was striking. Thus, MCO-HD does not induce reduction of a broad range of inflammatory mediators studied here. Long-term reduction over a 3-month period was not possible. Increased single session filtration, as evidenced by increased dialysate concentrations of inflammatory mediators during MCO-HD, might eventually be compensated for by compartment redistribution or increased production during dialysis session. Nevertheless, lasting effects on the T-cell phenotype were seen, which deserves further investigation.
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Zawada AM, Lang T, Ottillinger B, Kircelli F, Stauss-Grabo M, Kennedy JP. Impact of Hydrophilic Modification of Synthetic Dialysis Membranes on Hemocompatibility and Performance. MEMBRANES 2022; 12:932. [PMID: 36295691 PMCID: PMC9610916 DOI: 10.3390/membranes12100932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 06/16/2023]
Abstract
The dialyzer is the core element in the hemodialysis treatment of patients with end-stage kidney disease (ESKD). During hemodialysis treatment, the dialyzer replaces the function of the kidney by removing small and middle-molecular weight uremic toxins, while retaining essential proteins. Meanwhile, a dialyzer should have the best possible hemocompatibility profile as the perpetuated contact of blood with artificial surfaces triggers complement activation, coagulation and immune cell activation, and even low-level activation repeated chronically over years may lead to undesired effects. During hemodialysis, the adsorption of plasma proteins to the dialyzer membrane leads to a formation of a secondary membrane, which can compromise both the uremic toxin removal and hemocompatibility of the dialyzer. Hydrophilic modifications of novel dialysis membranes have been shown to reduce protein adsorption, leading to better hemocompatibility profile and performance stability during dialysis treatments. This review article focuses on the importance of performance and hemocompatibility of dialysis membranes for the treatment of dialysis patients and summarizes recent studies on the impact of protein adsorption and hydrophilic modifications of membranes on these two core elements of a dialyzer.
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Affiliation(s)
- Adam M. Zawada
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany
| | - Thomas Lang
- Global Biomedical Evidence Generation, Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany
| | | | - Fatih Kircelli
- Medical Information and Education (EMEA), Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany
| | - Manuela Stauss-Grabo
- Global Biomedical Evidence Generation, Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany
| | - James P. Kennedy
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany
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Effect of Membrane Surface Area on Solute Removal Performance of Dialyzers with Fouling. MEMBRANES 2022; 12:membranes12070684. [PMID: 35877887 PMCID: PMC9320527 DOI: 10.3390/membranes12070684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
In a clinical situation, since membrane fouling often causes the reduction of solute removal performance of the dialyzer, it is necessary to evaluate the performance of the dialyzer, considering the effects of fouling even in aqueous in vitro experiments that are useful for the better design of dialyzers. We replicated the membrane fouling by immobilizing albumin on the membrane in a dialyzer using glutaraldehyde as a stabilizer. The modules of various membrane surface areas with and without replication of the fouling were used for performance evaluation of solute (creatinine, vitamin B12, and inulin) removal in dialysis experiments in vitro. Clearances for these solutes in the modules with fouling were lower than those without fouling. Furthermore, the smaller the surface area, the larger the fouling effect was observed in all solutes. Calculated pressure distribution in a module by using a mathematical model showed that the solute removal performance might be greatly affected by the rate of internal filtration that enhances the solute removal, especially for larger solutes. The increase in the rate of internal filtration should contribute to improving the solute removal performance of the dialyzer, with a higher effect in modules with a larger membrane surface area.
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Semi-Quantitative Evaluation of Asymmetricity of Dialysis Membrane Using Forward and Backward Ultrafiltration. MEMBRANES 2022; 12:membranes12060624. [PMID: 35736331 PMCID: PMC9228116 DOI: 10.3390/membranes12060624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 12/03/2022]
Abstract
Performance of the dialysis membrane is strongly dependent upon the physicochemical structure of the membrane. The objective of this study is to devise a new in vitro evaluation technique to quantify the physicochemical structures of the membrane. Three commercial dialyzers with cellulose triacetate (CTA), asymmetric CTA (termed ATA®), and polyether sulfone (PES) membranes (Nipro Co., Osaka, Japan) were employed for investigation. Forward and backward ultrafiltration experiments were performed separately with aqueous vitamin B12 (MW 1355), α-chymotrypsin (MW 25,000), albumin (MW 66,000) and dextran solutions, introducing the test solution inside or outside the hollow fiber (HF), respectively. Sieving coefficients (s.c.) for these solutes were measured under the test solution flow rate of 200 mL/min and the ultrafiltration rate of 10 mL/min at 310 K, according to the guidelines provided by Japanese academic societies. We defined the ratio of s.c. in the backward ultrafiltration to that in the forward ultrafiltration and termed it the index for asymmetricity (IA). The IA values were unity for vitamin B12 and α-chymotrypsin in all three of the dialyzers. The IA values for albumin, however, were 1.0 in CTA, 1.9 in ATA®, and 3.9 in PES membranes, respectively, which corresponded well with the fact that CTA is homogeneous, whereas ATA® and PES are asymmetrical in structure. Moreover, the asymmetricity of ATA® and PES may be different by twofold. This fact was verified in continuous basis by employing dextran solution before and after being fouled with albumin. These findings may contribute to the development of a novel membrane for improved success of dialysis therapy.
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Korucu B, Yeter H, Gonen S, Derici MK, Ronco C, Derici U. Impact of medium cut-off membranes on S100A12 and soluble receptor for advanced glycation end products. Semin Dial 2022; 36:193-200. [PMID: 35686486 DOI: 10.1111/sdi.13107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Of the most remarkable molecules associated with atherosclerosis and the cardiovascular outcome are S100A12 (10,379.5 Da) and soluble receptor for advanced glycation end products (sRAGE-42,803 Da) in the hemodialysis (HD) population. We designed a study investigating the effects of the medium cut-off (MCO) dialyzers focusing on S100A12 and sRAGE in HD patients compared with low-flux and high-flux dialyzers. METHODS This single-site, prospective, observational study comprises age and sex-matched HD groups (low-flux, high-flux, and MCO). Blood samples were drawn at baseline (predialysis and postdialysis) and the sixth month (predialysis). RESULTS Groups had similar demographic features and laboratory parameters. Baseline S100A12 levels of the groups were similar [34.3 (±66.5), 30.9 (±42.7), and 40.6 (±29.6); p = 0.13]. Compared to their baseline, the sixth-month S100A12 levels were constant in low-flux and high-flux group and significantly lower in MCO group (p = 0.16, p = 0.33, and p = 0.004). Baseline sRAGE levels of the groups were similar at baseline [2.8 (±0.8), 2.7 (±0.6), and 2.6 (±0.7); p = 0.65], and the sixth-month [2.9 (±0.5), 2.4 (±0.7), and 2.4 (±0.8); p = 0.24]. sRAGE levels remained constant in all groups [p = 0.84, p = 0.13, and p = 0.39]. S100A12/sRAGE ratio at baseline and sixth month was constant in low-flux [22.3 (±63.7) and 18.1 (±24.8); p = 0.17] and high-flux groups [11.9 (±15.3) and 13.1 (±5.8); p = 0.26], the ratio decreased significantly in MCO group [16.5 (±11.6) to 7.8 (±5.5); p = 0.03]. CONCLUSION Our study suggests that prolonged use of MCO dialyzers is associated with better S100A12 and sRAGE levels. Long-term studies with larger samples are needed to understand the effects of a better S100A12-sRAGE profile provided by MCO dialyzers on HD patients' cardiovascular outcomes.
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Affiliation(s)
- Berfu Korucu
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Hasan Yeter
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevim Gonen
- HLA Tissue Typing Laboratory, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Kursat Derici
- Department of Pharmacology, Kirikkale University Faculty of Medicine, Ankara, Turkey
| | - Claudio Ronco
- Department of Nephrology, Dialysis, and Kidney Transplant, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Ulver Derici
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
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23
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Effects of Medium Cut-Off Polyarylethersulfone and Polyvinylpyrrolidone Blend Membrane Dialyzers in Hemodialysis Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. MEMBRANES 2022; 12:membranes12050443. [PMID: 35629769 PMCID: PMC9144787 DOI: 10.3390/membranes12050443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 11/25/2022]
Abstract
The use of medium cut-off (MCO) polyarylethersulfone and polyvinylpyrrolidone blend membrane is an emerging mode in hemodialysis. Recent studies have shown that MCO membranes exhibit a middle high molecular weight uremic toxin clearance superior to standard high flux hemodialysis. We conducted a systematic literature review and meta-analysis of randomized controlled trials to investigate whether MCO membranes efficiently increase the reduction ratio of middle molecules, and to explore the potential clinical applications of MCO membranes. We selected articles that compared beta 2-microglobulin (β2M), kappa free light chain (κFLC), lambda free light chain (λFLC), interleukin-6 (IL-6), and albumin levels among patients undergoing hemodialysis. Five randomized studies with 328 patients were included. The meta-analysis demonstrated a significantly higher reduction ratio of serum β2M (p < 0.0001), κFLC (p < 0.0001), and λFLC (p = 0.02) in the MCO group. No significant difference was found in serum IL-6 levels after hemodialysis. Albumin loss was observed in the MCO group (p = 0.04). In conclusion, this meta-analysis study demonstrated the MCO membranes’ superior ability to clear β2M, κFLC, and λFLC. Serum albumin loss is an issue and should be monitored. Further studies are expected to identify whether MCO membranes could significantly improve clinical outcomes and overall survival.
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24
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Maduell F, Broseta JJ. Hemodiafiltration (HDF) versus expanded hemodialysis (HDx). Semin Dial 2022; 35:436-439. [PMID: 35293638 DOI: 10.1111/sdi.13071] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 12/22/2022]
Abstract
Medium cutoff (MCO) membranes have resulted in a novel dialyzer class designed to improve membrane permeability and have been postulated as an alternative to online hemodiafiltration since MCO membranes may achieve similar solute clearances. These membranes have been incorporated into clinical practice, and the term expanded HD (HDx) has been proposed to differentiate from high-flux hemodialysis. Efficacy, safety, and quality of life comparison of HDF versus HDx have been reviewed in this article.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
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25
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Mohajerani F, Clark WR, Ronco C, Narsimhan V. Mass Transport in High-Flux Hemodialysis: Application of Engineering Principles to Clinical Prescription. Clin J Am Soc Nephrol 2022; 17:749-756. [PMID: 35277434 PMCID: PMC9269577 DOI: 10.2215/cjn.09410721] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An understanding of the processes underlying mass transfer is paramount for the attainment of adequate solute removal in the dialytic treatment of patients with kidney failure. In this review, engineering principles are applied to characterize the physical mechanisms behind the two major modes of mass transfer during hemodialysis, namely diffusion and convection. The manner in which flow rate, dialyzer geometry, and membrane microstructure affect these processes is discussed, with concepts such as boundary layers, effective membrane diffusivity, and sieving coefficients highlighted as critical considerations. The objective is to improve clinicians' understanding of these concepts as important factors influencing the prescription and delivery of hemodialysis therapy.
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Affiliation(s)
- Farzad Mohajerani
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Nephrology Department, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Vivek Narsimhan
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana
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26
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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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27
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Lesión renal aguda en COVID-19: puesta al día y revisión de la literatura. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC7659511 DOI: 10.1016/j.acci.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Los coronavirus humanos son virus que se asocian a varias patologías respiratorias como el síndrome respiratorio agudo severo y el síndrome respiratorio del Medio Oriente. Esto ha puesto a esta familia de virus en el centro de atención de la comunidad científica debido a la alta patogenicidad en humanos, especialmente ahora con la nueva pandemia por la enfermedad por coronavirus del 2019 (COVID-19). La COVID-19 se manifiesta principalmente como enfermedad respiratoria aguda con compromiso respiratorio bajo, pero puede afectar múltiples órganos como lo es el riñón, lo cual a conlleva a peores desenlaces. En este manuscrito revisaremos el compromiso renal por los diferentes coronavirus, en especial en la COVID-19, al igual que las terapias que juegan algún papel en el tratamiento de esta.
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28
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Rosner MH, Reis T, Husain-Syed F, Vanholder R, Hutchison C, Stenvinkel P, Blankestijn PJ, Cozzolino M, Juillard L, Kashani K, Kaushik M, Kawanishi H, Massy Z, Sirich TL, Zuo L, Ronco C. Classification of Uremic Toxins and Their Role in Kidney Failure. Clin J Am Soc Nephrol 2021; 16:1918-1928. [PMID: 34233920 PMCID: PMC8729494 DOI: 10.2215/cjn.02660221] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in our understanding of uremic retention solutes, and improvements in hemodialysis membranes and other techniques designed to remove uremic retention solutes, offer opportunities to readdress the definition and classification of uremic toxins. A consensus conference was held to develop recommendations for an updated definition and classification scheme on the basis of a holistic approach that incorporates physicochemical characteristics and dialytic removal patterns of uremic retention solutes and their linkage to clinical symptoms and outcomes. The major focus is on the removal of uremic retention solutes by hemodialysis. The identification of representative biomarkers for different classes of uremic retention solutes and their correlation to clinical symptoms and outcomes may facilitate personalized and targeted dialysis prescriptions to improve quality of life, morbidity, and mortality. Recommendations for areas of future research were also formulated, aimed at improving understanding of uremic solutes and improving outcomes in patients with CKD.
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Affiliation(s)
- Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Thiago Reis
- Department of Nephrology, University of Brazil, Brasília, Brazil,National Academy of Medicine, Rio de Janeiro, Brazil
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Justus-Liebig-University Giessen, Giessen, Germany
| | - Raymond Vanholder
- Department of Internal Medicine and Pediatrics, University Hospital, Ghent, Belgium
| | - Colin Hutchison
- Faculty of Medicine, University of Queensland, Herston, Australia,Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Peter Stenvinkel
- Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Peter J. Blankestijn
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mario Cozzolino
- Renal Division, Università degli Studi di Milano, Milan, Italy
| | - Laurent Juillard
- University of Lyon, Villeurbanne, France,Hôpital E. Herriot, Lyon, France
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Hideki Kawanishi
- Department of Artificial Organs, Tsuchiya General Hospital, Hiroshima, Japan
| | - Ziad Massy
- INSERM U1018, Villejuif, France,Service de Néphrologie et Dialyse, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, France
| | - Tammy Lisa Sirich
- Nephrology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California,Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy,Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, Vicenza, Italy
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29
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Comoglu M, Dede F, Yenigun EC, Topcuoglu C, Inan O, Sahiner ES, Ates I. Effects of Medium Cutoff Membranes on Pro-Inflammatory Cytokine and Oxidative Marker Levels in Patients with Sepsis Who Developed Acute Kidney Injury. Blood Purif 2021; 51:772-779. [PMID: 34814149 DOI: 10.1159/000519881] [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: 08/07/2021] [Accepted: 09/27/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION There is insufficient data on the role of the medium cutoff (MCO) membranes in the clearance of pro-inflammatory cytokines and oxidant radicals in patients with sepsis requiring hemodialysis. METHODS The study consisted of 38 septic patients who developed acute kidney injury (AKI) and who were scheduled to undergo 2 sessions of hemodialysis. Nineteen patients underwent their first dialysis session with the MCO membrane and 19 patients with the high-flux (HF) membrane. In the second session, the membranes were switched. Pro-inflammatory cytokine and oxidative marker levels were measured in blood samples obtained before and after both dialysis sessions. Reduction ratios were compared for the 2 types of hemodialysis membranes. RESULTS After the first session, there was a greater reduction in tumor necrosis factor (TNF)-α with the MCO membrane (28.2 ± 21.1 vs. 8.0 ± 6.6, p = 0.001). After the second session, there was a greater reduction in interleukin (IL)-6 (27.8 ± 26.5 vs. 5.9 ± 13.3, p = 0.003) and IL-1β (20.5 ± 21.1 vs. 4.0 ± 6.5, p = 0.004) with the MCO membrane. When the first and second sessions of all 38 patients were compared, the reductions in TNF-α, IL-6, and IL-1β were consistently greater for MCO than HF (p = 0.001, p = 0.006, p < 0.001, respectively). The reductions in total antioxidant status, total oxidant status, and myeloperoxidase were not statistically different for the 2 types of dialysis membranes. CONCLUSIONS MCO membrane was superior to HF membrane in the removal of cytokines in septic patients with AKI. However, a similar effect was not observed for oxidative stress markers.
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Affiliation(s)
- Mustafa Comoglu
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Fatih Dede
- Department of Nephrology, Ankara City Hospital, Ankara, Turkey
| | | | - Canan Topcuoglu
- Department of Biochemistry, Ankara City Hospital, Ankara, Turkey
| | - Osman Inan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | | | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
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30
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Abstract
PURPOSE OF REVIEW Improvement in hemodialysis treatment and membrane technology are focused on two aims: the first one is to achieve a better control of circulating uremic solutes by enhancing removal capacity and by broadening molecular weight spectrum of solutes cleared; the second one is to prevent inflammation by improving hemocompatibility of the global dialysis system. RECENT FINDINGS Despite impressive progresses in polymers chemistry few hazards are still remaining associated with leaching or sensitization to polymer additives. Research has focused on developing more stable polymers by means of additives or processes aiming to minimize such risks. Membrane engineering manufacturing with support of nanocontrolled spinning technology has opened up membrane to middle and large molecular weight substances, while preserving albumin losses. Combination of diffusive and enhanced convective fluxes in the same hemodialyzer module, namely hemodiafiltration, provides today the highest solute removal capacity over a broad spectrum of solutes. SUMMARY Dialysis membrane is a crucial component of the hemodialysis system to optimize solute removal efficacy and to minimize blood membrane biological reactions. Hemodialyzer is much more than a membrane. Dialysis membrane and hemodialyzer choice are parts of a treatment chain that should be operated in optimized conditions and adjusted to patient needs and tolerance, to improve patient outcomes.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
- University of Montpellier, UFR of Medicine, Montpellier, France
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31
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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32
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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.
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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
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33
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Comparative analysis of therapeutic effects between medium cut-off and high flux dialyzers using metabolomics and proteomics: exploratory, prospective study in hemodialysis. Sci Rep 2021; 11:17335. [PMID: 34462546 PMCID: PMC8405670 DOI: 10.1038/s41598-021-96974-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/10/2021] [Indexed: 12/03/2022] Open
Abstract
In this single-center prospective study of 20 patients receiving maintenance hemodialysis (HD), we compared the therapeutic effects of medium cut-off (MCO) and high flux (HF) dialyzers using metabolomics and proteomics. A consecutive dialyzer membrane was used for 15-week study periods: 1st HF dialyzer, MCO dialyzer, 2nd HF dialyzer, for 5 weeks respectively. 1H-nuclear magnetic resonance was used to identify the metabolites and liquid chromatography-tandem mass spectrometry (LC–MS/MS) analysis was used to identify proteins. To compare the effects of the HF and MCO dialyzers, orthogonal projection to latent structure discriminant analysis (OPLS-DA) was performed. OPLS-DA showed that metabolite characteristics could be significantly classified by 1st HF and MCO dialyzers. The Pre-HD metabolites with variable importance in projection scores ≥ 1.0 in both 1st HF versus MCO and MCO versus 2nd HF were succinate, glutamate, and histidine. The pre-HD levels of succinate and histidine were significantly lower, while those of glutamate were significantly higher in MCO period than in the HF period. OPLS-DA of the proteome also substantially separated 1st HF and MCO periods. Plasma pre-HD levels of fibronectin 1 were significantly higher, and those of complement component 4B and retinol-binding protein 4 were significantly lower in MCO than in the 1st HF period. Interestingly, as per Ingenuity Pathway Analysis, an increase in epithelial cell proliferation and a decrease in endothelial cell apoptosis occurred during the MCO period. Overall, our results suggest that the use of MCO dialyzers results in characteristic metabolomics and proteomics profiles during HD compared with HF dialyzers, which might be related to oxidative stress, insulin resistance, complement-coagulation axis, inflammation, and nutrition.
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34
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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.
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Affiliation(s)
- Fernando Hadad-Arrascue
- Renal Therapy Services, Murcia, Spain.,Department of Nephrology, Reina Sofía University Hospital, Murcia, Spain
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35
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Abe M, Masakane I, Wada A, Nakai S, Kanda E, Nitta K, Nakamoto H. High-performance dialyzers and mortality in maintenance hemodialysis patients. Sci Rep 2021; 11:12272. [PMID: 34112908 PMCID: PMC8192518 DOI: 10.1038/s41598-021-91751-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022] Open
Abstract
Few data are available regarding the association of dialyzer type with prognosis. In Japan, dialyzers are classified as types I, II, III, IV, and V based on β2-microglobulin clearance rates of < 10, < 30, < 50, < 70, and ≥ 70 mL/min, respectively. We investigated the relationship of the 5 dialyzer types with 1-year mortality. This nationwide cohort study used data collected at the end of 2008 and 2009 by the Japanese Society for Dialysis Therapy Renal Data Registry. We enrolled 203,008 patients on maintenance hemodialysis who underwent hemodialysis for at least 1 year and were managed with any of the 5 dialyzer types. To evaluate the association of dialyzer type with 1-year all-cause mortality, Cox proportional hazards models and propensity score-matched analyses were performed. After adjustment of the data with clinicodemographic factors, the type I, II, and III groups showed significantly higher hazard ratios (HRs) than the type IV dialyzers (reference). After adjustment for Kt/V and β2-microglobulin levels, the HRs were significantly higher in the type I and II groups. After further adjustment for nutrition- and inflammation-related factors, the HRs were not significantly different between the type IV and type I and II groups. However, type V dialyzers consistently showed a significantly lower HR. With propensity score matching, the HR for the type V dialyzer group was significantly lower than that for the type IV dialyzer group. Additional long-term trials are required to determine whether type V dialyzers, which are high-performance dialyzers, can improve prognosis.
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Affiliation(s)
- Masanori Abe
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan. .,Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Ikuto Masakane
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Yabuki Hospital, Yamagata, Japan
| | - Atsushi Wada
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Shigeru Nakai
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Clinical Engineering, Fujita Health University, Aichi, Japan
| | - Eiichiro Kanda
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Medical Science, Kawasaki Medical School, Okayama, Japan
| | - Kosaku Nitta
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hidetomo Nakamoto
- The Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of General Internal Medicine, Saitama Medical University, Saitama, Japan
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Lee Y, Jang MJ, Jeon J, Lee JE, Huh W, Choi BS, Park CW, Chin HJ, Kang CL, Kim DK, Han SS, Joo KW. Cardiovascular Risk Comparison between Expanded Hemodialysis Using Theranova and Online Hemodiafiltration (CARTOON): A Multicenter Randomized Controlled Trial. Sci Rep 2021; 11:10807. [PMID: 34031503 PMCID: PMC8144214 DOI: 10.1038/s41598-021-90311-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022] Open
Abstract
Expanded hemodialysis (HDx) with medium cutoff (MCO) membranes, which remove middle-to-large molecules well, may be a good option to replace online hemodiafiltration (online-HDF). To provide more evidence, this randomized controlled trial compared several cardiovascular parameters between patients undergoing HDx and online-HDF. Eighty patients undergoing thrice-weekly hemodialysis were randomly assigned to receive either HDx with a Theranova membrane (n = 43) or online-HDF (n = 37). The primary endpoints were changes in brachial-ankle pulse wave velocity (baPWV), echocardiographic parameters, and coronary artery calcium (CAC) scores over 1 year, and the secondary endpoints included blood cardiovascular biomarkers, mortality, and patient-reported outcomes. A linear mixed model and log-rank test were used to estimate the group differences. 65 patients had completed the trial. The changes in baPWV and echocardiographic parameters did not differ between the two groups. The CAC scores remained stable in the online-HDF group, whereas an increasing trend was shown in the HDx group (P = 0.012). Other endpoints, including cardiovascular and all-cause mortalities, were similar between the two groups. The changes in cardiovascular parameters did not differ between HDx with an MCO membrane and online-HDF. However, attention may be needed in patients with high CAC scores or scores with an increasing tendency when online-HDF is replaced with HDx with an MCO membrane.
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Affiliation(s)
- Yeonhee Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Myoung-Jin Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
| | - Chae Lin Kang
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Perez-Garcia R, Alcazar-Arroyo R, de Sequera-Ortiz P. What is the role of expanded hemodialysis in renal replacement therapy in 2020? Nefrologia 2021; 41:227-236. [PMID: 36166240 DOI: 10.1016/j.nefroe.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/13/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
- Rafael Perez-Garcia
- Hospital Universitario Infanta Leonor, Servicio de Nefrología, Madrid, Spain.
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38
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Tiong MK, Krishnasamy R, Smith ER, Hutchison CA, Ryan EG, Pascoe EM, Hawley CM, Hewitson TD, Jardine MJ, Roberts MA, Cho Y, Wong MG, Heath A, Nelson CL, Sen S, Mount PF, Vergara LA, Paul-Brent PA, Johnson DW, Toussaint ND. Effect of a medium cut-off dialyzer on protein-bound uremic toxins and mineral metabolism markers in patients on hemodialysis. Hemodial Int 2021; 25:322-332. [PMID: 33779046 DOI: 10.1111/hdi.12924] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/03/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Hemodialysis (HD) with medium cut-off (MCO) dialyzers may expand molecular clearance, predominantly larger middle molecules (molecular weight 25-60 kDa). However, the impact of MCO dialyzers on long-term clearance of various other components of the uremic milieu is unknown. The tRial Evaluating Mid cut-Off Value membrane clearance of Albumin and Light chains in HemoDialysis patients (REMOVAL-HD) provided an opportunity to assess the effect of MCO dialyzers on protein-bound uremic toxins and novel markers of mineral metabolism. METHODS This exploratory sub-study of REMOVAL-HD evaluated changes in protein-bound solutes (total and free indoxyl sulfate [IS] and p-cresyl sulfate [PCS]) and mineral metabolism markers (intact fibroblast growth factor-23 [iFGF23], fetuin-A and endogenous calciprotein particles [CPP-1 and CPP-2]). Mid-week, pre-HD serum samples were collected at baseline and after 12 and 24 weeks of MCO use in stable adult patients. Change from baseline to Week 12 and 24 was estimated using linear mixed effects models. FINDINGS Eighty-nine participants were studied (mean age 67 ± 15 years, 38% female, 51% diabetic, median urine output 200 ml/24 h). Serum iFGF23 was reduced at Week 12 compared to baseline (-26.8% [95%CI -39.7, -11.1], p = 0.001), which was sustained at Week 24 (-21.7% [95%CI -35.7, -4.5], p = 0.012). There was no significant change in serum IS, PCS, fetuin-A, CPP-1, or CPP-2. DISCUSSION The use of a MCO dialyzer over 24 weeks was associated with a sustained reduction in FGF23, while other measured components of the uremic milieu were not significantly altered. Further studies are required to determine whether FGF23 reduction is associated with improved patient outcomes.
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Affiliation(s)
- Mark K Tiong
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast University Hospital, Birtinya, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Colin A Hutchison
- Department of Medicine, Hawke's Bay Hospital, Hawkes Bay, New Zealand
| | - Elizabeth G Ryan
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Meg J Jardine
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
- The George Institute for Global Health, UNSW, Sydney, Australia
- SAN Renal Dialysis Unit, Sydney Adventist Hospital, Sydney, Australia
- Department of Nephrology, Concord Repatriation and General Hospital, Sydney, Australia
| | - Matthew A Roberts
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Muh Geot Wong
- The George Institute for Global Health, UNSW, Sydney, Australia
- SAN Renal Dialysis Unit, Sydney Adventist Hospital, Sydney, Australia
| | - Anne Heath
- SAN Renal Dialysis Unit, Sydney Adventist Hospital, Sydney, Australia
| | - Craig L Nelson
- Department of Nephrology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia
- Western Health Chronic Disease Alliance, Western Centre for Health Research and Education, Western Health, St Albans, Australia
| | - Shaundeep Sen
- Department of Nephrology, Concord Repatriation and General Hospital, Sydney, Australia
| | - Peter F Mount
- Department of Nephrology, Austin Health, Melbourne, Victoria, Australia
| | - Liza A Vergara
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
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39
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Ronco C, Reis T. Continuous renal replacement therapy and extended indications. Semin Dial 2021; 34:550-560. [PMID: 33711166 DOI: 10.1111/sdi.12963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Extracorporeal blood purification (EBP) techniques provide support for critically ill patients with single or multiple organ dysfunction. Continuous renal replacement therapy (CRRT) is the modality of choice for kidney support for those patients and orchestrates the interactions between the different artificial organ support systems. Intensive care teams should be familiar with the concept of sequential extracorporeal therapy and plan on how to incorporate new treatment modalities into their daily practices. Importantly, scientific evidence should guide the decision-making process at the bedside and provide robust arguments to justify the costs of implementing new EBP treatments. In this narrative review, we explore the extended indications for CRRT as an adjunctive treatment to provide support for the heart, lung, liver, and immune system. We detail practicalities on how to run the treatments and how to tackle the most frequent complications regarding each of the therapies, whether applied alone or integrated. The physicochemical processes and technologies involved at the molecular level encompassing the interactions between the molecules, membranes, and resins are spotlighted. A clinical case will illustrate the timing for the initiation, maintenance, and discontinuation of EBP techniques.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy.,Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, Brazil
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Clínica de Doenças Renais de Brasília, Molecular Pharmacology Laboratory, University of Brasília, Brasilia, Brazil
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40
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Huddam B, Alp A, Kırlı İ, Yılmaz M, Çağırtekin A, Allı H, Edebali S. Medium Cut-Off Membrane Can Be a New Treatment Tool in Amanita phalloides Poisoning. Wilderness Environ Med 2021; 32:192-197. [PMID: 33676852 DOI: 10.1016/j.wem.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/16/2022]
Abstract
Mushroom poisoning is a common health problem that can be seen seasonally and geographically. Most mushroom poisoning requiring treatment worldwide is due to Amanita phalloides. Although liver failure and kidney injury are frequent, poisoning can also lead to more serious clinical situations, such as shock, pancreatitis, encephalopathic coma, cardiac failure, disseminated intravascular coagulation, and multiple organ dysfunction syndrome, and may cause death. In addition, when standard treatment approaches fail, extracorporeal treatment methods are often used. We report 2 cases in which hemodialysis with medium cut-off membrane was performed. We observed an improvement in liver and kidney function in both of our cases. The first case recovered, but the second case proved fatal owing to Acinetobacter sepsis, despite an improvement in renal function. Medium cut-off membrane hemodialysis may be an alternative option in the treatment of Amanita phalloides poisoning.
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Affiliation(s)
- Bülent Huddam
- Department of Nephrology, Faculty of Medicine, Mugla University, Mugla, Turkey
| | - Alper Alp
- Department of Nephrology, Faculty of Medicine, Mugla University, Mugla, Turkey.
| | - İsmail Kırlı
- Department of Internal Medicine, Faculty of Medicine, Mugla University, Mugla, Turkey
| | - Mehmet Yılmaz
- Department of Internal Medicine, Faculty of Medicine, Mugla University, Mugla, Turkey
| | - Aytuğ Çağırtekin
- Department of Internal Medicine, Faculty of Medicine, Mugla University, Mugla, Turkey
| | - Hakan Allı
- Department of Biology, Faculty of Science and Arts, Mugla University, Mugla, Turkey
| | - Sultan Edebali
- Department of Internal Medicine, Faculty of Medicine, Mugla University, Mugla, Turkey
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41
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[What is the role of expanded hemodialysis in renal replacement therapy in 2020?]. Nefrologia 2021; 41:227-236. [PMID: 33685663 DOI: 10.1016/j.nefro.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022] Open
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Monardo P, Lacquaniti A, Campo S, Bucca M, Casuscelli di Tocco T, Rovito S, Ragusa A, Santoro A. Updates on hemodialysis techniques with a common denominator: The personalization of the dialytic therapy. Semin Dial 2021; 34:183-195. [PMID: 33592133 DOI: 10.1111/sdi.12956] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/02/2020] [Indexed: 12/14/2022]
Abstract
Hemodialysis (HD) is a life-saving therapy for patients with end-stage renal disease. In dialyzed patients, the prevalence of multi-morbidity is rising driven by various factors, such as the population aging, the incomplete correction of uremia, and the side effects of the dialysis therapy itself. Each dialyzed patient has their own specific clinical and biochemical problems. It is therefore unthinkable that the same dialysis procedure can be able to meet the needs of every patient on chronic dialysis. We have very sophisticated dialysis machines and different dialysis techniques and procedures beyond conventional HD, such as hemodiafiltration (HDF) with pre- and post-dilution, acetate-free biofiltration (AFB), hemofiltration (HF), and expanded HD. Each of these techniques has its own specific characteristics. To solve some intradialytic clinical issues, such as arterial hypotension and arrhythmias, we have biofeedback systems with automatic regulation of the blood volume, body temperature, arterial pressure, as well as potassium profiling techniques in the dialysis bath. New technical innovations, such as citrate-containing dialysate or heparin-coated membranes, could reduce the risk of bleeding. To better address to patient needs, the strengths and weaknesses of each of these systems must be well-known, in order to have a personalized dialysis prescription for each patient.
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Affiliation(s)
- Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | | | - Susanna Campo
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Maurizio Bucca
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | | | - Stefania Rovito
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Antonino Ragusa
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Antonio Santoro
- Department of Organ Failures and Transplantations, Policlinico S.Orsola-Malpighi- Bologna, Italy
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Low density lipoprotein (LDL) apheresis from blood plasma via anti-biofouling tuned membrane incorporated with graphene oxide-modified carrageenan. J Memb Sci 2021. [DOI: 10.1016/j.memsci.2020.118878] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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High cut-off dialysis mitigates pro-calcific effects of plasma on vascular progenitor cells. Sci Rep 2021; 11:1144. [PMID: 33441772 PMCID: PMC7807056 DOI: 10.1038/s41598-020-80016-7] [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: 06/11/2020] [Accepted: 11/10/2020] [Indexed: 11/08/2022] Open
Abstract
Mortality of patients with end-stage renal disease tremendously exceeds that of the general population due to excess cardiovascular morbidity. Large middle-sized molecules (LMM) including pro-inflammatory cytokines are major drivers of uremic cardiovascular toxicity and cannot be removed sufficiently by conventional high-flux (HFL) hemodialysis. We tested the ability of plasma from 19 hemodialysis patients participating in a trial comparing HFL with high cut-off (HCO) membranes facilitating removal of LMM to induce calcification in mesenchymal stromal cells (MSC) functioning as vascular progenitors. HCO dialysis favorably changed plasma composition resulting in reduced pro-calcific activity. LMM were removed more effectively by HCO dialysis including FGF23, a typical LMM we found to promote osteoblastic differentiation of MSC. Protein-bound uremic retention solutes with known cardiovascular toxicity but not LMM inhibited proliferation of MSC without direct toxicity in screening experiments. We could not attribute the effect of HCO dialysis on MSC calcification to distinct mediators. However, we found evidence of sustained reduced inflammation that might parallel other anti-calcifying mechanisms such as altered generation of extracellular vesicles. Our findings imply protection of MSC from dysfunctional differentiation by novel dialysis techniques targeted at removal of LMM. HCO dialysis might preserve their physiologic role in vascular regeneration and improve outcomes in dialysis patients.
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Alarcon JC, Bunch A, Ardila F, Zuñiga E, Vesga JI, Rivera A, Sánchez R, Sanabria RM. Impact of Medium Cut-Off Dialyzers on Patient-Reported Outcomes: COREXH Registry. Blood Purif 2020; 50:110-118. [PMID: 33176299 DOI: 10.1159/000508803] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/18/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A new generation of hemodialysis (HD) membranes called medium cut-off (MCO) membranes possesses enhanced capacities for middle molecule clearance, which have been associated with adverse outcomes in this population. These improvements could potentially positively impact patient-reported outcomes (PROs). OBJECTIVE The objective of this study was to evaluate the impact of MCO membranes on PROs in a cohort of HD patients in Colombia. METHODS This was a prospective, multicenter, observational cohort study of 992 patients from 12 renal clinics in Colombia who were switched from high-flux HD to MCO therapy and observed for 12 months. Changes in Kidney Disease Quality of Life 36-Item Short Form Survey (KDQoL-SF36) domains, Dialysis Symptom Index (DSI), and restless legs syndrome (RLS) 12 months after switching to MCO membranes were compared with time on high-flux membranes. Repeated measures of ANOVA were used to evaluate changes in KDQoL-SF36 scores; severity scoring was used to assess DSI changes over time; Cochran's Q test was used to evaluate changes in frequency of diagnostic criteria of RLS. RESULTS During 12 months of follow-up, 3 of 5 KDQoL-SF36 domains improved compared with baseline: symptoms (p < 0.0001), effects of kidney disease (p < 0.0001), and burden of kidney disease (p < 0.001). The proportion of patients diagnosed with RLS significantly decreased from 22.1% at baseline to 10% at 12 months (p < 0.0001). No significant differences in the number of symptoms (DSI, p = 0.1) were observed, although their severity decreased (p = 0.009). CONCLUSIONS In conventional HD patients, the expanded clearance of large middle molecules with MCO-HD membranes was associated with higher health-related quality of life scores and a decrease in the prevalence of RLS.
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Affiliation(s)
| | - Alfonso Bunch
- Renal Therapy Services-Latin America, Bogotá, Colombia
| | | | | | | | - Angela Rivera
- Baxter Healthcare Corporation, Deerfield, Illinois, USA
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46
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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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Lim JH, Jeon Y, Yook JM, Choi SY, Jung HY, Choi JY, Park SH, Kim CD, Kim YL, Cho JH. Medium cut-off dialyzer improves erythropoiesis stimulating agent resistance in a hepcidin-independent manner in maintenance hemodialysis patients: results from a randomized controlled trial. Sci Rep 2020; 10:16062. [PMID: 32994531 PMCID: PMC7524751 DOI: 10.1038/s41598-020-73124-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023] Open
Abstract
The response to erythropoiesis stimulating agents (ESAs) is affected by inflammation linked to middle molecules in hemodialysis (HD) patients. We evaluated the effect of a medium cut-off (MCO) dialyzer on ESA resistance in maintenance HD patients. Forty-nine patients who underwent high-flux HD were randomly allocated to the MCO or high-flux group. The primary outcome was the changes of erythropoietin resistance index (ERI; U/kg/wk/g/dL) between baseline and 12 weeks. The MCO group showed significant decrease in the ESA dose, weight-adjusted ESA dose, and ERI compared to the high-flux group at 12 weeks (p < 0.05). The generalized estimating equation models revealed significant interactions between groups and time for the ESA dose, weight-adjusted ESA dose, and ERI (p < 0.05). Serum iron and transferrin saturation were higher in the MCO group at 12 weeks (p < 0.05). The MCO group showed a greater reduction in TNF-α and lower serum TNF-α level at 12 weeks compared to the high-flux group (p < 0.05), whereas no differences were found in the reduction ratio of hepcidin and serum levels of erythropoietin, erythroferrone, soluble transferrin receptor and hepcidin between groups. HD with MCO dialyzer improves ESA resistance over time compared to high-flux HD in maintenance HD patients. The MCO dialyzer provides superior removal of the inflammatory cytokine and thus improves iron metabolism in a hepcidin-independent manner.
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Affiliation(s)
- Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yena Jeon
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Ju-Min Yook
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Soon-Youn Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Hee-Yeon Jung
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sun-Hee Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Lim Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea.
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48
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Weiner DE, Falzon L, Skoufos L, Bernardo A, Beck W, Xiao M, Tran H. Efficacy and Safety of Expanded Hemodialysis with the Theranova 400 Dialyzer: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2020; 15:1310-1319. [PMID: 32843372 PMCID: PMC7480550 DOI: 10.2215/cjn.01210120] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Expanded hemodialysis therapy enabled by medium cut-off membranes may promote greater clearance of larger middle molecules that comprise putative uremic solutes than conventional high-flux dialysis. This randomized trial evaluated the efficacy and safety of hemodialysis treatment with a medium cut-off dialyzer. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Clinically stable patients on maintenance hemodialysis were randomized to receive dialysis with either a medium cut-off dialyzer (Theranova 400) or a high-flux dialyzer (Elisio-17H) over 24 weeks of treatment. The primary safety end point was the predialysis serum albumin level after 24 weeks of treatment. The primary efficacy end point was the reduction ratio of free λ light chains at 24 weeks of treatment. RESULTS Among 172 patients on maintenance hemodialysis, mean age was 59±13 years, 61% were men, 40% were Black, and mean dialysis vintage was 5±4 years. Of the 86 patients randomized to each dialyzer, 65 completed the trial in each group. The reduction ratio for the removal of free λ light chains was significantly higher in the Theranova 400 group compared with the Elisio-17H group after 4 weeks (39% versus 20%) and 24 weeks (33% versus 17%; both P<0.001). Among secondary end points, the Theranova 400 group demonstrated significantly larger reduction ratios at 4 and 24 weeks for complement factor D, free κ light chains, TNFα, and β2-microglobulin (P<0.001 for all), but not for IL-6. Predialysis serum albumin levels were similar between groups after 24 weeks (4 g/dl with the Theranova 400 and 4.1 g/dl with the Elisio-17H), consistent with noninferiority of the Theranova 400 dialyzer in maintaining predialysis serum albumin levels after 24 weeks of treatment. CONCLUSIONS Hemodialysis therapy with the Theranova 400 dialyzer provides superior removal of larger middle molecules, as exemplified by free λ light chains, compared with a similar size high-flux dialyzer, while maintaining serum albumin level. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER A Multi-Center, Prospective, Randomized, Controlled, Open-Label, Parallel Study to Evaluate the Safety and Efficacy of the Theranova 400 Dialyzer in End Stage Renal Disease (ESRD) Patients, NCT03257410.
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Affiliation(s)
- Daniel E. Weiner
- Tufts Medical Center, Medicine, Nephrology, Boston, Massachusetts
| | - Luke Falzon
- Baxter Healthcare Corporation, Worldwide Medical, San Gwann, Malta
| | - Line Skoufos
- Baxter Healthcare Corporation, Worldwide Medical, Deerfield, Illinois
| | - Angelito Bernardo
- Baxter Healthcare Corporation, Worldwide Medical, Deerfield, Illinois
| | - Werner Beck
- Baxter International Inc., Worldwide Medical, Hechingen, Germany
| | - Mengqi Xiao
- Baxter Healthcare Corporation, Worldwide Medical, Deerfield, Illinois
| | - Ha Tran
- Baxter Healthcare Corporation, Worldwide Medical, Deerfield, Illinois
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49
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Putz FJ, Jung EM, Putz C, Banas MC, Bergler T, Vienken J, Banas B. Contrast-Enhanced Ultrasonography as a Novel Method for the Dynamic Visualization of Blood Flow and Fiber Blockage in Dialyzers: A Feasibility Study. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:2265-2275. [PMID: 32553530 DOI: 10.1016/j.ultrasmedbio.2020.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/07/2020] [Accepted: 05/05/2020] [Indexed: 06/11/2023]
Abstract
The capillary dialyzer represents the central element of the extracorporeal blood circuit of a therapy system for hemodialysis. The aim of this study was to assess the blood-flow characteristics of dialyzers with the help of modern ultrasound techniques. Five brand-new dialyzers (FX80 classix, Fresenius Medical Care, Bad Homburg, Germany) and five dialyzers after a dialysis session were analyzed by different ultrasound techniques to detect functional and structural changes. B-mode and Doppler techniques were not suitable to describe differences in brand-new and clinically applied dialyzers. Contrast-enhanced ultrasonography, however, was able to visualize blood-flow profiles in the capillaries. Although dialyzers displayed no signs of clinical dysfunction, contrast-enhanced ultrasonography was able to detect blocked capillaries of varying degrees after a dialysis session in all five examined dialyzers. Consequently, the blood-flow velocity was higher in the remaining unblocked capillaries in comparison to the velocity in the brand-new dialyzers. This information may be helpful for improving the geometric design of dialyzers, including their capillary membranes, and optimizing anti-coagulation strategies in hemodialysis patients.
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Affiliation(s)
- Franz Josef Putz
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany.
| | - Ernst Michael Jung
- Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Christina Putz
- Department of Cardio-thoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Miriam C Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | | | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
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50
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Santos A, Macías N, Vega A, Abad S, Linares T, Aragoncillo I, Cruzado L, Pascual C, Goicoechea M, López-Gómez JM. Efficacy of enoxaparin in preventing coagulation during high-flux haemodialysis, expanded haemodialysis and haemodiafiltration. Clin Kidney J 2020; 14:1120-1125. [PMID: 33841857 PMCID: PMC8023216 DOI: 10.1093/ckj/sfaa057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Low-molecular-weight heparins (LMWHs) are easily dialysable with high-flow membranes; however, it is not clear whether the LMWH dose should be adjusted according to the membrane type and dialysis technique. This study aimed to evaluate the influence of the dialyser on anticoagulation of the extracorporeal dialysis circuit. Methods Thirteen patients received the same dose of LMWH through the arterial port via three dialysis techniques: high-flux haemodialysis (HF-HD), online haemodiafiltration (HDF) and expanded haemodialysis (HDx). All dialysis was performed under similar conditions: duration, 4 h; blood flow, 400 mL/min; and dialysate flow, 500 mL/min. Antifactor Xa (aXa) activity and activated partial thromboplastin time (APTT) were measured before and after the dialysis. Clotting time of the vascular access site after haemodialysis, visual clotting score of the dialyser and any complications with the extracorporeal circuit or bleeding were registered. Results Post-dialysis aXa activity in HF-HD (0.26 ± 0.02 U/mL) was significantly different from that in HDF (0.21 ± 0.02 U/mL, P = 0.024), and there was a trend in HDx (0.22 ± 0.01 U/mL, P = 0.05). APTT post-dialysis in HF-HD (30.5 ± 0.7 s) was significantly different from that in HDx (28.2 ± 0.64 s, P = 0.009) and HDF (28.8 ± 0.73 s, P = 0.009). Conclusions AXa activity in HDF was significantly lower than that in HF-HD, possibly because of more losses of LMWH through the dialyser. Given the higher anticoagulant loss in HDF and probably in HDx than in HF-HD, the enoxaparin dose administered may be adjusted according to the dialysis technique.
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Affiliation(s)
- Alba Santos
- Nephrology Department, Hospital Universitario del Vinalopó, Elche, Spain
| | - Nicolás Macías
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonidas Cruzado
- Nephrology Department, Hospital Universitario de Elche, Elche, Spain
| | - Cristina Pascual
- Hematology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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