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Huang JY, Hsu CW, Yang CW, Hung CC, Huang WH. Role of anuria in the relationship between indoxyl sulfate and anemia in peritoneal dialysis patients. Ther Clin Risk Manag 2016; 12:1797-1803. [PMID: 27932887 PMCID: PMC5135005 DOI: 10.2147/tcrm.s120012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Experimental evidence suggests that indoxyl sulfate (IS) is associated with chronic kidney disease-related anemia. However, clinical studies are limited, and few have explored the potential confounding effect of anuria. This study, thus, evaluated the association between IS and anemia in both non-anuric and anuric peritoneal dialysis (PD) patients. Methods This cross-sectional and observational study included 165 chronic PD patients aged 19–84 years. Their serum IS levels in total and free forms were measured by ultra performance liquid chromatography. Correlations between serum IS and hemoglobin (Hb) were performed in both non-anuric and anuric groups. Results Among the study subjects, 90 were non-anuric and 75 were anuric. As a whole, there was no correlation between IS and Hb. Nonetheless, subsequent analysis of the non-anuric patients showed that Hb is negatively correlated with IS levels (rs=−0.405, P<0.001 for total form and rs=−0.296, P=0.005 for free form). Factors that significantly affected Hb levels in the stepwise multiple regression analysis include total IS and iron saturation. In contrast for anuric patients, serum ferritin, albumin, iron saturation, use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, but not serum IS, were predictors for anemia in the multiple regression model. Conclusions Serum IS is associated with an increased severity of anemia in non-anuric PD patients and not in anuric ones, indicating anuria could be a confounding factor in such association.
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Affiliation(s)
- Jeng-Yi Huang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taipei; Chang Gung University School of Medicine, Taoyuan, Taiwan
| | - Ching-Wei Hsu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taipei; Chang Gung University School of Medicine, Taoyuan, Taiwan
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taipei; Chang Gung University School of Medicine, Taoyuan, Taiwan
| | - Cheng-Chieh Hung
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taipei; Chang Gung University School of Medicine, Taoyuan, Taiwan
| | - Wen-Hung Huang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taipei; Chang Gung University School of Medicine, Taoyuan, Taiwan
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Lines SW, Carter AM, Dunn EJ, Lindley EJ, Tattersall JE, Wright MJ. A randomized controlled trial evaluating the erythropoiesis stimulating agent sparing potential of a vitamin E-bonded polysulfone dialysis membrane. Nephrol Dial Transplant 2013; 29:649-56. [PMID: 24293660 PMCID: PMC3938299 DOI: 10.1093/ndt/gft481] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Vitamin E (VE) bonded polysulfone dialysis membranes have putative erythropoiesis stimulating agent (ESA)-sparing and anti-inflammatory properties based on data from a small number of studies. We sought to investigate this in a large, prospective 12-month randomized controlled trial. Methods Two-hundred and sixty prevalent haemodialysis (HD) patients were randomized to dialysis with VE-bonded polysulfone membranes or non-VE-bonded equivalents. All ESA-dosing was performed by means of a computer-based anaemia management decision support system. Monthly data were used to calculate the ESA resistance index (ERI) and blood tests were performed at baseline, 6 and 12 months for measurement of C-reactive protein (CRP) levels. Results Of the 260 patients, 123 were randomized to dialysis with the VE-membrane and 12-month data was available for 220 patients. At the study population level, no beneficial effect of the VE membranes on the ERI or CRP levels was observed. Post hoc analyses indicated that there was a significant fall in ERI for patients with the highest baseline ESA resistance dialysed with the VE (9.28 [7.70–12.5] versus 7.70 [5.34–12.7] IU/week/kg/g/dL Hb, P = 0.01) but not the control membranes (9.45 [7.62–12.3] versus 8.14 [4.44–15.6] IU/week/kg/g/dL Hb, P = 0.41); this was not attributable to changes in CRP levels. Conclusions Wholesale switching of all chronic HD patients to dialysis with VE-bonded polysulfone membranes appears not to be associated with improvements in ESA-responsiveness or CRP. These membranes may have utility in patients with heightened ESA resistance.
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Affiliation(s)
- Simon W Lines
- Department of Nephrology, St. James's University Hospital, Leeds, UK
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Susantitaphong P, Siribamrungwong M, Jaber BL. Convective therapies versus low-flux hemodialysis for chronic kidney failure: a meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2013; 28:2859-74. [PMID: 24081858 DOI: 10.1093/ndt/gft396] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although convective therapies have gained popularity for the optimal removal of uremic solutes, their benefits and potential risks have not been fully elucidated. We conducted a meta-analysis of all randomized controlled trials comparing convective therapies with low-flux hemodialysis in patients with chronic kidney failure. METHODS We performed a literature search using MEDLINE (inception-December 2012), Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, scientific abstracts from meetings and bibliographies of retrieved articles. Randomized controlled trials comparing the effect of convective therapies including high-flux hemodialysis, hemofiltration or hemodiafiltration versus low-flux hemodialysis were included. Random-effects model meta-analyses were used to examine continuous and binary outcomes. RESULTS Sixty-five (29 crossover and 36 parallel-arm) trials were identified (n = 12 182). Convective therapies resulted in a decrease in all-cause mortality [relative risk (RR) 0.88; 95% confidence interval (CI) 0.76, 1.02, P = 0.09], cardiovascular mortality (RR 0.84; 95% CI 0.71, 0.98, P = 0.03), all-cause hospitalization (RR 0.91; 95% CI 0.82, 1.01; P = 0.08) and therapy-related hypotension (RR 0.55, 95% CI 0.35, 0.87, P = 0.01). Convective therapies also resulted in an increase in the clearance of several low-molecular-weight (urea, creatinine and phosphate), middle-sized (β-2 microglobulin and leptin) and protein-bound (homocysteine, advanced glycation end-products and pentosidine) solutes and a decrease in inflammatory markers (interleukin-6). There was no impact of convective therapies on cardiac morphological and functional parameters, and blood pressure and anemia parameters. CONCLUSIONS Although convective therapies are associated with improved clearance of uremic solutes, the potential long-term benefits of specific convective modalities require further study.
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Affiliation(s)
- Paweena Susantitaphong
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St. Elizabeth's Medical Center, Boston, MA, USA
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Palmer SC, Rabindranath KS, Craig JC, Roderick PJ, Locatelli F, Strippoli GFM. High-flux versus low-flux membranes for end-stage kidney disease. Cochrane Database Syst Rev 2012; 2012:CD005016. [PMID: 22972082 PMCID: PMC6956628 DOI: 10.1002/14651858.cd005016.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical practice guidelines regarding the use of high-flux haemodialysis membranes vary widely. OBJECTIVES We aimed to analyse the current evidence reported for the benefits and harms of high-flux and low-flux haemodialysis. SEARCH METHODS We searched Cochrane Renal Group's specialised register (July 2012), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1948 to March 2011), and EMBASE (1947 to March 2011) without language restriction. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared high-flux haemodialysis with low-flux haemodialysis in people with end-stage kidney disease (ESKD) who required long-term haemodialysis. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors for study characteristics (participants and interventions), risks of bias, and outcomes (all-cause mortality and cause-specific mortality, hospitalisation, health-related quality of life, carpal tunnel syndrome, dialysis-related arthropathy, kidney function, and symptoms) among people on haemodialysis. Treatment effects were expressed as a risk ratio (RR) or mean difference (MD), with 95% confidence intervals (CI) using the random-effects model. MAIN RESULTS We included 33 studies that involved 3820 participants with ESKD. High-flux membranes reduced cardiovascular mortality (5 studies, 2612 participants: RR 0.83, 95% CI 0.70 to 0.99) but not all-cause mortality (10 studies, 2915 participants: RR 0.95, 95% CI 0.87 to 1.04) or infection-related mortality (3 studies, 2547 participants: RR 0.91, 95% CI 0.71 to 1.14). In absolute terms, high-flux membranes may prevent three cardiovascular deaths in 100 people treated with haemodialysis for two years. While high-flux membranes reduced predialysis beta-2 microglobulin levels (MD -12.17 mg/L, 95% CI -15.83 to -8.51 mg/L), insufficient data were available to reliably estimate the effects of membrane flux on hospitalisation, carpal tunnel syndrome, or amyloid-related arthropathy. Evidence for effects of high-flux membranes was limited by selective reporting in a few studies. Insufficient numbers of studies limited our ability to conduct subgroup analyses for membrane type, biocompatibility, or reuse. In general, the risk of bias was either high or unclear in the majority of studies. AUTHORS' CONCLUSIONS High-flux haemodialysis may reduce cardiovascular mortality in people requiring haemodialysis by about 15%. A large well-designed RCT is now required to confirm this finding.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
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Knezevic MZ, Djordjevic VV, Radovanovic-Velickovic RM, Stankovic JJ, Cvetkovic TP, Djordjevic VM. Influence of dialysis modality and membrane flux on quality of life in hemodialysis patients. Ren Fail 2012; 34:849-55. [PMID: 22607060 DOI: 10.3109/0886022x.2012.684555] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The quality of life in patients undergoing hemodialysis is significantly disturbed. There are data that hemodiafiltration (HDF) may be more effective than conventional hemodialysis in the removal of uremic toxins and may reduce frequency and severity of intradialytic and postdialysis adverse symptoms in patients. Also, some researchers suggest advantages of using high-flux membranes compared with low-flux. OBJECTIVE The aim of this study was to examine whether hemodialysis modality and membrane flux, independent of membrane biocompatibility, make differences in quality of life in patients. METHODS In our cross-sectional study, we evaluated 124 patients who were divided, based on therapy, into three groups: online HDF, high-flux hemodialysis, and low-flux hemodialysis. Data were collected using the Short Form-36 questionnaire combined with special questionnaire, which included demographic and clinically related questions. RESULTS Health-related quality of life was better in patients on HDF compared with patients on hemodialysis, especially compared with low-flux hemodialysis patients in most of the scales and in both dimensions: physical component scale and mental component scale. There were no statistically significant differences in Short Form-36 domains between high-flux hemodialysis and low-flux hemodialysis. CONCLUSION Our data suggest the potential advantages of HDF with regard to influence on quality of life, which is sufficient to justify further research in prospective and longitudinal study design.
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Schneider A, Drechsler C, Krane V, Krieter DH, Scharnagl H, Schneider MP, Wanner C. The effect of high-flux hemodialysis on hemoglobin concentrations in patients with CKD: results of the MINOXIS study. Clin J Am Soc Nephrol 2011; 7:52-9. [PMID: 22096040 DOI: 10.2215/cjn.02710311] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Hemodialysis treatment induces markers of inflammation and oxidative stress, which could affect hemoglobin levels and the response to erythropoietin use. This study sought to determine whether high-flux dialysis would help improve markers of renal anemia, inflammation, and oxidative stress compared with low-flux dialysis. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS In a prospective, controlled study, 221 patients undergoing maintenance hemodialysis and receiving darbepoetin-alfa treatment (mean age, 66 years; 55% male) from 19 centers were screened in a 20-week run-in period of low-flux hemodialysis with a synthetic dialysis membrane. Thereafter, 166 patients were enrolled and randomly assigned to receive a synthetic high-flux membrane or to continue on low-flux dialysis for 52 weeks. Data on myeloperoxidase, oxidized LDL, high-sensitivity C-reactive protein, and the Malnutrition Inflammation Score were collected at baseline and after 52 weeks; routine laboratory data, such as hemoglobin, ferritin, and albumin, and the use of darbepoetin-alfa, were also measured in the run-in period. Results After 52 weeks, the low-flux and the high-flux groups did not differ with respect to hemoglobin (mean ± SD, 11.7±0.9 g/dl versus 11.7±1.1 g/dl; P=0.62) or use of darbepoetin-alfa (mean dosage ± SD, 29.8±24.8 μg/wk versus 26.0±31.1 μg/wk; P=0.85). Markers of inflammation, oxidative stress, or nutritional status also did not differ between groups. CONCLUSION Over 1 year, high-flux dialysis had no superior effects on hemoglobin levels or markers of inflammation, oxidative stress, and nutritional status. These data do not support the hypothesis that enhanced convective toxin removal would improve patient outcome.
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Affiliation(s)
- Andreas Schneider
- Department of Medicine, Division of Nephrology, University Hospital Würzburg, Germany.
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Abstract
Approximately 5-10% of patients with chronic kidney disease demonstrate hyporesponsiveness to erythropoiesis-stimulating agents (ESA), defined as a continued need for greater than 300 IU/kg per week erythropoietin or 1.5 mug/kg per week darbepoetin administered by the subcutaneous route. Such hyporesponsiveness contributes significantly to morbidity, mortality and health-care economic burden in chronic kidney disease and represents an important diagnostic and management challenge. The commonest causes of ESA resistance are non-compliance, absolute or functional iron deficiency and inflammation. It is widely accepted that maintaining adequate iron stores, ideally by administering iron parenterally, is the most important strategy for reducing the requirements for, and enhancing the efficacy of ESA. There have been recent epidemiologic studies linking parenteral iron therapy to an increased risk of infection and atherosclerosis, although other investigations have refuted this. Inflammatory ESA hyporesponsiveness has been reported to be improved by a number of interventions, including the use of biocompatible membranes, ultrapure dialysate, transplant nephrectomy, ascorbic acid therapy, vitamin E supplementation, statins and oxpentifylline administration. Other variably well-established causes of ESA hyporesponsiveness include inadequate dialysis, hyperparathyroidism, nutrient deficiencies (vitamin B12, folate, vitamin C, carnitine), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aluminium overload, antibody-mediated pure red cell aplasia, primary bone marrow disorders, myelosuppressive agents, haemoglobinopathies, haemolysis and hypersplenism. This paper reviews the causes of ESA hyporesponsiveness and the clinical evidence for proposed therapeutic interventions. A practical algorithm for approaching the investigation and management of patients with ESA hyporesponsiveness is also provided.
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Affiliation(s)
- David W Johnson
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Locatelli F, Del Vecchio L, Pozzoni P, Andrulli S. Dialysis adequacy and response to erythropoiesis-stimulating agents: what is the evidence base? Semin Nephrol 2007; 26:269-74. [PMID: 16949464 DOI: 10.1016/j.semnephrol.2006.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Despite an increase in the use and average dose of erythropoiesis-stimulating agents (ESA) over the past 15 years, a substantial percentage of patients still do not achieve hemoglobin targets recommended by international guidelines. A clear relationship among hemoglobin or hematocrit levels, ESA dose, and increase in dialysis dose has been pointed out by a number of prospective or retrospective studies. This is particularly true in patients receiving inadequate dialysis. Increasing attention also has been paid to the relationship between dialysis, increased inflammatory stimulus, and ESA response because dialysate contamination and low-compatible treatments may increase cytokine production and consequently inhibit erythropoiesis. The biocompatibility of dialysis membranes and flux are other important factors. However, in highly selected, adequately dialyzed patients without iron or vitamin depletion, the effect of these treatment modalities on anemia seems to be smaller than expected. The role of on-line treatments still is controversial given that it is still difficult to discriminate between the effect of on-line hemodiafiltration per se from that of an increased dialysis dose. Very preliminary results obtained with short or long nocturnal daily hemodialysis on anemia correction are encouraging.
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Affiliation(s)
- Francesco Locatelli
- The Department of Nephrology and Dialysis, Ospedale A. Manzoni, Lecco, Italy.
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Abstract
The anemia of chronic kidney disease is associated with cardiovascular disease, decreased quality of life, and mortality. The introduction of recombinant human erythropoietin (rHuEPO) has transformed the management of this condition. However, a significant proportion of patients fail to respond to even high doses of rHuEPO. Several factors have been implicated in the hyporesponsiveness to rHuEPO. Iron deficiency, whether absolute or functional, is considered the most important, and maintenance of adequate iron stores reduces rHuEPO requirements among patients on hemodialysis. However, traditional indices of iron that are currently utilized may not reflect iron stores accurately, and there is also increasing concern regarding the potential long-term toxicity of parenteral iron therapy. Infection and inflammation also influence the response to rHuEPO, both by disruption of iron metabolism and by eliciting the release of cytokines that inhibit erythropoiesis. Oxidative stress may contribute to rHuEPO hyporesponsiveness directly by promoting lipid peroxidation in cell membranes, leading to increased erythrocyte fragility and reduced life span and also through its strong association with inflammation. Severe hyperparathyroidism can lead to a reduced number of erythroid progenitor cells. Inadequate dialysis dose, aluminum overload, nutritional factors such as deficiencies of carnitine, vitamin B12, folic acid, and vitamin C can also reduce the efficacy of rHuEPO therapy. Hyporesponsiveness to rHuEPO presents a challenge to both diagnosis and management in an era where optimizing response to rHuEPO is critical both in limiting the burgeoning costs of anemia management and improving clinical outcomes in the dialysis population.
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Affiliation(s)
- Christina Kwack
- Division of Nephrology, Department of Medicine, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA
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References. Am J Kidney Dis 2006. [DOI: 10.1053/j.ajkd.2006.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Vlatković V, Mitrović Đ, Arežina A, Vuković L, Bogićević K, Radivojević S. Epidemiology of renal disease patients treated by continuous dialyses in Republika Srpska. SCRIPTA MEDICA 2004. [DOI: 10.5937/scrimed0401023v] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Vlatković V. Improvement of hemodialysis quality by application of various models for adequacy aseessment. SCRIPTA MEDICA 2004. [DOI: 10.5937/scrimed0402099x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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