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Zhang F, Liao J, Bai Y, Zhang Z, Huang L, Zhong Y. Effects of haemodiafiltration or haemofiltration compared with haemodialysis on prognosis in patients with end-stage renal disease: protocol an updated systematic review and meta-analysis of randomised trials with trial sequential analysis. BMJ Open 2024; 14:e080541. [PMID: 38521518 PMCID: PMC10961500 DOI: 10.1136/bmjopen-2023-080541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/29/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Haemodialysis is the most common treatment option for patients with life-sustaining end-stage kidney disease (ESKD). In recent years, haemodiafiltration or haemofiltration has been widely used in patients with ESKD, and there are still conflicting findings as to whether both are superior to traditional haemodialysis. This systematic review and meta-analysis were designed to determine whether haemodiafiltration or haemofiltration is more effective than haemodialysis in reducing all-cause mortality risk in patients with ESKD. METHODS AND ANALYSIS We will perform a systematic PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library and Scopus search, including studies published before September 2023. Randomised controlled trials will be included exploring the effects of haemodiafiltration or haemofiltration compared with haemodialysis on prognosis in patients with ESKD. Outcomes of interest include all-cause mortality, cardiovascular events, dialysis adequacy and adverse effects. The Cochrane Collaboration tools (ROB-2) will assess the bias risk. Available data will be used to calculate effect sizes. Heterogeneity between studies will be evaluated with I2. The trial sequential analysis will be used to eliminate false-positive results. The certainty of the evidence will be assessed using Grading of Recommendations, Assessment, Development and Evaluation criteria. ETHICS AND DISSEMINATION This systematic review and meta-analysis was deemed exempt from ethics review. Results will be disseminated through publication in peer-reviewed journals and research conferences. PROSPERO REGISTRATION NUMBER CRD42023464509.
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Affiliation(s)
- Fan Zhang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jing Liao
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yan Bai
- Department of Cardiology, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zixuan Zhang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liuyan Huang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yifei Zhong
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Li P, Qu LP, Qi D, Shen B, Wang YM, Xu JR, Jiang WH, Zhang H, Ding XQ, Teng J. High-dose versus low-dose haemofiltration for the treatment of critically ill patients with acute kidney injury: an updated systematic review and meta-analysis. BMJ Open 2017; 7:e014171. [PMID: 29061597 PMCID: PMC5665234 DOI: 10.1136/bmjopen-2016-014171] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE The purpose of this study was to perform a systematic review and meta-analysis to evaluate the effect of high-dose versus low-dose haemofiltration on the survival of critically ill patients with acute kidney injury (AKI). We hypothesised that high-dose treatments are not associated with a higher risk of mortality. DESIGN Meta-analysis. SETTING Randomised controlled trials and two-arm prospective and retrospective studies were included. PARTICIPANTS Critically ill patients with AKI. INTERVENTIONS Continuous renal replacement therapy. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes: 90-day mortality, intensive care unit (ICU) mortality, hospital mortality; secondary outcomes: length of ICU and hospital stay. RESULT Eight studies including 2970 patients were included in the analysis. Pooled results showed no significant difference in the 90-mortality rate between patients treated with high-dose or low-dose haemofiltration (pooled OR=0.90, 95% CI 0.73 to 1.11, p=0.32). Findings were similar for ICU (pooled OR=1.12, 95% CI 0.94 to 1.34, p=0.21) and hospital mortality (pooled OR=1.03, 95% CI 0.81 to 1.30, p=0.84). Length of ICU and hospital stay were similar between high-dose and low-dose groups. Pooled results are not overly influenced by any one study, different cut-off points of prescribed dose or different cut-off points of delivered dose. Meta-regression analysis indicated that the results were not affected by the percentage of patients with sepsis or septic shock. CONCLUSION High-dose and low-dose haemofiltration produce similar outcomes with respect to mortality and length of ICU and hospital stay in critically ill patients with AKI.This study was not registered at the time the data were collected and analysed. It has since been registered on 17 February 2017 at http://www.researchregistry.com/, registration number: reviewregistry211.
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Affiliation(s)
- Peng Li
- Department of Nephrology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
| | - Li-ping Qu
- Department of Obstetrics, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
| | - Dong Qi
- Department of Nephrology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Yi-mei Wang
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Jia-rui Xu
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Wu-hua Jiang
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Hao Zhang
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
| | - Xiao-qiang Ding
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
- Kidney and Blood Purification Laboratory of Shanghai, Shanghai, China
| | - Jie Teng
- Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Kidney and Dialysis Institute of Shanghai, Shanghai, China
- Kidney and Blood Purification Laboratory of Shanghai, Shanghai, China
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Samolsky Dekel BG, Donati G, Vasarri A, Croci Chiocchini AL, Gori A, Cavallari G, Di Nino G, Mercolini L, Protti M, Mandrioli R, Melotti RM, La Manna G. Dialyzability of Oxycodone and Its Metabolites in Chronic Noncancer Pain Patients with End-Stage Renal Disease. Pain Pract 2016; 17:604-615. [PMID: 27589376 DOI: 10.1111/papr.12483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 05/21/2016] [Accepted: 06/03/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Opioids are the preferred analgesic drugs to treat severe chronic pain conditions among dialysis patients; however, knowledge about their dialyzability features is limited. Oxycodone is increasingly used for the treatment of chronic pain conditions as oral controlled release (CR) tablets; however, evidence about this drug and its metabolites' dialyzability is lacking. METHODS We assessed, during 4-hour dialysis sessions, the effect of standard hemodialysis (HD) and online hemodiafiltration (HDF) methods on the plasma concentration of oxycodone and its metabolites in n = 20 chronic pain patients with end-stage renal disease who were stably treated with oral CR oxycodone. Chromatographic techniques were used to evaluate the studied compounds' plasma concentrations at three different time points during dialysis. RESULTS Mean plasma concentrations of oxycodone and noroxycodone in the sample showed an overall reduction trend over time, but it was less enhanced for noroxycodone. Mean reduction in oxycodone and noroxycodone arterial concentrations was significant and higher with HDF (54% and 27%, respectively) than with HD (22% and 17%, respectively). Analysis of the regression of these compounds' clearance on their increasing arterial concentration showed a more stable and linear clearance prediction with HDF (roughly 85 mL/min); with HD, for increasing arterial concentration, clearance of oxycodone decreased while noroxycodone clearance increased. DISCUSSION While no oxymorphone or noroxymorphone metabolites were detected, limited dialyzability of oxycodone and noroxycodone was documented along with insignificant postdialysis pain increment. This evidence will contribute toward considerations as to the safety of the use of oxycodone in dialysis patients in the future.
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Affiliation(s)
- Boaz Gedaliahu Samolsky Dekel
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy.,Anesthesiology and Intensive Care Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
| | - Gabriele Donati
- Nephrology, Dialysis and Renal Transplant Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Nephrology, University of Bologna, Bologna, Italy
| | - Alessio Vasarri
- Anesthesiology and Intensive Care Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
| | - Anna Laura Croci Chiocchini
- Nephrology, Dialysis and Renal Transplant Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Nephrology, University of Bologna, Bologna, Italy
| | - Alberto Gori
- Anesthesiology and Intensive Care Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
| | - Giuseppe Cavallari
- Nephrology, Dialysis and Renal Transplant Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Nephrology, University of Bologna, Bologna, Italy
| | - Gianfranco Di Nino
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy.,Anesthesiology and Intensive Care Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
| | - Laura Mercolini
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Michele Protti
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Roberto Mandrioli
- Department for Life Quality Studies, University of Bologna, Rimini, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy.,Anesthesiology and Intensive Care Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy.,Nephrology, Dialysis and Renal Transplant Unit, University of Bologna's Teaching Hospital, Azienda Ospedaliera-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.,Post Graduate School of Nephrology, University of Bologna, Bologna, Italy
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Abstract
In the early 1700s, a substance ultimately identified as urea was reported for the first time in urine. About a century later, in 1828, synthesis of this organic compound was achieved, thus giving rise to modern organic chemistry. In parallel, physicians showed that urine comes from the kidneys and contains large amounts of urea, which is produced outside of the kidneys, establishing the humoral approach of renal physiology. Urea was the first uremic retention solute to be identified and it has been used as a marker of renal disease ever since. However, progress in the knowledge of urea metabolism has shown that it is susceptible to many extrarenal variations and, therefore, it cannot be a reliable marker of renal function. It reflects protein intake in the stable patient and has been used to assess nutrition and dialysis efficacy in renal patients. Although it has been studied for almost 200 years, its toxicity has been largely debated. An indirect toxicity occurring through carbamylation of lysine residues is now well established and some evidence from recent work also supports direct toxicity of urea, offering additional rationale for interventional prevention of uremic complications.
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Affiliation(s)
| | - Thomas A Depner
- Division of Nephrology, Department of Internal Medicine, University of California Davis, Sacramento, CA
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Wald R, Friedrich JO, Bagshaw SM, Burns KEA, Garg AX, Hladunewich MA, House AA, Lapinsky S, Klein D, Pannu NI, Pope K, Richardson RM, Thorpe K, Adhikari NKJ. Optimal Mode of clearance in critically ill patients with Acute Kidney Injury (OMAKI)--a pilot randomized controlled trial of hemofiltration versus hemodialysis: a Canadian Critical Care Trials Group project. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R205. [PMID: 23095370 PMCID: PMC3682309 DOI: 10.1186/cc11835] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 10/03/2012] [Indexed: 11/10/2022]
Abstract
Introduction Among critically ill patients with acute kidney injury (AKI) needing continuous renal replacement therapy (CRRT), the effect of convective (via continuous venovenous hemofiltration [CVVH]) versus diffusive (via continuous venovenous hemodialysis [CVVHD]) solute clearance on clinical outcomes is unclear. Our objective was to evaluate the feasibility of comparing these two modes in a randomized trial. Methods This was a multicenter open-label parallel-group pilot randomized trial of CVVH versus CVVHD. Using concealed allocation, we randomized critically ill adults with AKI and hemodynamic instability to CVVH or CVVHD, with a prescribed small solute clearance of 35 mL/kg/hour in both arms. The primary outcome was trial feasibility, defined by randomization of >25% of eligible patients, delivery of >75% of the prescribed CRRT dose, and follow-up of >95% of patients to 60 days. A secondary analysis using a mixed-effects model examined the impact of therapy on illness severity, defined by sequential organ failure assessment (SOFA) score, over the first week. Results We randomized 78 patients (mean age 61.5 years; 39% women; 23% with chronic kidney disease; 82% with sepsis). Baseline SOFA scores (mean 15.9, SD 3.2) were similar between groups. We recruited 55% of eligible patients, delivered >80% of the prescribed dose in each arm, and achieved 100% follow-up. SOFA tended to decline more over the first week in CVVH recipients (-0.8, 95% CI -2.1, +0.5) driven by a reduction in vasopressor requirements. Mortality (54% CVVH; 55% CVVHD) and dialysis dependence in survivors (24% CVVH; 19% CVVHD) at 60 days were similar. Conclusions Our results suggest that a large trial comparing CVVH to CVVHD would be feasible. There is a trend toward improved vasopressor requirements among CVVH-treated patients over the first week of treatment. Trial Registration ClinicalTrials.gov: NCT00675818
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Abstract
Adequate dialysis is difficult to define because we have not identified the toxic solutes that contribute most to uremic illness. Dialysis prescriptions therefore cannot be adjusted to control the levels of these solutes. The current solution to this problem is to define an adequate dose of dialysis on the basis of fraction of urea removed from the body. This has provided a practical guide to treatment as the dialysis population has grown over the past 25 years. Indeed, a lower limit to Kt/V(urea) (or the related urea reduction ratio) is now established as a quality indicator by the Centers for Medicare and Medicaid for chronic hemodialysis patients in the United States. For the present, this urea-based standard provides a useful tool to avoid grossly inadequate dialysis. Dialysis dosing, however, based on measurement of a single, relatively nontoxic solute can provide only a very limited guide toward improved treatment. Prescriptions which have similar effects on the index solute can have widely different effects on other solutes. The dose concept discourages attempts to increase the removal of such solutes independent of the index solute. The dose concept further assumes that important solutes are produced at a constant rate relative to body size, and discourages attempts to augment dialysis treatment by reducing solute production. Identification of toxic solutes would provide a more rational basis for the prescription of dialysis and ultimately for improved treatment of patients with renal failure.
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Affiliation(s)
- Timothy W. Meyer
- Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
| | - Tammy L. Sirich
- Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
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Blagg CR. Many Hemodialysis Patients in the 1960s Had Substantially Fewer Symptoms Than Today's Patients. Am J Kidney Dis 2009; 53:560-1; author reply 561-2. [DOI: 10.1053/j.ajkd.2008.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 11/06/2008] [Indexed: 11/11/2022]
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Santoro A. Hemodialysis versus hemofiltration. Am J Kidney Dis 2009; 53:560; author reply 561-2. [PMID: 19231741 DOI: 10.1053/j.ajkd.2008.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 09/11/2008] [Indexed: 11/11/2022]
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