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Lee H, Liu KH, Yang YH, Liao JD, Lin BS, Wu ZZ, Chang AC, Tseng CC, Wang MC, Tsai YS. Advances in uremic toxin detection and monitoring in the management of chronic kidney disease progression to end-stage renal disease. Analyst 2024; 149:2784-2795. [PMID: 38647233 DOI: 10.1039/d4an00057a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Patients with end-stage kidney disease (ESKD) rely on dialysis to remove toxins and stay alive. However, hemodialysis alone is insufficient to completely remove all/major uremic toxins, resulting in the accumulation of specific toxins over time. The complexity of uremic toxins and their varying clearance rates across different dialysis modalities poses significant challenges, and innovative approaches such as microfluidics, biomarker discovery, and point-of-care testing are being investigated. This review explores recent advances in the qualitative and quantitative analysis of uremic toxins and highlights the use of innovative methods, particularly label-mediated and label-free surface-enhanced Raman spectroscopy, primarily for qualitative detection. The ability to analyze uremic toxins can optimize hemodialysis settings for more efficient toxin removal. Integration of multiple omics disciplines will also help identify biomarkers and understand the pathogenesis of ESKD, provide deeper understanding of uremic toxin profiling, and offer insights for improving hemodialysis programs. This review also highlights the importance of early detection and improved understanding of chronic kidney disease to improve patient outcomes.
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Affiliation(s)
- Han Lee
- Laboratory of Engineered Materials for Biomedical Applications, Department of Materials Science and Engineering, National Cheng Kung University, 1 University Road, Tainan 701, Taiwan.
| | - Kuan-Hung Liu
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
| | - Yu-Hsuan Yang
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
| | - Jiunn-Der Liao
- Laboratory of Engineered Materials for Biomedical Applications, Department of Materials Science and Engineering, National Cheng Kung University, 1 University Road, Tainan 701, Taiwan.
| | - Bo-Shen Lin
- Laboratory of Engineered Materials for Biomedical Applications, Department of Materials Science and Engineering, National Cheng Kung University, 1 University Road, Tainan 701, Taiwan.
| | - Zheng-Zhe Wu
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
| | - Alice Chinghsuan Chang
- Center for Measurement Standards, Industrial Technology Research Institute, No. 321, Kuang Fu Road, Section 2, Hsinchu 300, Taiwan.
| | - Chin-Chung Tseng
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
| | - Ming-Cheng Wang
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
| | - Yau-Sheng Tsai
- Center for Clinical Medicine Research, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
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Huang PY, Hsu BG, Wang CH, Tsai JP. The Prognostic Role of Serum β-Trace Protein Levels among Patients on Maintenance Hemodialysis. Diagnostics (Basel) 2024; 14:974. [PMID: 38786272 PMCID: PMC11119092 DOI: 10.3390/diagnostics14100974] [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: 03/28/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
Cardiovascular (CV) diseases are the most commonly encountered etiology of mortality in patients having kidney failure. β-Trace protein (BTP) is a biomarker of glomerular filtration function as well as a potential predictor of adverse CV outcomes. This study aimed to determine the prognostic value of BTP in patients on chronic hemodialysis (HD). A total of 96 patients undergoing HD were enrolled. Baseline variables were collected, and the patients were tracked for 3 years. Twenty-five patients died at 3 years. Those who experienced mortality were noted to have higher serum concentrations of BTP and a higher incidence of diabetes mellitus (DM). The area under the receiver operating characteristic curve for serum BTP distinguishing mortality from survival was 0.659 (95% confidence interval [CI], 0.555-0.752; p = 0.027). After the adjustment of variables potentially affecting survival rates, BTP levels above the median (adjusted hazard ratio [aHR]: 2.913, 95% CI, 1.256-6.754; p = 0.013), the presence of DM (aHR: 2.474, 95% CI, 1.041-5.875; p = 0.040), and low serum albumin (aHR: 0.298, 95% CI, 0.110-0.806; p = 0.017) independently correlated with survival in HD patients. Serum BTP is a novel biomarker for predicting overall outcomes in HD patients.
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Affiliation(s)
- Po-Yu Huang
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan;
- Institute of Medical Sciences, Tzu Chi University, Hualien 97004, Taiwan
| | - Bang-Gee Hsu
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan; (B.-G.H.); (C.-H.W.)
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Chih-Hsien Wang
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan; (B.-G.H.); (C.-H.W.)
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Jen-Pi Tsai
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan;
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
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Ward RA, Daugirdas JT. Kinetics of β -2-Microglobulin with Hemodiafiltration and High-Flux Hemodialysis. Clin J Am Soc Nephrol 2024:01277230-990000000-00374. [PMID: 38650079 DOI: 10.2215/cjn.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
Key Points
Addition of hemodiafiltration has a relatively small impact on reducing either predialysis or time-averaged serum β-2-microglobulin levels.Residual kidney function has a major impact on the predialysis and time-averaged serum β-2-microglobulin levels.
Background
A kinetic model for β-2-microglobulin removal and generation was used to explore the impact of adding hemodiafiltration on predialysis and time-averaged serum values.
Methods
The model was tested on data from the HEMO study and on a sample of patients undergoing high-flux hemodialysis. The impact of hemodiafiltration on β-2-microglobulin levels was evaluated by modeling four randomized studies of hemodiafiltration versus hemodialysis. The impact of residual kidney function on β-2-microglobulin was tested by comparing results of previously reported measured data with model predictions.
Results
In the low-flux and high-flux arms of the HEMO study, measured median β-2-microglobulin reduction ratios could be matched by dialyzer clearances of 5.9 and 29 ml/min, respectively. Median predialysis serum β-2-microglobulin levels were matched if generation rates of β-2-microglobulin were set to approximately 235 mg/d. In another group of patients treated with dialyzers with increased β-2-microglobulin clearances, measured cross-dialyzer clearances (57±28 ml/min) were used as inputs. In these studies, the kinetic model estimates of intradialysis and early postdialysis serum β-2-microglobulin levels were similar to median measured values. The model was able to estimate the changes in predialysis serum β-2-microglobulin in each of four published randomized comparisons of hemodiafiltration with hemodialysis, although the model predicted a greater decrease in predialysis serum β-2-microglobulin with hemodiafiltration than was reported in two of the studies. The predicted impact of residual kidney clearance on predialysis serum β-2-microglobulin concentrations was similar to that reported in one published observational study. Modeling predicted that postdilution hemodiafiltration using 25 L/4 hours replacement fluid would lower serum time-averaged concentration of β-2-microglobulin by about 18.2%, similar to the effect of 1.50 ml/min residual kidney GFR.
Conclusions
A two-pool kinetic model of β-2-microglobulin yielded values of reduction ratio and predialysis serum concentration that were consistent with measured values with various hemodiafiltration and hemodialysis treatment regimens.
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Affiliation(s)
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois
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Hunderup MM, Kampmann JD, Kristensen FB, Hafsund M. The short-term effect of hemodialysis on the level of high-sensitive cardiac troponin T - A systematic review. Semin Dial 2024; 37:110-116. [PMID: 37779378 DOI: 10.1111/sdi.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/10/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular disease, but interpreting cardiac troponin is difficult in this population. The effect of renal replacement therapy (RRT) is important to consider when interpreting serial cardiac troponin T (cTnT) results for patients with ESRD suspected of acute coronary syndrome (ACS). The aim of this systematic review is to answer how low-flux hemodialysis (LF-HD), high-flux hemodialysis (HF-HD), and hemodiafiltration (HDF) affect the blood concentration of high-sensitive cardiac troponin T (hs-cTnT). METHOD Several databases were searched and identified records were evaluated independently by two of the authors. Pre- and postdialysis hs-cTnT concentrations together with other relevant data were extracted from the included studies. The quality (potential bias and applicability issues) were assessed for each of the included studies. RESULTS The literature search identified 2,540 records and 15 studies were included. The relative pre- to postdialysis change of hs-cTnT varied from -41 to 29%. LF-HD increased the hs-cTnT concentration with relative changes between 2 and 17%. HDF decreased the concentration with relative changes from -41% to -9%. Both increases and decreases were seen for HF-HD (-16% to 12%). DISCUSSION/CONCLUSION In this systematic review, we found LF-HD to increase the hs-cTnT concentration and HDF to decrease the concentration. Results for HF-HD and unspecified HD are more heterogeneous. Because of the differences between the included studies, a meta-analysis was not meaningful. This systematic review can help with the assessment of patients with ESRD suspected of ACS in relation to hemodialysis/HDF treatment.
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Affiliation(s)
- Michael Mejer Hunderup
- Department of Clinical Biochemistry and Immunology, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Clinical Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark
| | - Jan Dominik Kampmann
- Department of Internal Medicine, University Hospital of Southern Denmark, Sonderborg, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Frans Brandt Kristensen
- Department of Internal Medicine, University Hospital of Southern Denmark, Sonderborg, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marius Hafsund
- Department of Internal Medicine, University Hospital of Southern Denmark, Sonderborg, Denmark
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Daugirdas JT, Chan CT. Survival Benefit with Hemodiafiltration: Are We Convinced, and If So, What Might Be the Mechanism? Clin J Am Soc Nephrol 2024; 19:388-390. [PMID: 37902765 PMCID: PMC10937017 DOI: 10.2215/cjn.0000000000000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/19/2023] [Indexed: 10/31/2023]
Affiliation(s)
- John T. Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Christopher T. Chan
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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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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Huang PY, Huang CS, Lin YL, Chen YH, Hung SC, Tsai JP, Hsu BG. Positive Association of Serum Galectin-3 with the Development of Aortic Stiffness of Patients on Peritoneal Dialysis. J Clin Med 2023; 12:jcm12103519. [PMID: 37240626 DOI: 10.3390/jcm12103519] [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: 03/24/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
A novel cardiovascular stress biomarker known as galectin-3 might be useful for anticipating adverse cardiovascular outcomes. The objective of the current investigation was to assess the association between serum galectin-3 levels and aortic stiffness (AS) in 196 patients on peritoneal dialysis. An enzyme-linked immunosorbent examination and a cuff-based volumetric displacement were employed to determine the levels of serum galectin-3 and the carotid-femoral pulse wave velocity (cfPWV), respectively. The AS group had 48 patients in total (24.5%) with cfPWV greater than 10 m/s. The AS group, when compared with the group without AS, had a significantly higher prevalence of diabetes mellitus and hypertension in addition to greater fasting glucose levels, waist circumference, systolic blood pressure, and serum galectin-3 levels. Multivariate logistic and linear regression analysis demonstrated that serum glactin-3 levels, in addition to gender and age, were significantly and independently associated with cfPWV and AS. Serum galectin-3 levels were linked with AS, according to a receiver operating characteristic curve analysis, with an area under the curve of 0.648 (95% confidence interval, 0.576-0.714; p = 0.0018). In summary, there was a significant correlation between serum galectin-3 levels and cfPWV in patients undergoing peritoneal dialysis therapy for end-stage kidney disease.
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Affiliation(s)
- Po-Yu Huang
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Chen-Sen Huang
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan
| | - Yu-Li Lin
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Yi-Hsin Chen
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 40201, Taiwan
| | - Szu-Chun Hung
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei 23142, Taiwan
| | - Jen-Pi Tsai
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Bang-Gee Hsu
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
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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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Nenadović M, Nikolić A, Stanojević-Pirković M, Trbojević-Stanković J, Nikolić T, Petrović D, Djulejić V. Assessment of the Influence of Asymmetric Triacetate Cellulose Membrane on the Rate of Removal of Middle Molecular Weight Uremic Toxins in Patients Treated with Postdilution Online Hemodiafiltration. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND: Postdilution online hemodiafiltration (OL-HDF) effectively removes uremic toxins of middle molecular weight from the blood of patients with end-stage chronic kidney disease. The rate of removal of uremic toxins depends on the type of dialysis membrane, blood flow rate (Qb), net ultrafiltration flow rate (Qnuf), and total convective volume (Vconv).
AIM: The aim of this study was to examine the efficacy of asymmetric triacetate cellulose dialysis membrane in patients on post-dilution OL-HDF.
METHODS: Thirty-five patients treated with post-dilution OL-HDF hemodiafiltration for at least 3 months were examined. The main parameters for assessing the efficiency of removal of uremic toxins of middle molecular weight are the concentration of β2-microglobulin (β2-M) and interleukin-6 (IL-6) in serum before and after a single session of post-dilution OL-HDF. The followings were used for statistical analysis: Kolmogorov–Smirnov test, Student’s T test for bound samples and Wilcoxon test.
RESULTS: The average Vconv was 20.90 ± 3.30 liters/session. The β2-M reduction index during a single session of postdilution OL-HDF was 71.10 ± 6.39%, the IL-6 reduction index was 43.75 ± 15.60%, and the albumin reduction index was 4.55 ± 2.31%.
CONCLUSION: The asymmetric triacetate cellulose dialysis membrane effectively removes β2-M and IL-6 during a single session of postdilution OL-HDF. The β2-M reduction index is ∼70%, the IL-6 reduction index is ∼40%, and albumin loss is <4.0 g/4 h. The examined dialysis membrane and dialysis modality prevent the development of amyloidosis associated with dialysis, microinflammation and reduce the risk of developing atherosclerotic cardiovascular diseases in the population of patients treated with regular hemodiafiltration.
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Dellepiane S, Marengo M, D'Arezzo M, Donati G, Fabbrini P, Lacquaniti A, Ronco C, Cantaluppi V. The Next Evolution of HemoDialysis eXpanded: From a Delphi Questionnaire-Based Approach to the Real Life of Italian Dialysis Units. Blood Purif 2022; 51:943-952. [PMID: 35231902 PMCID: PMC9808684 DOI: 10.1159/000522038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/17/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Impact assessment of new technologies in chronic hemodialysis (HD) is challenging due to HD patient frailty, the complexity of HD clinical trials and practice variability among countries. Among the most recent HD innovations, medium cut-off (MCO) dialyzers present an optimized membrane geometry that provides enhanced clearances for middle and large molecular weight uremic toxins (UT). These toxins are poorly cleared by available HD techniques and largely contribute to patient morbidity and mortality. The aim of this paper is to assess the available clinical evidence about MCO membranes and to identify the next steps needed to generate conclusive data on their use in HD. METHODS With this purpose, we first reviewed and compared the current HD technologies aimed to improve the clearance of middle and large UT; subsequently, we used a Delphi questionnaire to identify and discuss the consensus about MCO efficacy within a large sample of the Italian Nephrology community. RESULTS AND CONCLUSIONS Our investigation gathered a significant degree of consensus on the beneficial role of MCO membrane and expanded HD. Finally, we used our results to propose future trial designs and clinical investigations aimed to improve evidence quality about the use of these membranes in the present clinical scenario of dialysis units.
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Affiliation(s)
- Sergio Dellepiane
- Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Mario D'Arezzo
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti − Ancona University Hospital, Ancona, Italy
| | - Gabriele Donati
- Nephrology Dialysis and Renal Transplantation Unit, St. Orsola University Hospital, Bologna, Italy
| | - Paolo Fabbrini
- Nephrology and Dialysis Unit, San Gerardo Hospital and Milano Bicocca University, Monza, Italy
| | | | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy,Division of Nephrology, Dialysis and Kidney Transplantation Unit, International Renal Research Institute Vicenza (IRRIV), “San Bortolo” Hospital, Vicenza, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), “Maggiore della Carità” University Hospital, Novara, Italy,*Vincenzo Cantaluppi,
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Ren J, Yang X, Yan W, Feng X, Zhao Y, Chen L. mPEG-b-PES-b-mPEG-based candidate hemodialysis membrane with enhanced performance in sieving, flux, and hemocompatibility. J Memb Sci 2022. [DOI: 10.1016/j.memsci.2022.120680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Cho NJ, Jeong SH, Lee KY, Yu JY, Park S, Lee EY, Gil HW. Clinical Safety of Expanded Hemodialysis Compared with Hemodialysis Using High-Flux Dialyzer during a Three-Year Cohort. J Clin Med 2022; 11:jcm11082261. [PMID: 35456352 PMCID: PMC9025951 DOI: 10.3390/jcm11082261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022] Open
Abstract
Expanded hemodialysis (HD) equipped with a medium cut-off (MCO) membrane provides superior removal of larger middle molecules. However, there is still little research on the long-term benefits of expanded HD. Over a three-year period, this observational study evaluated the efficacy and safety profile of expanded HD for inflammatory cytokines, including IL-6. We conducted a prospective cohort study to investigate the inflammatory cytokine changes and a retrospective observational cohort study to investigate long-term clinical efficacy and safety over a three-year period. We categorized the patients according to dialyzer used: MCO and high-flux (HF) dialyzer. The inflammatory cytokines, including IFN-γ, IL-1β, IL-6, and TNF-α, were measured annually. The concentrations and changes of the four cytokines over time did not differ between the HF group (n = 15) and MCO group (n = 27). In both prospective and retrospective (HF group, n = 38; MCO group, n = 76) cohorts, there were no significant differences in either death, cardiovascular events, infections, or hospitalizations. Furthermore, the temporal changes in laboratory values, including serum albumin and erythropoietin prescriptions, did not differ significantly between the two groups in either the prospective or retrospective cohorts. In conclusion, clinical efficacy and safety outcomes, as well as inflammatory cytokines, did not differ with expanded HD compared with HF dialysis during a three-year treatment course, although the level of inflammatory cytokine was stable.
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13
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Halim A, Narayanan G, Hato T, Ho L, Wan D, Siedlecki AM, Rhee EP, Allegretti AS, Nigwekar SU, Zehnder D, Hiemstra TF, Bonventre JV, Charytan DM, Kalim S, Thadhani R, Lu T, Lim K. Myocardial Cytoskeletal Adaptations in Advanced Kidney Disease. J Am Heart Assoc 2022; 11:e022991. [PMID: 35179046 PMCID: PMC9075094 DOI: 10.1161/jaha.121.022991] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Abstract
Background The myocardial cytoskeleton functions as the fundamental framework critical for organelle function, bioenergetics and myocardial remodeling. To date, impairment of the myocardial cytoskeleton occurring in the failing heart in patients with advanced chronic kidney disease has been largely undescribed. Methods and Results We conducted a 3-arm cross-sectional cohort study of explanted human heart tissues from patients who are dependent on hemodialysis (n=19), hypertension (n=10) with preserved renal function, and healthy controls (n=21). Left ventricular tissues were subjected to pathologic examination and next-generation RNA sequencing. Mechanistic and interference RNA studies utilizing in vitro human cardiac fibroblast models were performed. Left ventricular tissues from patients undergoing hemodialysis exhibited increased myocardial wall thickness and significantly greater fibrosis compared with hypertension patients (P<0.05) and control (P<0.01). Transcriptomic analysis revealed that the focal adhesion pathway was significantly enriched in hearts from patients undergoing hemodialysis. Hearts from patients undergoing hemodialysis exhibited dysregulated components of the focal adhesion pathway including reduced β-actin (P<0.01), β-tubulin (P<0.01), vimentin (P<0.05), and increased expression of vinculin (P<0.05) compared with controls. Cytoskeletal adaptations in hearts from the hemodialysis group were associated with impaired mitochondrial bioenergetics, including dysregulated mitochondrial dynamics and fusion, and loss of cell survival pathways. Mechanistic studies revealed that cytoskeletal changes can be driven by uremic and metabolic abnormalities of chronic kidney disease, in vitro. Furthermore, focal adhesion kinase silencing via interference RNA suppressed major cytoskeletal proteins synergistically with mineral stressors found in chronic kidney disease in vitro. Conclusions Myocardial failure in advanced chronic kidney disease is characterized by impairment of the cytoskeleton involving disruption of the focal adhesion pathway, mitochondrial failure, and loss of cell survival pathways.
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Affiliation(s)
- Arvin Halim
- Division of Nephrology and HypertensionIndiana University School of MedicineIndianapolisIN
| | - Gayatri Narayanan
- Division of Nephrology and HypertensionIndiana University School of MedicineIndianapolisIN
| | - Takashi Hato
- Division of Nephrology and HypertensionIndiana University School of MedicineIndianapolisIN
| | - Lilun Ho
- Department of Computer Science, Computer Science and Artificial Intelligence LaboratoryMassachusetts Institute of TechnologyCambridgeMA
| | - Douglas Wan
- Division of CardiologyUniversity of Toronto and Sunnybrook Health Sciences CentreTorontoCanada
| | | | - Eugene P. Rhee
- Division of Nephrology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
| | - Sagar U. Nigwekar
- Division of Nephrology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
| | - Daniel Zehnder
- Department of Nephrology and Department of Acute MedicineNorth Cumbria University Hospital NHS TrustCarlisleUnited Kingdom
| | - Thomas F. Hiemstra
- Cambridge Clinical Trials Unit and School of Clinical MedicineUniversity of CambridgeUnited Kingdom
| | | | - David M. Charytan
- Division of NephrologyNew York University School of MedicineNew YorkNY
| | - Sahir Kalim
- Division of Nephrology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
| | | | - Tzongshi Lu
- Renal Division, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Kenneth Lim
- Division of Nephrology and HypertensionIndiana University School of MedicineIndianapolisIN
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14
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Ribeiro AC, Silva RE, Justino PBI, Santos EC, Gonçalves RV, Novaes RD. Relationship between time-dependent variability in cardiometabolic risk factors and biochemical markers with cytokine and adipokine levels in hemodialysis patients. Cytokine 2022; 151:155802. [DOI: 10.1016/j.cyto.2022.155802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
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15
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Abstract
Almost 200 years ago, the first evidence described by Robert Bright (1836) showed the strong interaction between the kidneys and heart and, since then, the scientific community has dedicated itself to better understanding the mechanisms involved in the kidney-heart relationship, known in recent decades as cardiorenal syndrome (CRS). This syndrome includes a wide clinical variety that affects the kidneys and heart, in an acute or chronic manner. Moreover, it is well established in the literature that the immune system, the sympathetic nervous system, the renin-angiotensin-aldosterone, and the oxidative stress actively play a strong role in the cellular and molecular processes present in CRS. More recently, uremic molecules and epigenetic factors have been also shown to be key mediators in the development of syndrome. The present review intends to present the state of the art regarding CRS and to show the paths known, until now, in the long road between the kidneys and heart.
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16
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Penny JD, Jarosz P, Salerno FR, Lemoine S, McIntyre CW. Impact of Expanded Hemodialysis Using Medium Cut-off Dialyzer on Quality of Life: Application of Dynamic Patient-Reported Outcome Measurement Tool. Kidney Med 2021; 3:992-1002.e1. [PMID: 34939008 PMCID: PMC8664707 DOI: 10.1016/j.xkme.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale & Objective Current hemodialysis (HD) treatments have limited ability to clear larger-molecular-weight uremic toxins. Retention is associated with increased symptom burden, low health-related quality of life (HRQoL), and high mortality. Improved clearance, using novel medium cut-off dialyzers, termed expanded HD (HDx), may be associated with improved subjective experience. We have previously developed a dynamic patient-reported outcome measure (PROM) instrument to allow iterative recording to better appreciate the overall burden of disease and assess the impact of therapy changes. Study Design Single-center interventional pilot study. Setting & Participants 28 patients established on maintenance HD, London, Ontario, Canada. Intervention Initial study consisting of 2-week observation (baseline-conventional high-flux HD) followed by 12 weeks of HDx. HRQoL was assessed using the dynamic PROM instrument thrice weekly (enabled in a dedicated app as the London Evaluation of Illness [LEVIL]). Extension phase; 2-week baseline with 24 weeks of HDx and 8-week washout. Outcomes Principal aim was to establish whether HDx therapy was associated with improved HRQoL, evidence of dose-dependant response, and whether effects were durable over time, using LEVIL. Results Patients with lower LEVIL scores (<70/100) at baseline showed improvement in overall HRQoL after 8 weeks of therapy with similar carryover effect. General well-being, energy, and sleep quality were improved significantly as a consequence of HDx therapy. There were no detrimental effects of HDx detected in patients with higher baseline HRQoL. Limitations Small nonrandomized sample size. The coronavirus disease 2019 pandemic interfered with the extension phase. Conclusions Dynamic PROM assessment effectively identified patients with lower HRQoL and higher symptom burden, demonstrating durable time/dose-dependent improvements across a range of symptom domains. The use of this instrument may allow targeted selection of patients most likely to benefit from HDx therapy and assist in monitoring response and defining effect size and treatment duration to allow optimal design of further definitive randomized controlled trials of this newly introduced technology. Funding Baxter Healthcare Canada. Trial Registration ClinicalTrials.gov ID: NCT03640858.
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Affiliation(s)
- Jarrin D. Penny
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Patricia Jarosz
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
| | - Fabio R. Salerno
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Sandrine Lemoine
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
| | - Christopher W. McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Address for Correspondence: Christopher W. McIntyre, MD, PhD, The Lilibeth Caberto Kidney Clinical Research Unit, Victoria Hospital, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario, Canada N6A 5W9.
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17
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Genton L, Pruijm M, Teta D, Bassi I, Cani PD, Gaïa N, Herrmann FR, Marangon N, Mareschal J, Muccioli GG, Stoermann C, Suriano F, Wurzner-Ghajarzadeh A, Lazarevic V, Schrenzel J. Gut barrier and microbiota changes with glycine and branched-chain amino acid supplementation in chronic haemodialysis patients. J Cachexia Sarcopenia Muscle 2021; 12:1527-1539. [PMID: 34535959 PMCID: PMC8718035 DOI: 10.1002/jcsm.12781] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND We have previously shown that glycine increases fat-free mass in chronic haemodialysis patients with features of malnutrition as compared with branched-chain amino acids (BCAAs). This multicentre randomized double-blind crossover study evaluates the impact of these amino acids on the gut barrier and microbiota. METHODS Haemodialysis patients were included if they had plasma albumin <38 g/L or weight loss >5% of dry body weight, and daily dietary intakes <30 kcal/kg and <1 g protein/kg. They consumed glycine or BCAA (7 g twice daily) for 4 months and underwent a 1 month washout period, before crossover of supplementations. Faecal microbiota (16S rRNA gene sequencing) and immunoglobulin A (IgA), serum levels of cytokines, surrogate markers of intestinal permeability, appetite mediators, and endocannabinoids were obtained at the start and end of each supplementation. Supplementations were compared by multiple mixed linear regression models, adjusted for age, sex, month of supplementation (0 and 4 in each period), and period (Period 1: first 4 months; Period 2: last 4 months). Microbiota comparisons were performed using principal coordinate analysis and permutational multivariate analysis of variance, Shannon diversity index estimate and analysis of composition of microbiomes analysis, and Wilcoxon tests. RESULTS We analysed 27 patients compliant to the supplementations. Multiple mixed linear regression models were significant only for interleukin-6 (P = 0.002), glucagon-like peptide 1 (P = 0.028), cholecystokinin (P = 0.021), and peptide YY (P = 0.002), but not for the other outcomes. The significant models did not show any impact of the type of supplementation (P < 0.05 in all models). Principal coordinate analysis and permutational multivariate analysis of variance (P = 0.0001) showed strong microbiota clustering by subject, but no effect of the amino acids. Bacterial alpha diversity and zero-radius operational taxonomic unit richness remained stable, whatever the supplementation. Lacticaseibacillus paracasei (0.030; Q1-Q3 0.008-0.078 vs. 0.004; Q1-Q3 0.001-0.070) and Bifidobacterium dentium (0.0247; Q1-Q3 0.002-0.191 vs. 0.003; Q1-Q3 0.001-0.086) significantly decreased with the BCAA supplementation. CONCLUSIONS The BCAA and glycine supplementations had no impact on the serum levels of cytokines, appetite mediators, intestinal permeability, endocannabinoids, or faecal IgA. Overall faecal microbiota composition and microbial diversity did not change with the glycine or BCAA supplementation but decreased the abundance of L. paracasei and B. dentium.
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Affiliation(s)
- Laurence Genton
- Unit of Nutrition, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Menno Pruijm
- Service of Nephrology, University Hospitals of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Daniel Teta
- Service of Nephrology, Cantonal Hospital of Sion, Sion, Switzerland
| | - Isabelle Bassi
- Service of Nephrology, Cantonal Hospital of Sion, Sion, Switzerland
| | - Patrice D Cani
- Louvain Drug Research Institute, Metabolism and Nutrition Research Group, Walloon Excellence in Life Sciences and BIOtechnology (WELBIO), Université catholique de Louvain, Brussels, Belgium
| | - Nadia Gaïa
- Genomic Research Lab and Service of Infectious Diseases, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - François R Herrmann
- Department of Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Nicola Marangon
- Service of Nephrology, Geneva University Hospitals and Clinique of Champel, Geneva, Switzerland
| | - Julie Mareschal
- Unit of Nutrition, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Giulio G Muccioli
- Louvain Drug Research Institute, Bioanalysis and Pharmacology of Bioactive Lipids Research Group, Université catholique de Louvain, Brussels, Belgium
| | - Catherine Stoermann
- Service of Nephrology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Francesco Suriano
- Louvain Drug Research Institute, Metabolism and Nutrition Research Group, Walloon Excellence in Life Sciences and BIOtechnology (WELBIO), Université catholique de Louvain, Brussels, Belgium
| | - Arlene Wurzner-Ghajarzadeh
- Service of Nephrology, University Hospitals of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Vladimir Lazarevic
- Genomic Research Lab and Service of Infectious Diseases, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jacques Schrenzel
- Genomic Research Lab and Service of Infectious Diseases, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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18
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Yang J, Ke G, Liao Y, Guo Y, Gao X. Efficacy of medium cut-off dialyzers and comparison with high-flux dialyzers in patients on maintenance hemodialysis: A systematic review and meta-analysis. Ther Apher Dial 2021; 26:756-768. [PMID: 34773675 PMCID: PMC9545768 DOI: 10.1111/1744-9987.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/24/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022]
Abstract
Medium cut‐off (MCO) dialyzers were designed to provide better clearance of uremic toxins. We conducted a meta‐analysis comparing MCO with high‐flux (HF) dialyzers for the effect on uremic toxins in maintenance hemodialysis (HD) patients. Five databases were systematically searched for relevant studies and nine studies were identified finally. Reduction ratio (RR) of urea, urea, creatinine, β2‐macroglobulin (β2‐MG), kappa free light chain (κFLC), and lambda FLC (λFLC) levels were not significantly different between MCO and HF dialyzers. But RR of β2‐MG, κFLC, and λFLC were greater for MCO than HF dialyzers. MCO dialyzers could better reduce tumor necrosis factor‐α (TNF‐α) levels. Subgroup analysis stratified by study design indicated that in randomized controlled trial (RCT) studies, albumin levels was lower in MCO than HF dialyzers group, but the two dialyzers treatments were equivalent in non‐RCT subgroup. Compared with HF dialyzers, MCO dialyzers provided higher middle‐molecules uremic toxins clearance and obviously reduced TNF‐α levels.
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Affiliation(s)
- Jia Yang
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| | - Guibao Ke
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuanjiang Liao
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| | - Yong Guo
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
| | - Xiaoling Gao
- Department of Nephrology, Chongqing Ninth People' Hospital, Chongqing, China
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19
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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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20
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Falconi CA, Junho CVDC, Fogaça-Ruiz F, Vernier ICS, da Cunha RS, Stinghen AEM, Carneiro-Ramos MS. Uremic Toxins: An Alarming Danger Concerning the Cardiovascular System. Front Physiol 2021; 12:686249. [PMID: 34054588 PMCID: PMC8160254 DOI: 10.3389/fphys.2021.686249] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022] Open
Abstract
The kidneys and heart share functions with the common goal of maintaining homeostasis. When kidney injury occurs, many compounds, the so-called “uremic retention solutes” or “uremic toxins,” accumulate in the circulation targeting other tissues. The accumulation of uremic toxins such as p-cresyl sulfate, indoxyl sulfate and inorganic phosphate leads to a loss of a substantial number of body functions. Although the concept of uremic toxins is dated to the 1960s, the molecular mechanisms capable of leading to renal and cardiovascular injuries are not yet known. Besides, the greatest toxic effects appear to be induced by compounds that are difficult to remove by dialysis. Considering the close relationship between renal and cardiovascular functions, an understanding of the mechanisms involved in the production, clearance and overall impact of uremic toxins is extremely relevant for the understanding of pathologies of the cardiovascular system. Thus, the present study has as main focus to present an extensive review on the impact of uremic toxins in the cardiovascular system, bringing the state of the art on the subject as well as clinical implications related to patient’s therapy affected by chronic kidney disease, which represents high mortality of patients with cardiac comorbidities.
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Affiliation(s)
- Carlos Alexandre Falconi
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Carolina Victoria da Cruz Junho
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Fernanda Fogaça-Ruiz
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Imara Caridad Stable Vernier
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Regiane Stafim da Cunha
- Experimental Nephrology Laboratory, Basic Pathology Department, Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Marcela Sorelli Carneiro-Ramos
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
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21
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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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22
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Paats J, Adoberg A, Arund J, Fridolin I, Lauri K, Leis L, Luman M, Tanner R. Optical Method and Biochemical Source for the Assessment of the Middle-Molecule Uremic Toxin β2-Microglobulin in Spent Dialysate. Toxins (Basel) 2021; 13:toxins13040255. [PMID: 33807387 PMCID: PMC8067283 DOI: 10.3390/toxins13040255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023] Open
Abstract
Optical monitoring of spent dialysate has been used to estimate the removal of water-soluble low molecular weight as well as protein-bound uremic toxins from the blood of end stage kidney disease (ESKD) patients. The aim of this work was to develop an optical method to estimate the removal of β2-microglobulin (β2M), a marker of middle molecule (MM) uremic toxins, during hemodialysis (HD) treatment. Ultraviolet (UV) and fluorescence spectra of dialysate samples were recorded from 88 dialysis sessions of 22 ESKD patients, receiving four different settings of dialysis treatments. Stepwise regression was used to obtain the best model for the assessment of β2M concentration in the spent dialysate. The correlation coefficient 0.958 and an accuracy of 0.000 ± 0.304 mg/L was achieved between laboratory and optically estimated β2M concentrations in spent dialysate for the entire cohort. Optically and laboratory estimated reduction ratio (RR) and total removed solute (TRS) of β2M were not statistically different (p > 0.35). Dialytic elimination of MM uremic toxin β2M can be followed optically during dialysis treatment of ESKD patients. The main contributors to the optical signal of the MM fraction in the spent dialysate were provisionally identified as tryptophan (Trp) in small peptides and proteins, and advanced glycation end-products.
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Affiliation(s)
- Joosep Paats
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
- Correspondence:
| | - Annika Adoberg
- Centre of Nephrology, North Estonia Medical Centre, 13419 Tallinn, Estonia; (A.A.); (L.L.)
| | - Jürgen Arund
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
| | - Ivo Fridolin
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
| | - Kai Lauri
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
- SYNLAB Eesti OÜ, 10138 Tallinn, Estonia
| | - Liisi Leis
- Centre of Nephrology, North Estonia Medical Centre, 13419 Tallinn, Estonia; (A.A.); (L.L.)
| | - Merike Luman
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
- Centre of Nephrology, North Estonia Medical Centre, 13419 Tallinn, Estonia; (A.A.); (L.L.)
| | - Risto Tanner
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
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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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24
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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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25
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Sanabria RM, Hutchison CA, Vesga JI, Ariza JG, Sanchez R, Suarez AM. Expanded Hemodialysis and Its Effects on Hospitalizations and Medication Usage: A Cohort Study. Nephron Clin Pract 2021; 145:179-187. [PMID: 33596561 DOI: 10.1159/000513328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Expanded hemodialysis (HDx) effectively removes large middle molecular uremic toxins (>25 kDa) while still retaining albumin, potentially reducing their adverse effects. We compare the clinical laboratory parameters, hospitalization rates, and medication use in a cohort of patients switched from high-flux HD to HDx. METHODS This is a multicenter, observational cohort study of 81 adult patients, across 3 clinics, with end-stage kidney disease (ESKD) on chronic hemodialysis (HD). Patients received high-flux HD for at least 1 year and then switched to HDx and were followed up for 1 year. Patients were excluded if they discontinued therapy, changed provider, underwent kidney transplant, recovered kidney function, or changed to peritoneal dialysis, another dialyzer, or renal clinic. RESULTS Twelve months after switching to HDx, the rate of hospitalization events per patient-year decreased from 0.77 (95% CI: 0.60-0.98, 61 events) to 0.71 (95% CI: 0.55-0.92, 57 events) (p = 0.6987). The hospital day rate per patient-year was significantly reduced from 5.94 days in the year prior to switching compared with 4.41 days after switching (p = 0.0001). The mean dose of erythropoiesis-stimulating agent (SC epoetin-α) and intravenous iron also significantly decreased (p = 0.0361 and p = 0.0003, respectively). CONCLUSION Switching to HDx was associated with reductions in hospital day rate and medication use, suggesting HDx has the potential to reduce the burden of ESKD on patients and healthcare systems.
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Affiliation(s)
| | - Colin A Hutchison
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | | | | | - Ricardo Sanchez
- Clinical Research Institute, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Cozzolino M, Magagnoli L, Ciceri P, Conte F, Galassi A. Effects of a medium cut-off (Theranova ®) dialyser on haemodialysis patients: a prospective, cross-over study. Clin Kidney J 2021; 14:382-389. [PMID: 33564442 PMCID: PMC7857781 DOI: 10.1093/ckj/sfz155] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/02/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Despite significant advances in haemodialysis (HD) in recent decades, current dialysis techniques are limited by inadequate removal of uraemic solutes such as middle molecules and protein-bound uraemic toxins. Novel medium cut-off (MCO) membrane or 'expanded haemodialysis' (HDx) provides diffusive removal of conventional and large middle molecular weight uraemic toxins, with marginal albumin leak. METHODS This prospective, open-label, controlled, cross-over pilot study compared HDx (novel MCO membrane Theranova® 400) and conventional HD in 20 prevalent HD patients. Biochemical, dialysis adequacy and safety measures (adverse events, infections and hospitalization frequency) were recorded. Ten patients underwent conventional HD high-flux dialyser and 10 patients underwent HDx for 3 months, and the patients then switched and received the other treatment for a further 3 months. RESULTS Treatment with HDx was associated with a significant reduction in serum albumin concentration [median (interquartile range) reduction -0.45 g/dL (-0.575 to -0.05); P = 0.025]. However, median albumin levels were ≥3.5 g/dL and no patients had clinical symptoms of hypoalbuminaemia or needed intravenous albumin administration. The number of infections was lower in patients treated with HDx (n = 7/19) compared with patients treated with HD (n = 14/20; P = 0.03). Patients treated with HDx had reduced levels of interleukin (IL)-1β (from 0.06 ± 0.02 pg/mL versus 0.28 ± 0.18 pg/mL with HD) and IL-6 (6.45 ± 1.57 pg/mL versus 9.48 ± 2.15 pg/mL), while tumour necrosis factor-α levels remain unchanged. CONCLUSIONS This study demonstrates that the chronic use of the novel MCO dialyser Theranova® appears to be safe and well-tolerated, without serious side effects or hypoalbuminaemia, as well as fewer infections. These results need to be confirmed in larger randomized clinical trials.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Lorenza Magagnoli
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione Ca’ Granda IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ferruccio Conte
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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27
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Chao CT, Lin SH. Uremic Vascular Calcification: The Pathogenic Roles and Gastrointestinal Decontamination of Uremic Toxins. Toxins (Basel) 2020; 12:toxins12120812. [PMID: 33371477 PMCID: PMC7767516 DOI: 10.3390/toxins12120812] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/11/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022] Open
Abstract
Uremic vascular calcification (VC) commonly occurs during advanced chronic kidney disease (CKD) and significantly increases cardiovascular morbidity and mortality. Uremic toxins are integral within VC pathogenesis, as they exhibit adverse vascular influences ranging from atherosclerosis, vascular inflammation, to VC. Experimental removal of these toxins, including small molecular (phosphate, trimethylamine-N-oxide), large molecular (fibroblast growth factor-23, cytokines), and protein-bound ones (indoxyl sulfate, p-cresyl sulfate), ameliorates VC. As most uremic toxins share a gut origin, interventions through gastrointestinal tract are expected to demonstrate particular efficacy. The “gastrointestinal decontamination” through the removal of toxin in situ or impediment of toxin absorption within the gastrointestinal tract is a practical and potential strategy to reduce uremic toxins. First and foremost, the modulation of gut microbiota through optimizing dietary composition, the use of prebiotics or probiotics, can be implemented. Other promising strategies such as reducing calcium load, minimizing intestinal phosphate absorption through the optimization of phosphate binders and the inhibition of gut luminal phosphate transporters, the administration of magnesium, and the use of oral toxin adsorbent for protein-bound uremic toxins may potentially counteract uremic VC. Novel agents such as tenapanor have been actively tested in clinical trials for their potential vascular benefits. Further advanced studies are still warranted to validate the beneficial effects of gastrointestinal decontamination in the retardation and treatment of uremic VC.
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Affiliation(s)
- Chia-Ter Chao
- Nephrology Division, Department of Medicine, National Taiwan University Hospital BeiHu Branch, Taipei 10845, Taiwan;
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Shih-Hua Lin
- Department of Internal Medicine, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
- Correspondence:
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28
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Reis T, Martino F, Dias P, de Freitas GRR, da Silva Filho ER, de Azevedo MLC, Reis F, Cozzolino M, Rizo-Topete L, Ronco C. Removal of middle molecules with medium cutoff dialyzer in patients on short frequent hemodialysis. Hemodial Int 2020; 25:180-187. [PMID: 33225535 DOI: 10.1111/hdi.12906] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Medium cutoff (MCO) membranes for hemodialysis (HD) remove more effectively large middle molecules than high-flux (HF) membranes. In patients on in-center short frequent HD regimen (5 sessions per week, 2 hours and 30 minutes per session) the effect of MCO on middle weight uremic toxins has not been elucidated. METHODS This retrospective study included 15 patients previously performing short frequent HD with HF dialyzer (HF-HD), that were switched to short frequent HD with MCO dialyzer (MCO-HD) for 2 months, and returned to HF-HD. The primary endpoint was the predialysis concentration of α1-acid glycoprotein during the different study phases. Secondary endpoints were predialysis concentration of other middle molecules, albumin, and assessment of the quality of life using the 36-item short-form health survey (SF-36). FINDINGS During MCO-HD phase there was a reduction in mean ± SD α1-acid glycoprotein concentration (98.71 ± 25.2 vs. 88.6 ± 24.6 mg/dL, P = 0.107), followed by an increment 2 months after returning to HF-HD (89.18 ± 26.12 vs. 97.33 ± 31.29 mg/dL, P = 0.002); however, only the second variation was statistically significant. MCO-HD provided lower median predialysis concentration of prolactin (16 [10.2-25.6] vs. 14.1 [11.7-34.8] ng/mL, P = 0.036). Single-pool Kt/V, standard Kt/V, predialysis β2-microglobulin, myoglobin, and SF-36 questionnaire remained stable during the first two phases (pre-MCO and MCO). β2-Microglobulin increased in the post-MCO phase (20.02 ± 8.14 vs. 21.27 ± 7.64 μg/mL, P = 0.000). Mean predialysis concentration of albumin reduced significantly from pre-MCO vs. MCO phases (39.9 ± 3.7 vs. 38.3 ± 3.3 g/L, P = 0.020) and rebounded significantly from MCO vs. post-MCO phases (38.7 ± 3.1 vs. 41.3 ± 3.0 g/L, P = 0.007). DISCUSSION In this retrospective analysis, short frequent MCO-HD promotes a reduction in prolactin, a middle weight uremic toxin, and trends toward a reduction in α1-acid glycoprotein. No patients developed hypoalbuminemia. These findings are encouraging and deserve investigation in prospective studies.
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Affiliation(s)
- 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, Brasília, Brazil
| | - Francesca Martino
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Priscila Dias
- Department of Nephrology, Clínica de Doenças Renais de Brasília, Brasília, Brazil.,Department of Kidney Transplantation, University Hospital of Brasília, Brasília, Brazil
| | - Geraldo R R de Freitas
- Department of Nephrology, Clínica de Doenças Renais de Brasília, Brasília, Brazil.,Department of Kidney Transplantation, University Hospital of Brasília, Brasília, Brazil
| | | | - Maria L C de Azevedo
- Department of Nephrology, Clínica de Doenças Renais de Brasília, Brasília, Brazil
| | - Fábio Reis
- Department of Nephrology, Clínica de Doenças Renais de Brasília, Brasília, Brazil
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Milan, Italy.,Department of Nephrology and Dialysis, ASST Santi Paolo e Carlo, Milan, Italy
| | - Lilia Rizo-Topete
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Internal Medicine, Nephrology Service, Hospital Universitario "José Eleuterio González", Hospital Christus Muguerza Alta Especialidad, UDEM, Monterrey, Mexico
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
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Penny JD, Salerno FR, Akbari A, McIntyre CW. Pruritus: Is there a grain of salty truth? Hemodial Int 2020; 25:E10-E14. [PMID: 32996258 DOI: 10.1111/hdi.12885] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/06/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022]
Abstract
Hemodialysis patients characteristically suffer from a range of unpleasant symptoms. Uremic pruritus effects close to half of the chronic kidney disease population, reducing quality of life and associated with increased mortality. Its pathophysiology though is poorly understood; currently deployed therapeutic approaches are ineffective. Excessive levels of skin and soft tissue sodium accumulate in dialysis patients, producing a range of biological consequences, including inflammation. We report an index case of a hemodialysis patient with debilitating pruritus and extreme levels of tissue sodium, measured with Sodium-23 magnetic resonance imaging. Both the tissue sodium loading and pruritus responded fully to initiation of expanded hemodialysis therapy with a recently introduced medium cutoff dialysis membrane-based dialyzer.
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Affiliation(s)
- Jarrin D Penny
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada
| | - Fabio R Salerno
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada
| | - Alireza Akbari
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada
| | - Christopher W McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada.,Division of Nephrology, London Health Sciences Centre, London, Canada.,Lawson Health Research Institute, London, Canada
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30
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Belmouaz M, Bauwens M, Hauet T, Bossard V, Jamet P, Joly F, Chikhi E, Joffrion S, Gand E, Bridoux F. Comparison of the removal of uraemic toxins with medium cut-off and high-flux dialysers: a randomized clinical trial. Nephrol Dial Transplant 2020; 35:328-335. [PMID: 31578564 DOI: 10.1093/ndt/gfz189] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/21/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Accumulation of middle-weight uraemic toxins in haemodialysis (HD) patients results in increased morbidity and mortality. Whether medium cut-off HD (MCO-HD) improves removal of middle-weight uraemic toxins remains to be demonstrated. METHODS This cross-over prospective study included 40 patients randomly assigned to receive either 3 months of MCO-HD followed by 3 months of high-flux HD (HF-HD), or vice versa. The primary endpoint was myoglobin reduction ratio (RR) after 3 months of MCO-HD. Secondary endpoints were the effect of MCO-HD on other middle-weight toxins and protein-bound toxins, and on parameters of nutrition, inflammation, anaemia and oxidative stress. RESULTS Compared with HF-HD, MCO-HD provided higher mean RR of myoglobin (36 ± 8 versus 57 ± 13%, P < 0.0001), beta2-microglobulin (68 ± 6 versus 73 ± 15%, P = 0.04), prolactin (32 ± 13 versus 59 ± 11%, P < 0.0001), fibroblast growth factor 23 (20 ± 21 versus 41 ± 22%, P = 0.0002), homocysteine (43 ± 7 versus 46 ± 9%, P = 0.03) and higher median RR of kappa [54 (48-58) versus 70 (63-74)%, P < 0.0001] and lambda free light chain (FLC) [15 (9-22) versus 44 (38-49)%, P < 0.0001]. Mean ± SD pre-dialysis levels of beta2-microglobulin (28.4 ± 5.6 versus 26.9 ± 5.1 mg/L, P = 0.01) and oxidized low-density lipoprote (6.9 ± 4.4 versus 5.5 ± 2.5 pg/mL, P = 0.04), and median (interquartile range) kappa FLC [145 (104-203) versus 129 (109-190) mg/L, P < 0.03] and lambda FLC [106 (77-132) versus 89 (62-125) mg/L, P = 0.002] were significantly lower. Mean albumin levels decreased significantly (38.2 ± 4.1 versus 36.9 ± 4.3 g/L, P = 0.004), without an effect on nutritional status as suggested by unchanged normalized protein catabolic rate and transthyretin level. CONCLUSIONS Compared with HF-HD, MCO-HD provides higher myoglobin and other middle molecules RR and is associated with moderate hypoalbuminemia. The potential benefits of this strategy on long-term clinical outcomes deserve further evaluation.
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Affiliation(s)
- Mohamed Belmouaz
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Marc Bauwens
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Thierry Hauet
- Department of Biochemistry, Poitiers University Hospital, Poitiers, France.,Institut National de la Sante et de la Recherche Médicale (INSERM), U1082 (IRTOMIT), Poitiers University Hospital, Poitiers, France
| | - Valentin Bossard
- Department of Biochemistry, Poitiers University Hospital, Poitiers, France
| | - Pierre Jamet
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Florent Joly
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Elise Chikhi
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Sandrine Joffrion
- Department of Biochemistry, Poitiers University Hospital, Poitiers, France.,Institut National de la Sante et de la Recherche Médicale (INSERM), U1082 (IRTOMIT), Poitiers University Hospital, Poitiers, France
| | - Elise Gand
- Department of Biostatistics, Centre d'Investigation Clinique CIC 1402, Poitiers University Hospital, Poitiers, France
| | - Frank Bridoux
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
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31
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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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32
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Brys A, Stasio ED, Lenaert B, Picca A, Calvani R, Marzetti E, Gambaro G, Bossola M. Peridialytic serum cytokine levels and their relationship with postdialysis fatigue and recovery in patients on chronic haemodialysis - A preliminary study. Cytokine 2020; 135:155223. [PMID: 32799010 DOI: 10.1016/j.cyto.2020.155223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/15/2020] [Accepted: 07/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aetiology of postdialysis fatigue (PDF), an intermittent but debilitating fatigue occurring after haemodialysis (HD) treatment, is still unclear. In other inflammatory diseases, increasing evidence points toward the involvement of the immune system in the onset of fatigue symptoms. Altered serum levels of inflammatory cytokines have also been shown in HD patients. Therefore, we investigated whether pre- and postdialysis serum levels of pro- and anti-inflammatory cytokines (i.e. IL-1β, IL-6, TNF-α and IL-10) or their intradialytic changes (if any) were related to PDF or the time HD patients reported needing to recover from HD treatment (TIRD). METHODS Serum levels of IL-1β, IL-6, TNF-α and IL-10 were measured immediately before and after HD in 45 patients using commercially available kits on an ELLA™ automated immunoassay system. The presence and severity of PDF as well as TIRD duration were assessed by self-report measures. KEY RESULTS Seventy-four percent of patients reported PDF, with a median PDF severity index of 3.30 [IQR: 3.00-4.30] on a scale from 1 to 5. Median TIRD was 120 min [IQR: 60-480]. PDF severity correlated strongly with TIRD, rs = 0.85, p < 0.001. Only predialysis levels of IL-10 significantly and positively correlated with PDF severity (rs = 0.43, p = 0.003). CONCLUSION Findings of the present study do not support the involvement of the immune system in the onset of PDF or the time patients needed to recover from HD treatment. A positive, but counterintuitive relationship was found between predialysis levels of anti-inflammatory IL-10 and PDF severity, which warrants further research.
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Affiliation(s)
- Astrid Brys
- Divisione di Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy; Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands.
| | - Enrico Di Stasio
- Università Cattolica del Sacro Cuore, Rome, Italy; UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bert Lenaert
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands; School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Anna Picca
- Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Calvani
- Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Emanuele Marzetti
- Università Cattolica del Sacro Cuore, Rome, Italy; Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Gambaro
- Divisione di Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Division of Nephrology, University Hospital of Verona, Verona, Italy
| | - Maurizio Bossola
- Università Cattolica del Sacro Cuore, Rome, Italy; Haemodialysis Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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33
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Ronco C, Reis T, Cozzolino M. Rationale for Medium Cutoff Membranes in COVID-19 Patients Requiring Renal Replacement Therapy. Nephron Clin Pract 2020; 144:550-554. [PMID: 32750694 PMCID: PMC7490487 DOI: 10.1159/000509807] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022] Open
Abstract
The current pandemic of coronavirus disease 2019 (COVID-19) spotlighted the vulnerability of patients with chronic kidney disease stage 5 on maintenance hemodialysis (HD) to the viral infection. Social distancing is the most effective preventive measure to reduce the risk of infection. Nonetheless, the necessity to frequently reach the dialysis center and the inherent social gathering both impede social distancing and also self-quarantine for infected individuals. A baseline hyperinflammatory state driven by factors such as the retention of uremic toxins afflicts these patients. Concomitantly, a condition of relative immunosuppression is also attributed to similar factors. The use of high-flux (HF) dialyzers for HD is the standard of care. However, with HF membranes, the removal of large middle molecules is scant. Medium cutoff (MCO) dialyzers are a new class of membranes that allow substantial removal of large middle molecules with negligible albumin losses. Recent trials confirmed long-term safety and long-term sustained reduction in the concentration of large uremic toxins with MCO dialyzers. Herein, we discuss the rationale for applying MCO membranes in COVID-19 patients and its possible immunoadjuvant effects that could mitigate the burden of COVID-19 infection in dialysis patients. We also discuss the direct cytopathic effect of the virus on renal tissue and extracorporeal blood purification techniques that can prevent kidney damage or reduce acute kidney injury progression.
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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, San Bortolo Hospital, Vicenza, Italy
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Clínica de Doenčas Renais de Brasília, Brasília, Brazil
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Milan, Italy
- Department of Nephrology and Dialysis, ASST Santi Paolo e Carlo, Milan, Italy
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Sevinc M, Hasbal NB, Yilmaz V, Basturk T, Ahbap E, Sakaci T, Ozcafer PN, Unsal A. Comparison of Circulating Levels of Uremic Toxins in Hemodialysis Patients Treated with Medium Cut-Off Membranes and High-Flux Membranes: Theranova in Sisli Hamidiye Etfal (THE SHE) Randomized Control Study. Blood Purif 2020; 49:733-742. [PMID: 32634815 DOI: 10.1159/000508061] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/20/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Removal of uremic toxins is a main objective of hemodialysis; however, whether high-flux and medium cut-off (MCO) membranes differ as regards removal of middle and large uremic toxins is not clear. OBJECTIVE To compare medium cut-off and high-flux dialyzers as regards their intra- and interdialysis effect on circulating levels of middle and large uremic toxins and serum albumin. METHODS Fifty-two patients were randomized to have hemodialysis with either 3 months of high-flux dialyzer followed by 3 months of MCO or vice versa. Blood samples were taken before and after dialysis at the first and last sessions of each dialyzer for analyses of middle and large uremic toxins including inflammatory mediators and vascular endothelial growth factor (VEGF), and serum albumin. RESULTS Reduction rates were higher, and postdialysis levels of β-2 microglobulin, free kappa and lambda light chains, and myoglobulin were lower at the first and last sessions with MCO dialyzers compared to high-flux dialyzers (p < 0.05 for all). Last session predialysis levels of β-2 microglobulin, free kappa light chain, and free lambda light chain were lower than first session predialysis levels in MCO dialyzers as compared to high-flux dialyzers (p < 0.05 for all). Last session levels of interleukin-6, interleukin-10, interleukin-17, and interferon-gamma did not differ between dialyzers (p > 0.05 for all). VEGF level was lower in the MCO group compared to the high-flux group (p = 0.043). Last session level of serum albumin with MCO dialyzers was lower than that with high-flux dialyzers (3.62 [3.45-3.88] vs. 3.78 [3.58-4.02] g/L) (p = 0.04) and 6.7% lower (p < 0.001) than at the first session of MCO dialyzers. CONCLUSION The decline in circulating levels of several middle and large uremic toxins including VEGF following hemodialysis was more pronounced when using MCO membranes as compared to high-flux membranes while their effect on inflammatory molecules was similar.
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Affiliation(s)
- Mustafa Sevinc
- Nephrology Department, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | | | - Vuslat Yilmaz
- Neuroscience Department, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Taner Basturk
- Nephrology Department, University of Health Sciences, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey,
| | - Elbis Ahbap
- Nephrology Department, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Tamer Sakaci
- Nephrology Department, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Perin Nazif Ozcafer
- Nephrology Department, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Abdulkadir Unsal
- Nephrology Department, University of Health Sciences, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
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Dourado M, Cavalcanti F, Vilar L, Cantilino A. Relationship between Prolactin, Chronic Kidney Disease, and Cardiovascular Risk. Int J Endocrinol 2020; 2020:9524839. [PMID: 32655635 PMCID: PMC7327580 DOI: 10.1155/2020/9524839] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
CKD has a high prevalence worldwide, mainly due to its main etiologies-diabetes and hypertension. It has high cardiovascular morbidity and mortality, with traditional risk factors such as atherosclerosis, hypertension, diabetes, smoking, and left ventricular hypertrophy being common. Nontraditional cardiovascular risk factors, such as anemia, hyperparathyroidism, chronic inflammation, and microalbuminuria, are also well studied. Prolactin is a hormone not only related to lactation but also being considered a uremic toxin by some authors. It accumulates with loss of renal function, and it is associated with cardiovascular outcomes in both normal renal function population and CKD population. The purpose of this narrative review is to raise the main common aspects of CKD, prolactinemia, and cardiovascular risk.
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Affiliation(s)
- Marclébio Dourado
- Nephrology Department, Medical Sciences Center (CCM), Federal University of Pernambuco, Recife, Brazil
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Frederico Cavalcanti
- Nephrology Department, Medical Sciences Center (CCM), Federal University of Pernambuco, Recife, Brazil
- Nephrology Department, Real Hospital Portugues, Recife, Pernambuco, Brazil
| | - Lucio Vilar
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Amaury Cantilino
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Federal University of Pernambuco, Recife, Pernambuco, Brazil
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Huang C, Ren J, Ji F, Muyldermans S, Jia L. Nanobody-Based high-performance immunosorbent for selective beta 2-microglobulin purification from blood. Acta Biomater 2020; 107:232-241. [PMID: 32092428 DOI: 10.1016/j.actbio.2020.02.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 12/18/2022]
Abstract
Removing β2-microglobulin (β2M) from blood circulation is considered to be the most effective method to delay the occurrence of dialysis-related amyloidosis (DRA). The ideal extracorporeal β2M removal system should be cost-effective, highly specific and having a high capacity. However, the traditional technologies based on size exclusion do not have an adequate specificity, and alternative immunosorbents have limited applications due to low capacity and their high cost. Nanobodies (Nbs), the smallest functional recombinant antibody fragments, offer several advantages to overcome these obstacles. In this study, an anti-β2M Nb with a C-terminal thiol-tag was successfully prepared from E. coli for site-directed and oriented immobilization and usage as capture ligand in a β2M-selective immunosorbent. The prepared immunosorbent showed a high binding capacity of up to 7 mg β2M per mL resin, which is 17 times higher than that of previous studies using single-chain variable antibody fragments (scFv). Furthermore, an exceptional high specificity has been demonstrated as other human serum proteins were not adsorbed during dynamic adsorption experiments. About 80% of the original binding capacity of the immunosorbent was restored after four consecutive easy regenerations, whereas 90% of the original capacity was retained after 1-month storage of the resin. Moreover, the mathematical model fitted very well the in vitro perfusion. The results with this pioneering immunosorbent confirm its possible clinical application and is expected to reach the required clinical effect of immunoadsorption therapy. STATEMENT OF SIGNIFICANCE: Dialysis-related amyloidosis (DRA), associated with the accumulation of β2-microglobulin (β2M), is a serious complication of end-stage kidney disease. Removing β2M from blood circulation by extracorporeal blood purification is considered to be the most effective method to delay the occurrence of DRA. However, the existing methods are incapable to eliminate sufficient quantities of β2M from circulation, either because of lack of specificity, high cost or for low capacity. In this manuscript, we provide a practical and economic immunosorbent based on anti-β2M nanobody for DRA. The prepared immunosorbent was reusable and storable, and demonstrated high specificity and realized a high binding capacity of up to 7 mg β2M per mL resin, which is 17 times higher than that of the previous studies.
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Alique M, Bodega G, Corchete E, García-Menéndez E, de Sequera P, Luque R, Rodríguez-Padrón D, Marqués M, Portolés J, Carracedo J, Ramírez R. Microvesicles from indoxyl sulfate-treated endothelial cells induce vascular calcification in vitro. Comput Struct Biotechnol J 2020; 18:953-966. [PMID: 32368330 PMCID: PMC7184105 DOI: 10.1016/j.csbj.2020.04.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 12/12/2022] Open
Abstract
Vascular calcification (VC), an unpredictable pathophysiological process and critical event in patients with cardiovascular diseases (CVDs), is the leading cause of morbi-mortality and disability in chronic kidney disease (CKD) patients worldwide. Currently, no diagnostic method is available for identifying patients at risk of VC development; the pathology is detected when the process is irreversible. Extracellular vesicles (EVs) from endothelial cells might promote VC. Therefore, their evaluation and characterization could be useful for designing new diagnostic tools. The aim of the present study is to investigate whether microvesicles (MVs) from endothelial cells damaged by uremic toxin and indoxyl sulfate (IS) could induce calcification in human vascular smooth muscle cells (VMSCs). Besides, we have also analyzed the molecular mechanisms by which these endothelial MVs can promote VC development. Endothelial damage has been evaluated according to the percentage of senescence in endothelial cells, differential microRNAs in endothelial cells, and the amount of MVs released per cell. To identify the role of MVs in VC, VSMCs were treated with MVs from IS-treated endothelial cells. Calcium, inflammatory gene expression, and procalcification mediator levels in VSMCs were determined. IS-treated endothelial cells underwent senescence and exhibited modulated microRNA expression and an increase in the release of MVs. VSMCs exposed to these MVs modulated the expression of pro-inflammatory genes and some mediators involved in calcification progression. MVs produced by IS-treated endothelial cells promoted calcification in VSMCs.
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Affiliation(s)
- Matilde Alique
- Departamento de Biología de Sistemas, Universidad de Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Guillermo Bodega
- Departamento de Biomedicina y Biotecnología, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Elena Corchete
- Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | | | - Rafael Luque
- Departamento de Química Orgánica, Universidad de Córdoba, Edificio Marie Curie (C-3), Carretera Nacional IV-A, Km 396, Córdoba, Spain
| | - Daily Rodríguez-Padrón
- Departamento de Química Orgánica, Universidad de Córdoba, Edificio Marie Curie (C-3), Carretera Nacional IV-A, Km 396, Córdoba, Spain
| | - María Marqués
- Servicio Nefrología, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - José Portolés
- Servicio Nefrología, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Julia Carracedo
- Departamento de Genética, Fisiología y Microbiología, Facultad de Ciencias Biológicas, Universidad Complutense de Madrid/ Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Rafael Ramírez
- Departamento de Biología de Sistemas, Universidad de Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
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Kim TH, Kim SH, Kim TY, Park HY, Jung KS, Lee MH, Jhee JH, Lee JE, Choi HY, Park HC. Removal of large middle molecules via haemodialysis with medium cut-off membranes at lower blood flow rates: an observational prospective study. BMC Nephrol 2019; 21:2. [PMID: 31892319 PMCID: PMC6937993 DOI: 10.1186/s12882-019-1669-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Online haemodiafiltration (OL-HDF) may improve middle molecular clearance in contrast to conventional haemodialysis (HD). However, OL-HDF requires higher convective flows and cannot sufficiently remove large middle molecules. This study evaluated the efficacy of a medium cut-off (MCO) dialyser in removing large middle molecular uraemic toxins and compared it with that of conventional high-flux (HF) dialysers in HD and predilution OL-HDF. Methods Six clinically stable HD patients without residual renal function were investigated. Dialyser and treatment efficacies were examined during a single midweek treatment in three consecutive periods: 1) conventional HD using an HF dialyser, 2) OL-HDF using the same HF dialyser, and 3) conventional HD using an MCO dialyser. Treatment efficacy was assessed by calculating the reduction ratio (RR) for β2-microglobulin (β2M), myoglobin, κ and λ free light chains (FLCs), and fibroblast growth factor (FGF)-23 and measuring clearance for FLCs. Results All three treatments showed comparable RRs for urea, phosphate, creatinine, and uric acid. MCO HD showed greater RRs for myoglobin and λFLC than did HF HD and predilution OL-HDF (myoglobin: 63.1 ± 5.3% vs. 43.5 ± 8.9% and 49.8 ± 7.3%; λFLC: 43.2 ± 5.6% vs. 26.8 ± 4.4% and 33.0 ± 9.2%, respectively; P < 0.001). Conversely, predilution OL-HDF showed the greatest RR for β2M, whereas MCO HD and HF HD showed comparable RRs for β2M (predilution OL-HDF vs. MCO HD: 80.1 ± 4.9% vs. 72.6 ± 3.8%, P = 0.01). There was no significant difference among MCO HD, HF HD, and predilution OL-HDF in the RRs for κFLC (63.2 ± 6.0%, 53.6 ± 15.5%, and 61.5 ± 7.0%, respectively; P = 0.37), and FGF-23 (55.5 ± 20.3%, 34.6 ± 13.1%, and 35.8 ± 23.2%, respectively; P = 0.13). Notably, MCO HD showed improved clearances for FLCs when compared to HF HD or OL-HDF. Conclusions MCO HD showed significantly greater RR of large middle molecules and achieved improved clearance for FLCs than conventional HD and OL-HDF, without the need for large convection volumes or high blood flow rates. This would pose as an advantage for elderly HD patients with poor vascular access and HD patients without access to OL-HDF. Trial registration Clinical Research Information Service (CRIS): KCT 0003009. The trial was prospectively registered on the 21 Jul 2018.
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Affiliation(s)
- Tae Hoon Kim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, 17046, Republic of Korea
| | - Seok-Hyung Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, 24253, Republic of Korea
| | - Tae Yeon Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Hae Yeul Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Kwon Soo Jung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Moon Hyoung Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jong Hyun Jhee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jung Eun Lee
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, 17046, Republic of Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea.,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Hyeong Cheon Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea. .,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.
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Lai J, Wu Y, Hang L, Gael A, Deng T, Yan Q, Fu Q, Li Z. [Zhenwu Decoction delays ventricular hypertrophy in rats with uremic cardiomyopathy]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:113-119. [PMID: 30692076 DOI: 10.12122/j.issn.1673-4254.2019.01.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the inhibitory effect of Zhenwu Decoction on ventricular hypertrophy in rats with uremic cardiomyopathy and explore the mechanism. METHODS Cardiocytes isolated from suckling rats were divided into control group and indoxyl sulfate (IS) group, and the protein synthesis was assayed with [3H]- leucine incorporation and cellular protein expressions were detected using Western blotting. Fifty SD rats were randomly divided into sham operation group, model group, and low- and high-dose Zhenwu Decoction treatment groups, and except for those in the sham operation group, all the rats underwent 5/6 nephrectomy. Four weeks after the operation, the rats in low- and high-dose treatment groups were given Zhenwu Decoction via gavage at the dose of 4.5 g/kg and 13.5 g/kg, respectively; the rats in the sham-operated and model groups were given an equal volume of distilled water. After 4 weeks of treatment, serum levels of IS were determined, and cardiac and ventricular mass indexes were measured in the rats; cardiac ultrasound was performed and Western blotting was used to measure the expressions of BNP, p-ERK1/2, p-p38 and p-JNK in the myocardium. RESULTS Rat cardiomyocytes treated with IS showed significantly enhanced protein synthesis and increased expression levels of BNP, p-erk1/2, and p-p38 as compared with the control cells (P < 0.01), but the expression of p-jnk was comparable between the two groups. In the animal experiment, the rats in the model group showed significantly increased serum creatinine (SCr) and urea nitrogen (BUN) levels, 24-h urine protein (24 hUpro), plasma IS level, left ventricular mass index (LVMI) and whole heart mass index (HMI) compared with those in the sham group (P < 0.01); Both LVESD and LVEDD were significantly reduced and LVAWS, LVAWD, LVPWS and LVPWD were significantly increased in the model rat, which also presented with obvious cardiomyocyte hypertrophy and increased myocardial expressions of BNP, p-ERK1/2, p-p38 and p-jnk (P < 0.01). Compared with the rats in the model group, the rats treated with low-dose and high-dose Zhenwu Decoction had significantly lowered levels of SCr, BUN, 24 hUpro and IS (P < 0.05) and decreased LVMI and HMI; LVESD, LVEDD, LVPWS, LVAWS, and LVAWD were improved more obviously in the high-dose group, and the myocardial expressions of BNP, p-ERK1/2, p-p38 and p-JNK was significantly downregulated after the treatment. CONCLUSIONS Zhenwu Decoctin can reduce plasma IS levels and inhibit ventricular hypertrophy to delay ventricular remodeling in rats with uremic cardiomyopathy.
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Affiliation(s)
- Jun Lai
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Yingzhi Wu
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Liwei Hang
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Akindavyi Gael
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Ting Deng
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Quanneng Yan
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Qiang Fu
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Zhiliang Li
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
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