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Himmelein S, Perez Ruiz de Garibay A, Brandel V, Zierfuß F, Bingold TM. The ADVanced Organ Support (ADVOS) hemodialysis system removes IL-6: an in vitro proof-of-concept study. Intensive Care Med Exp 2024; 12:66. [PMID: 39083101 PMCID: PMC11291793 DOI: 10.1186/s40635-024-00652-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/21/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND IL-6 is a pleiotropic cytokine modulating inflammation and metabolic pathways. Its proinflammatory effect plays a significant role in organ failure pathogenesis, commonly elevated in systemic inflammatory conditions. Extracorporeal blood purification devices, such as the Advanced Organ Support (ADVOS) multi hemodialysis system, might offer potential in mitigating IL-6's detrimental effects, yet its efficacy remains unreported. METHODS We conducted a proof-of-concept in vitro study to assess the ADVOS multi system's efficacy in eliminating IL-6. Varying concentrations of IL-6 were introduced into a swine blood model and treated with ADVOS multi for up to 12 h, employing different blood and concentrate flow rates. IL-6 reduction rate, clearance, and dynamics in blood and dialysate were analyzed. RESULTS IL-6 clearance rates of 0.70 L/h and 0.42 L/h were observed in 4 and 12-h experiments, respectively. No significant differences were noted across different initial concentrations. Reduction rates ranged between 40 and 46% within the first 4 h, increasing up to 72% over 12 h, with minimal impact from flow rate variations. Our findings suggest that an IL-6-albumin interaction and convective filtration are implicated in in vitro IL-6 elimination with ADVOS multi. CONCLUSIONS This study demonstrates for the first time an efficient and continuous in vitro removal of IL-6 by ADVOS multi at low blood flow rates. Initial concentration-dependent removal transitions to more consistent elimination over time. Further clinical investigations are imperative for comprehensive data acquisition.
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Affiliation(s)
| | | | - Veronika Brandel
- Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Frank Zierfuß
- Department of Internal Medicine, Universitätsklinikum Frankfurt, Frankfurt, Germany
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2
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Armenta-Alvarez A, Lopez-Gil S, Osuna I, Grobe N, Tao X, Ferreira Dias G, Wang X, Chao J, Raimann JG, Thijssen S, Perez-Grovas H, Canaud B, Kotanko P, Madero M. Removal of Middle Molecules and Dialytic Albumin Loss: A Cross-over Study of Medium Cutoff and High-Flux Membranes with Hemodialysis and Hemodiafiltration. KIDNEY360 2023; 4:1095-1102. [PMID: 37651666 PMCID: PMC10476684 DOI: 10.34067/kid.0000000000000185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 09/02/2023]
Abstract
Key Points HDF and MCO have shown greater clearance of middle-size uremic solutes in comparison with HF dialyzers; MCO has never been studied in HDF. MCO in HDF does not increase the clearance of B2M and results in a higher loss of albumin. Background Middle molecule removal and albumin loss have been studied in medium cutoff (MCO) membranes on hemodialysis (HD). It is unknown whether hemodiafiltration (HDF) with MCO membranes provides additional benefit. We aimed to compare the removal of small solutes and β 2-microglobulin (B2M), albumin, and total proteins between MCO and high-flux (HFX) membranes with both HD and HDF, respectively. Methods The cross-over study comprised 4 weeks, one each with postdilutional HDF using HFX (HFX-HDF), MCO (MCO-HDF), HD with HFX (HFX-HD), and MCO (MCO-HD). MCO and HFX differ with respect to several characteristics, including membrane composition, pore size distribution, and surface area (HFX, 2.5 m2; MCO, 1.7 m2). There were two study treatments per week, one after the long interdialytic interval and another midweek. Reduction ratios of vitamin B12, B2M, phosphate, uric acid, and urea corrected for hemoconcentration were computed. Dialysis albumin and total protein loss during the treatment were quantified from dialysate samples. Results Twelve anuric patients were studied (six female patients; 44±19 years; dialysis vintage 35.2±28 months). The blood flow was 369±23 ml/min, dialysate flow was 495±61 ml/min, and ultrafiltration volume was 2.8±0.74 L. No significant differences were found regarding the removal of B2M, vitamin B12, and water-soluble solutes between dialytic modalities and dialyzers. Albumin and total protein loss were significantly higher in MCO groups than HFX groups when compared with the same modality. HDF groups had significantly higher albumin and total protein loss than HD groups when compared with the same dialyzer. MCO-HDF showed the highest protein loss among all groups. Conclusions MCO-HD is not superior to HFX-HD and HFX-HDF for both middle molecule and water-soluble solute removal. Protein loss was more pronounced with MCO when compared with HFX on both HD and HDF modalities. MCO-HDF has no additional benefits regarding better removal of B2M but resulted in greater protein loss than MCO-HD.
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Affiliation(s)
- Armando Armenta-Alvarez
- Division of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Salvador Lopez-Gil
- Division of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Iván Osuna
- Center for Research in Infectious Diseases, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Nadja Grobe
- Research Division, Renal Research Institute, New York, New York
| | - Xia Tao
- Research Division, Renal Research Institute, New York, New York
| | | | - Xiaoling Wang
- Research Division, Renal Research Institute, New York, New York
| | - Joshua Chao
- Research Division, Renal Research Institute, New York, New York
| | | | | | - Hector Perez-Grovas
- Division of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Magdalena Madero
- Division of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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3
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Zhou Z, Kuang H, Wang F, Liu L, Zhang L, Fu P. High cut-off membranes in patients requiring renal replacement therapy: a systematic review and meta-analysis. Chin Med J (Engl) 2023; 136:34-44. [PMID: 36848147 PMCID: PMC10106154 DOI: 10.1097/cm9.0000000000002150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Whether high cut-off (HCO) membranes are more effective than high-flux (HF) membranes in patients requiring renal replacement therapy (RRT) remains controversial. The aim of this systematic review was to investigate the efficacy of HCO membranes regarding the clearance of inflammation-related mediators, β2-microglobulin and urea; albumin loss; and all-cause mortality in patients requiring RRT. METHODS We searched all relevant studies on PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure, with no language or publication year restrictions. Two reviewers independently selected studies and extracted data using a prespecified extraction instrument. Only randomized controlled trials (RCTs) were included. Summary estimates of standardized mean differences (SMDs) or weighted mean differences (WMDs) and risk ratios (RRs) were obtained by fixed-effects or random-effects models. Sensitivity analyses and subgroup analyses were performed to determine the source of heterogeneity. RESULTS Nineteen RCTs involving 710 participants were included in this systematic review. Compared with HF membranes, HCO membranes were more effective in reducing the plasma level of interleukin-6 (IL-6) (SMD -0.25, 95% confidence interval (CI) -0.48 to -0.01, P = 0.04, I2 = 63.8%); however, no difference was observed in the clearance of tumor necrosis factor-α (TNF-α) (SMD 0.03, 95% CI -0.27 to 0.33, P = 0.84, I2 = 4.3%), IL-10 (SMD 0.22, 95% CI -0.12 to 0.55, P = 0.21, I2 = 0.0%), or urea (WMD -0.27, 95% CI -2.77 to 2.23, P = 0.83, I2 = 19.6%). In addition, a more significant reduction ratio of β 2 -microglobulin (WMD 14.8, 95% CI 3.78 to 25.82, P = 0.01, I2 = 88.3%) and a more obvious loss of albumin (WMD -0.25, 95% CI -0.35 to -0.16, P < 0.01, I2 = 40.8%) could be observed with the treatment of HCO membranes. For all-cause mortality, there was no difference between the two groups (risk ratio [RR] 1.10, 95% CI 0.87 to 1.40, P = 0.43, I2 = 0.0%). CONCLUSIONS Compared with HF membranes, HCO membranes might have additional benefits on the clearance of IL-6 and β 2-microglobulin but not on TNF-α, IL-10, and urea. Albumin loss is more serious with the treatment of HCO membranes. There was no difference in all-cause mortality between HCO and HF membranes. Further larger high-quality RCTs are needed to strengthen the effects of HCO membranes.
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Affiliation(s)
- Zhifeng Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huang Kuang
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Fang Wang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Lu Liu
- Preventive Medicine, West China School of Public Health, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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4
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Saar-Kovrov V, Zidek W, Orth-Alampour S, Fliser D, Jankowski V, Biessen EAL, Jankowski J. Reduction of protein-bound uraemic toxins in plasma of chronic renal failure patients: A systematic review. J Intern Med 2021; 290:499-526. [PMID: 33792983 DOI: 10.1111/joim.13248] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/07/2020] [Accepted: 12/16/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Protein-bound uraemic toxins (PBUTs) accumulate in patients with chronic kidney disease and impose detrimental effects on the vascular system. However, a unanimous consensus on the most optimum approach for the reduction of plasma PBUTs is still lacking. METHODS In this systematic review, we aimed to identify the most efficient clinically available plasma PBUT reduction method reported in the literature between 1980 and 2020. The literature was screened for clinical studies describing approaches to reduce the plasma concentration of known uraemic toxins. There were no limits on the number of patients studied or on the duration or design of the studies. RESULTS Out of 1274 identified publications, 101 studies describing therapeutic options aiming at the reduction of PBUTs in CKD patients were included in this review. We stratified the studies by the PBUTs and the duration of the analysis into acute (data from a single procedure) and longitudinal (several treatment interventions) trials. Reduction ratio (RR) was used as the measure of plasma PBUTs lowering efficiency. For indoxyl sulphate and p-cresyl sulphate, the highest RR in the acute studies was demonstrated for fractionated plasma separation, adsorption and dialysis system. In the longitudinal trials, supplementation of haemodialysis patients with AST-120 (Kremezin®) adsorbent showed the highest RR. However, no superior method for the reduction of all types of PBUTs was identified based on the published studies. CONCLUSIONS Our study shows that there is presently no technique universally suitable for optimum reduction of all PBUTs. There is a clear need for further research in this field.
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Affiliation(s)
- V Saar-Kovrov
- From the, Institute for Molecular Cardiovascular Research IMCAR, University hospital, Aachen, Germany.,Experimental Vascular Pathology Group, Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - W Zidek
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - S Orth-Alampour
- From the, Institute for Molecular Cardiovascular Research IMCAR, University hospital, Aachen, Germany
| | - D Fliser
- From the, Institute for Molecular Cardiovascular Research IMCAR, University hospital, Aachen, Germany.,Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - V Jankowski
- From the, Institute for Molecular Cardiovascular Research IMCAR, University hospital, Aachen, Germany
| | - E A L Biessen
- From the, Institute for Molecular Cardiovascular Research IMCAR, University hospital, Aachen, Germany.,Experimental Vascular Pathology Group, Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - J Jankowski
- From the, Institute for Molecular Cardiovascular Research IMCAR, University hospital, Aachen, Germany.,Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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5
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Sahathevan S, Khor BH, Ng HM, Abdul Gafor AH, Mat Daud ZA, Mafra D, Karupaiah T. Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review. Nutrients 2020; 12:E3147. [PMID: 33076282 PMCID: PMC7602515 DOI: 10.3390/nu12103147] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.
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Affiliation(s)
- Sharmela Sahathevan
- Dietetics Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia;
| | - Ban-Hock Khor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (B.-H.K.); (A.H.A.G.)
| | - Hi-Ming Ng
- School of Medicine, Faculty of Health & Medical Sciences, Taylor’s University Lakeside Campus, No 1, Jalan Taylors, Subang Jaya 47500, Malaysia;
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (B.-H.K.); (A.H.A.G.)
| | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, UPM Serdang 43400, Malaysia;
| | - Denise Mafra
- Post Graduation Program in Medical Sciences and Post-Graduation Program in Cardiovascular Sciences, (UFF), Federal Fluminense University Niterói-Rio de Janeiro (RJ), Niterói-RJ 24033-900, Brazil;
| | - Tilakavati Karupaiah
- School of BioSciences, Faculty of Health & Medical Sciences, Taylor’s University Lakeside Campus, No 1, Jalan Taylors, Subang Jaya 47500, Malaysia
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6
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Ward RA, Beck W, Bernardo AA, Alves FC, Stenvinkel P, Lindholm B. Hypoalbuminemia: a price worth paying for improved dialytic removal of middle-molecular-weight uremic toxins? Nephrol Dial Transplant 2020; 34:901-907. [PMID: 30102329 DOI: 10.1093/ndt/gfy236] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 01/17/2023] Open
Abstract
Hemodiafiltration (HDF) increases the removal of middle-molecular-weight uremic toxins and may improve outcomes in patients with end-stage kidney disease (ESKD), but it requires complex equipment and comes with risks associated with infusion of large volumes of substitution solution. New high-flux hemodialysis membranes with improved diffusive permeability profiles do not have these limitations and offer an attractive alternative to HDF. However, both strategies are associated with increased albumin loss into the dialysate, raising concerns about the potential for decreased serum albumin concentrations that have been associated with poor outcomes in ESKD. Many factors can contribute to hypoalbuminemia in ESKD, including protein energy wasting, inflammation, volume expansion, renal loss and loss into the dialysate; of these factors, loss into the dialysate is not necessarily the most important. Furthermore, recent studies suggest that mild hypoalbuminemia per se is not an independent predictor of increased mortality in dialysis patients, but in combination with inflammation it is a poor prognostic sign. Thus, whether hypoalbuminemia predisposes to increased morbidity and mortality may depend on the presence or absence of inflammation. In this review we summarize recent findings on the role of dialysate losses in hypoalbuminemia and the importance of concomitant inflammation on outcomes in patients with ESKD. Based on these findings, we discuss whether hypoalbuminemia may be a price worth paying for increased dialytic removal of middle-molecular-weight uremic toxins.
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Affiliation(s)
| | - Werner Beck
- R&D, Baxter International Inc., Hechingen, Germany
| | | | - Filipa C Alves
- Department of Nephrology, Hospital Espírito Santo, Évora, Portugal.,Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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7
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New Insights into the Roles of Monocytes/Macrophages in Cardiovascular Calcification Associated with Chronic Kidney Disease. Toxins (Basel) 2019; 11:toxins11090529. [PMID: 31547340 PMCID: PMC6784181 DOI: 10.3390/toxins11090529] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease (CVD) is an important cause of death in patients with chronic kidney disease (CKD), and cardiovascular calcification (CVC) is one of the strongest predictors of CVD in this population. Cardiovascular calcification results from complex cellular interactions involving the endothelium, vascular/valvular cells (i.e., vascular smooth muscle cells, valvular interstitial cells and resident fibroblasts), and monocyte-derived macrophages. Indeed, the production of pro-inflammatory cytokines and oxidative stress by monocyte-derived macrophages is responsible for the osteogenic transformation and mineralization of vascular/valvular cells. However, monocytes/macrophages show the ability to modify their phenotype, and consequently their functions, when facing environmental modifications. This plasticity complicates efforts to understand the pathogenesis of CVC-particularly in a CKD setting, where both uraemic toxins and CKD treatment may affect monocyte/macrophage functions and thereby influence CVC. Here, we review (i) the mechanisms by which each monocyte/macrophage subset either promotes or prevents CVC, and (ii) how both uraemic toxins and CKD therapies might affect these monocyte/macrophage functions.
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8
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van Gelder MK, Abrahams AC, Joles JA, Kaysen GA, Gerritsen KGF. Albumin handling in different hemodialysis modalities. Nephrol Dial Transplant 2019; 33:906-913. [PMID: 29106652 DOI: 10.1093/ndt/gfx191] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/20/2017] [Indexed: 11/14/2022] Open
Abstract
Hypoalbuminemia is a major risk factor for morbidity and mortality in dialysis patients. With increasing interest in highly permeable membranes and convective therapies to improve removal of middle molecules, transmembrane albumin loss increases accordingly. Currently, the acceptable upper limit of albumin loss for extracorporeal renal replacement therapies is unknown. In theory, any additional albumin loss should be minimized because it may contribute to hypoalbuminemia and adversely affect the patient's prognosis. However, hypoalbuminemia-associated mortality may be a consequence of inflammation and malnutrition, rather than low albumin levels per se. The purpose of this review is to give an overview of albumin handling with different extracorporeal renal replacement strategies. We conclude that the acceptable upper limit of dialysis-related albumin loss remains unknown. Whether enhanced middle molecule removal outweighs the potential adverse effects of increased albumin loss with novel highly permeable membranes and convective therapies is yet to be determined.
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Affiliation(s)
- Maaike K van Gelder
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George A Kaysen
- Department of Medicine Division of Nephrology, University of California, Davis, CA, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, CA, USA
| | - Karin G F Gerritsen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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9
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Toxines urémiques de moyen poids moléculaire : un véritable regain d’intérêt. Nephrol Ther 2019; 15:82-90. [DOI: 10.1016/j.nephro.2018.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/02/2018] [Indexed: 01/20/2023]
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10
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Abstract
The objectives of hemodialysis have moved from the diffusive clearance of small molecular weight uremic toxins and achieving dialyzer urea adequacy targets to emphasis on improving clinical outcomes in end stage renal failure patients by increasing larger sized uremic toxin clearance. Clinical emphasis in the last few decades has focused on increasing middle molecule weight toxin clearance by hemodiafiltration. Although long-term data is still lacking, short-term outcomes appear promising. Advancements in nanotechnology have now introduction a new generation of medium cut-off membrane dialyzers which allow diffusive clearance of similar middle molecular weight uremia toxin clearance as hemodiafiltration, without increased albumin losses. As these dialyzers have only recently been introduced into clinical practice, no long-term outcomes are available to determine the relative benefits or advantages of this approach. As dialyzers are now designed to maximize diffusive or convective clearance, or provide a combination, then clinicians can now choose dialyzers tailored to the individual patient needs depending on clinical circumstances. We review the key important features in choosing a dialyzer for patients with end stage renal failure and acute kidney injury.
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Affiliation(s)
- Sabrina Haroon
- National University Hospital, UCL department of renal medicine, London, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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11
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Kohlová M, Amorim CG, Araújo A, Santos-Silva A, Solich P, Montenegro MCBSM. The biocompatibility and bioactivity of hemodialysis membranes: their impact in end-stage renal disease. J Artif Organs 2018; 22:14-28. [DOI: 10.1007/s10047-018-1059-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/08/2018] [Indexed: 12/15/2022]
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12
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The Impact of Uremic Toxins on Vascular Smooth Muscle Cell Function. Toxins (Basel) 2018; 10:toxins10060218. [PMID: 29844272 PMCID: PMC6024314 DOI: 10.3390/toxins10060218] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/26/2018] [Accepted: 05/27/2018] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with profound vascular remodeling, which accelerates the progression of cardiovascular disease. This remodeling is characterized by intimal hyperplasia, accelerated atherosclerosis, excessive vascular calcification, and vascular stiffness. Vascular smooth muscle cell (VSMC) dysfunction has a key role in the remodeling process. Under uremic conditions, VSMCs can switch from a contractile phenotype to a synthetic phenotype, and undergo abnormal proliferation, migration, senescence, apoptosis, and calcification. A growing body of data from experiments in vitro and animal models suggests that uremic toxins (such as inorganic phosphate, indoxyl sulfate and advanced-glycation end products) may directly impact the VSMCs’ physiological functions. Chronic, low-grade inflammation and oxidative stress—hallmarks of CKD—are also strong inducers of VSMC dysfunction. Here, we review current knowledge about the impact of uremic toxins on VSMC function in CKD, and the consequences for pathological vascular remodeling.
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13
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Wolley M, Jardine M, Hutchison CA. Exploring the Clinical Relevance of Providing Increased Removal of Large Middle Molecules. Clin J Am Soc Nephrol 2018; 13:805-814. [PMID: 29507008 PMCID: PMC5969479 DOI: 10.2215/cjn.10110917] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Dialysis technologies have continued to advance over recent decades; however, these advancements have not always been met with improved patient outcomes. In part, the high morbidity and mortality associated with dialysis have been attributed to a group of uremic toxins, which are described as "difficult to remove." With a new generation of hemodialysis membranes now making meaningful clearance of these molecules possible, it is an apt time to review the clinical relevance of these middle molecules. Our review describes the developments in membrane technology that enable the removal of large middle molecules (molecular mass >15 kD) that is limited with high-flux dialysis membranes. Of the known 58 middle molecules, a literature search identified 27 that have molecular mass >15 kD. This group contains cytokines, adipokines, hormones, and other proteins. These molecules are implicated in chronic inflammation, atherosclerosis, structural heart disease, and secondary immunodeficiency in the literature. Single-center safety and efficacy studies have identified that use of these membranes in maintenance dialysis populations is associated with limited loss of albumin and increased clearance of large middle molecules. Larger, robustly conducted, multicenter studies are now evaluating these findings. After completion of these safety and efficacy studies, the perceived clinical benefits of providing clearance of large middle molecules must be assessed in rigorously conducted, randomized clinical studies.
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Affiliation(s)
- Martin Wolley
- Department of Renal Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Meg Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital and University of Sydney, Sydney, New South Wales, Australia; and
| | - Colin A. Hutchison
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Medicine, Hawke’s Bay District Health Board, Hastings, New Zealand
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14
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15
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Updates on the Mechanisms and the Care of Cardiovascular Calcification in Chronic Kidney Disease. Semin Nephrol 2018; 38:233-250. [DOI: 10.1016/j.semnephrol.2018.02.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Siebeck M, Dimski T, Brandenburger T, Slowinski T, Kindgen-Milles D. Super High-Flux Continuous Venovenous Hemodialysis Using Regional Citrate Anticoagulation: Long-Term Stability of Middle Molecule Clearance. Ther Apher Dial 2018; 22:355-364. [PMID: 29417731 DOI: 10.1111/1744-9987.12656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/26/2017] [Accepted: 11/03/2017] [Indexed: 12/13/2022]
Abstract
Continuous renal replacement therapy is a standard treatment in critically ill patients with acute kidney injury. All CRRT techniques provide a high low-molecular weight clearance but even with hemofiltration, clearance of middle molecules is low. We investigated whether a new super high-flux hemofilter provides effective and sustained middle molecule clearance during citrate-anticoagulated continuous venovenous hemodialysis for up to 72 h. We included 14 critically ill patients with AKI-KDIGO-III in a prospective observational trial. We measured/calculated blood and urine concentrations, clearances and sieving coefficients of eight molecules with molecular weights from 60 to 66 kDa, hemodynamic parameters and SAPS-II scores. All filters were patent at 72 h. Clearance and sieving coefficients of small solutes were high and sustained over time, those for larger solutes decreased over 72 h but remained high enough to decrease blood concentrations of solutes up to 25 kDa. Albumin serum levels remained unaffected. Catecholamine doses and SAPS-II scores decreased significantly. This new hemofilter may improve blood purification in critically ill patients with AKI.
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Affiliation(s)
- Martin Siebeck
- Department of Anaesthesiology, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Thomas Dimski
- Department of Anaesthesiology, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Timo Brandenburger
- Department of Anaesthesiology, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Torsten Slowinski
- Department of Nephrology, University Hospital Charité, Berlin, Germany
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Schepers E, Glorieux G, Eloot S, Hulko M, Boschetti-de-Fierro A, Beck W, Krause B, Van Biesen W. Assessment of the association between increasing membrane pore size and endotoxin permeability using a novel experimental dialysis simulation set-up. BMC Nephrol 2018; 19:1. [PMID: 29304774 PMCID: PMC5756443 DOI: 10.1186/s12882-017-0808-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background Membranes with increasing pore size are introduced to enhance removal of large uremic toxins with regular hemodialysis. These membranes might theoretically have higher permeability for bacterial degradation products. In this paper, permeability for bacterial degradation products of membranes of comparable composition with different pore size was investigated with a new in vitro set-up that represents clinical flow and pressure conditions. Methods Dialysis was simulated with an AK200 machine using a low-flux, high-flux, medium cut-off (MCO) or high cut-off (HCO) device (n = 6/type). A polyvinylpyrrolidone-solution (PVP) was recirculated at blood side. At dialysate side, a challenge solution containing a filtrated lysate of two water-borne bacteria (Pseudomonas aeruginosa and Pelomononas saccharophila) was infused in the dialysate flow (endotoxin ≥ 4EU/ml). Blood and dialysate flow were set at 400 and 500 ml/min for 60 min. PVP was sampled before (PVPpre) and after (PVPpost) the experiment and dialysate after 5 and 55 min. Limulus Amebocyte Lysate (LAL) test was performed. Additionally, samples were incubated with a THP-1 cell line (24 h) and IL-1β levels were measured evaluating biological activity. Results The LAL-assay confirmed presence of 9.5 ± 7.4 EU/ml at dialysate side. For none of the devices the LAL activity in PVPpre vs. PVPpost was significantly different. Although more blood side PVP solutions had a detectable amount of endotoxin using a highly sensitive LAL assay in the more open vs traditional membranes, the permeability for endotoxins of the 4 tested dialysis membranes was not significantly different but the number of repeats is small. None of the PVP solutions induced IL-1β in the THP-1 assay. Conclusions A realisitic in vitro dialysis was developed to assess membrane translocation of bacterial products. LAL activity on the blood side after endotoxin exposure did not change for all membranes. Also, none of the PVPpost solutions induced IL-1β in the THP-1 bio-assay.
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Affiliation(s)
- Eva Schepers
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium.
| | - Griet Glorieux
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium
| | - Sunny Eloot
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium
| | | | | | - Werner Beck
- Baxter International Inc., R&D, Hechingen, Germany
| | - Bernd Krause
- Baxter International Inc., R&D, Hechingen, Germany
| | - Wim Van Biesen
- Department of Internal Medicine, Nephrology Division, Ghent University Hospital, Gent, Belgium
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Willy K, Girndt M, Voelkl J, Fiedler R, Martus P, Storr M, Schindler R, Zickler D. Expanded Haemodialysis Therapy of Chronic Haemodialysis Patients Prevents Calcification and Apoptosis of Vascular Smooth Muscle Cells in vitro. Blood Purif 2017; 45:131-138. [PMID: 29402827 DOI: 10.1159/000484925] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Vascular calcification is a common phenomenon in patients with chronic kidney disease and strongly associated with increased cardiovascular mortality. Vascular calcification is an active process mediated in part by inflammatory processes in vascular smooth muscle cells (VSMC). These could be modified by the insufficient removal of proinflammatory cytokines through conventional high-flux (HF) membranes. Recent trials demonstrated a reduction of inflammation in VSMC by use of dialysis membranes with a higher and steeper cut-off. These membranes caused significant albumin loss. Therefore, the effect of high retention Onset (HRO) dialysis membranes on vascular calcification and its implications in vitro was evaluated. METHODS In the PERCI II trial, 48 chronic dialysis patients were dialyzed using HF and HRO dialyzers and serum samples were collected. Calcifying VSMC were incubated with the serum samples. Calcification was determined using alizarin red staining (AZR) and determination of alkaline phosphatase (ALP) activity. Furthermore, apoptosis was evaluated, and release of matrix Gla protein (MGP), osteopontin (OPN) and growth differentiation factor 15 (GDF-15) were measured in cell supernatants. RESULTS Vascular calcification in vitro was significantly reduced by 24% (ALP) and 36% (AZR) after 4 weeks of HRO dialysis and by 33% (ALP) and 48% (AZR) after 12 weeks of dialysis using HRO membranes compared to HF dialysis. Apoptosis was significantly lower in the HRO group. The concentrations of MGP and OPN were significantly elevated after incubation with HF serum compared to HRO serum and healthy controls. Similarly, GDF-15 release in the supernatant was elevated after incubation with HF serum, an effect significantly ameliorated after treatment with HRO medium. CONCLUSIONS Expanded haemodialysis therapy reduces the pro-calcific potential of serum from dialysis patients in vitro. With a markedly reduced albumin filtration compared to high cut-off dialysis, use of the HRO dialyzers may possibly provide a treatment option for chronic dialysis patients to reduce the progression of vascular calcification.
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Affiliation(s)
- Kevin Willy
- Charité University Medicine Berlin, Campus Virchow Clinic, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Jakob Voelkl
- Department of Internal Medicine and Cardiology, Charité Campus Virchow, Charité Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Markus Storr
- Department of Research and Development, Gambro Dialysatoren GmbH, Hechingen, Germany
| | - Ralf Schindler
- Charité University Medicine Berlin, Campus Virchow Clinic, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany
| | - Daniel Zickler
- Charité University Medicine Berlin, Campus Virchow Clinic, Department of Nephrology and Internal Intensive Care Medicine, Berlin, Germany
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Tangvoraphonkchai K, Davenport A. Enhancing dialyser clearance-from target to development. Pediatr Nephrol 2017; 32:2225-2233. [PMID: 28401301 DOI: 10.1007/s00467-017-3647-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 01/18/2023]
Abstract
Products of metabolism accumulate in kidney failure and potentially have toxic effects. Traditionally these uraemic toxins are classified as small, middle-sized and protein-bound toxins, and clearance during dialysis is affected by diffusion, convection and adsorption. As current dialysis practice effectively clears small solutes, increasing evidence supports a toxic effect for middle-sized and protein-bound toxins. Therefore, newer approaches to standard dialysis practice are required to look beyond urea clearance. Current dialysers have been developed to effectively clear small solutes and secondly to increase middle-sized toxin clearances. However, there is no ideal dialyser which can effectively clear all uraemic toxins. Advances in nanotechnology have led to improvements in manufacturing, with the production of smoother membrane surfaces and uniformity of pore size. The introduction of haemodiafiltration has led to changes in dialyser design to improve convective clearances. Both diffusional and convectional clearances can be increased by changing dialyser designs to alter blood and dialysate flows, and novel dialyser designs using microfluidics offer more efficient solute clearances. Adjusting surface hydrophilicity and charge alter adsorptive properties, and greater clearance of protein-bound toxins can be achieved by adding carbon or other absorptive monoliths into the circuit or by developing composite dialyser membranes. Other strategies to increase protein-bound toxins clearances have centred on disrupting binding and so displacing toxins from proteins. Just as the hollow fibre design replaced the flat plate dialyser, we are now entering a new era of dialyser designs aimed to increase the spectrum of uraemic toxins which can be cleared by dialysis.
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Affiliation(s)
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, Rowland Hill Street, London, NW3 2PF, UK.
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Medium Cut-Off (MCO) Membranes Reduce Inflammation in Chronic Dialysis Patients-A Randomized Controlled Clinical Trial. PLoS One 2017; 12:e0169024. [PMID: 28085888 PMCID: PMC5234772 DOI: 10.1371/journal.pone.0169024] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/08/2016] [Indexed: 11/26/2022] Open
Abstract
Background To increase the removal of middle-sized uremic toxins a new membrane with enhanced permeability and selectivity, called Medium Cut-Off membrane (MCO-Ci) has been developed that at the same time ensures the retention of albumin. Because many middle-sized substances may contribute to micro-inflammation we hypothesized that the use of MCO-Ci influences the inflammatory state in hemodialysis patients. Methods The randomized crossover trial in 48 patients compared MCO-Ci dialysis to High-flux dialysis of 4 weeks duration each plus 8 weeks extension phase. Primary endpoint was the gene expression of TNF-α and IL-6 in peripheral blood mononuclear cells (PBMCs), secondary endpoints were plasma levels of specified inflammatory mediators and cytokines. Results After four weeks of MCO-Ci the expression of TNF-α mRNA (Relative quantification (RQ) from 0.92 ± 0.34 to 0.75 ± 0.31, -18.5%, p<0.001)-α and IL-6 mRNA (RQ from 0.78 ± 0.80 to 0.60 ± 0.43, -23.1%, p<0.01) was reduced to a significantly greater extent than with High-flux dialyzers (TNF mRNA-RQ: -14.3%; IL-6 mRNA-RQ: -3.5%). After retransformation of logarithmically transformed data, measurements after MCO were reduced to 82% of those after HF (95% CI 74%–91%). 4 weeks use of MCO-Ci resulted in long-lasting change in plasma levels of several cytokines and other substances with a significant decrease for sTNFR1, kappa and lambda free light chains, urea and an increase for Lp-PLA2 (PLA2G7) compared to High-flux. Albumin levels dropped significantly after 4 weeks of MCO dialysis but increased after additional 8 weeks of MCO dialysis. Twelve weeks treatment with MCO-Ci was well tolerated regarding the number of (S)AEs. In the extension period levels of CRP, TNF-α-mRNA and IL-6 mRNA remained stable in High-flux as well as in MCO-Ci. Conclusions MCO-Ci dialyzers modulate inflammation in chronic HD patients to a greater extent compared to High-flux dialyzers. Transcription of pro-inflammatory cytokines in peripheral leukocytes is markedly reduced and removal of soluble mediators is enhanced with MCO dialysis. Serum albumin concentrations stabilize after an initial drop. These results encourage further trials with longer treatment periods and clinical endpoints.
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Trojanowicz B, Ulrich C, Fiedler R, Storr M, Boehler T, Martus P, Pawlak M, Glomb MA, Henning C, Templin M, Werner K, Zickler D, Willy K, Schindler R, Girndt M. Impact of serum and dialysates obtained from chronic hemodialysis patients maintained on high cut-off membranes on inflammation profile in human THP-1 monocytes. Hemodial Int 2016; 21:348-358. [DOI: 10.1111/hdi.12494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Bogusz Trojanowicz
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
| | - Christof Ulrich
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
| | - Roman Fiedler
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
| | - Markus Storr
- Department of Research and Development; Gambro Dialysatoren GmbH; Hechingen Germany
| | - Torsten Boehler
- Department of Research and Development; Gambro Dialysatoren GmbH; Hechingen Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biostatistics, University of Tübingen; Germany
| | | | - Marcus A. Glomb
- Food Chemistry, Institute for Chemistry, Martin-Luther-University Halle; Germany
| | - Christian Henning
- Food Chemistry, Institute for Chemistry, Martin-Luther-University Halle; Germany
| | | | - Kristin Werner
- Department of Research and Development; Gambro Dialysatoren GmbH; Hechingen Germany
| | - Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine; Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic; Berlin Germany
| | - Kevin Willy
- Department of Nephrology and Internal Intensive Care Medicine; Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic; Berlin Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine; Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic; Berlin Germany
| | - Matthias Girndt
- Department of Internal Medicine II; Martin-Luther-University Halle; Germany
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Forni LG, Ricci Z, Ronco C. Extracorporeal renal replacement therapies in the treatment of sepsis: where are we? Semin Nephrol 2015; 35:55-63. [PMID: 25795499 DOI: 10.1016/j.semnephrol.2015.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute kidney injury (AKI) is common among the critically ill, affecting approximately 40% of patients. Sepsis is the cause of AKI in almost 50% of cases of intensive care patients, however, any evidence-based treatment for sepsis-associated AKI is lacking. Furthermore, the underlying pathophysiology of septic AKI is inadequately understood given the disparity between severe functional changes and limited tubular injury. What is clear is that within this complex interplay leading to septic AKI, the inflammatory response plays a pivotal role and hence modulation of this response may translate to improved outcomes. We outline the use of extracorporeal therapies in the treatment of sepsis and septic AKI. We consider the classic aspects of extracorporeal renal replacement therapy including indications, timing, and delivered dose. The various techniques that currently are used to try and achieve immune homeostasis also are outlined. As well as discussing the evidence accumulated to date, we also suggest possibilities for the future treatment of our patients.
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Affiliation(s)
- Lui G Forni
- Department of Intensive Care Medicine, Surrey Peri-operative Anaesthesia Critical Care Collaborative Research Group, Royal Surrey County Hospital, and Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
| | - Zaccaria Ricci
- Department of Paediatric Cardiac Surgery, Bambino Gesu Children's Hospital, Rome, Italy
| | - Claudio Ronco
- International Renal Research Institute, Vicenza, Italy; Department of Nephrology, St Bortolo Hospital, Vicenza, Italy
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