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Bignardi PR, Delfino VDA. Is hemodiafiltration superior to high-flow hemodialysis in reducing all-cause and cardiovascular mortality in kidney failure patients? A meta-analysis of randomized controlled trials. Hemodial Int 2024; 28:139-147. [PMID: 38369730 DOI: 10.1111/hdi.13136] [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: 08/26/2023] [Revised: 12/02/2023] [Accepted: 01/30/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Hemodiafiltration (HDF) and high-flux hemodialysis (hf-HD) are different methods of kidney replacement therapy (KRT) used for the treatment of kidney failure patients. A debate has raged over the last decade about the survival benefit of patients with the use of HDF compared with hf-HD, but with divergent results from randomized controlled trials. Therefore, this study aimed to perform a meta-analysis to compare HDF and hf-HD regarding all-cause and cardiovascular mortality. METHODS PubMed and Cochrane databases were searched until July 19, 2023, for randomized clinical trials comparing HDF and hf-HD in patients on maintenance dialysis. A meta-analysis was performed using Stata 16.1, applying fixed or random effect models according to the heterogeneity between studies. FINDINGS Of the 496 studies found, five met the inclusion criteria. Compared with the hf-HD group, the risk ratio (RR) for all-cause mortality with HDF use was 0.76 (95% CI: 0.67-0.88, I2 = 0%). HDF was associated with lower cardiovascular mortality, although the sensitivity analysis showed that the result differed between scenarios. Subgroup analysis showed lower all-cause mortality among patients without diabetes in the HDF group compared with hf-HD (RR 0.66, 95% CI: 0.51-0.81, I2 = 0%), but not in diabetic patients (RR = 0.89, 95% CI: 0.65-1.12, I2 = 0.0%). A subgroup analysis considering convection volumes was not performed, but the studies with the highest weight in the meta-analysis described convection volume as more than 20 L/session. DISCUSSION More clinical studies considering critical risk factors, such as advanced age and preexisting cardiovascular disease, are needed to confirm the supremacy of HDF over hf-HD on the survival of patients treated by these two forms of kidney replacement therapy.
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Affiliation(s)
| | - Vinicius Daher Alvares Delfino
- School of Medicine, Pontifícia Universidade Católica do Paraná, Londrina, Brazil
- Internal Medicine Departament, Universitary Hospital, State University of Londrina, Londrina, Brazil
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da Rocha EP, Kojima CA, Modelli de Andrade LG, Costa DM, Magalhaes AO, Rocha WF, de Vasconcelos Junior LN, Rosa MG, Wagner Martins CS. Comparing Survival Outcomes between Hemodialysis and Hemodiafiltration Using Real-World Data from Brazil. J Clin Med 2024; 13:594. [PMID: 38276101 PMCID: PMC10817062 DOI: 10.3390/jcm13020594] [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: 12/12/2023] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
The CONVINCE trial demonstrates that high-dose hemodiafiltration offers a survival advantage for patients in the high-flux hemodiafiltration group compared to hemodialysis. We compared the outcomes of hemodialysis and hemodiafiltration using real-world data. We conducted an analysis on a cohort of patients who underwent hemodiafiltration therapy (HDF) at a single center, NefroStar Clinics. The results obtained were then compared with data from patients receiving hemodialysis (HD) therapy within the Brazilian Public Health System (SUS). The primary outcome was mortality from any cause. Results: A total of 85 patients undergoing hemodiafiltration were compared with 149,372 patients receiving hemodialysis through the Brazilian Public Health System (SUS). Using a 2:1 propensity score, we compared the 170 best-match HD patients with 85 HDF patients. In the Cox analysis, HDF therapy showed a reduced risk of mortality with an HR of 0.29 [0.11-0.77]. The propensity score analysis showed a HR of 0.32 [95% CI: 0.11-0.91]. This analysis was adjusted for age, type of access, KT/v, hemoglobin, and phosphorus. The Kaplan-Meier analysis showed respective survival rates for HDF and HD at the end of one year, 92.1% and 79.9%, p < 0.001. These results suggest high-flux hemodiafiltration has survival advantages over hemodialysis in a real-world scenario.
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Affiliation(s)
- Erica Pires da Rocha
- NefroStar Kidney Care, Osasco 06010-067, Brazil; (C.A.K.); (D.M.C.); (A.O.M.); (W.F.R.); (L.N.d.V.J.); (M.G.R.); (C.S.W.M.)
| | - Christiane Akemi Kojima
- NefroStar Kidney Care, Osasco 06010-067, Brazil; (C.A.K.); (D.M.C.); (A.O.M.); (W.F.R.); (L.N.d.V.J.); (M.G.R.); (C.S.W.M.)
| | | | - Daniel Monte Costa
- NefroStar Kidney Care, Osasco 06010-067, Brazil; (C.A.K.); (D.M.C.); (A.O.M.); (W.F.R.); (L.N.d.V.J.); (M.G.R.); (C.S.W.M.)
| | - Andrea Olivares Magalhaes
- NefroStar Kidney Care, Osasco 06010-067, Brazil; (C.A.K.); (D.M.C.); (A.O.M.); (W.F.R.); (L.N.d.V.J.); (M.G.R.); (C.S.W.M.)
| | - Whelington Figueiredo Rocha
- NefroStar Kidney Care, Osasco 06010-067, Brazil; (C.A.K.); (D.M.C.); (A.O.M.); (W.F.R.); (L.N.d.V.J.); (M.G.R.); (C.S.W.M.)
| | | | - Maria Gabriela Rosa
- NefroStar Kidney Care, Osasco 06010-067, Brazil; (C.A.K.); (D.M.C.); (A.O.M.); (W.F.R.); (L.N.d.V.J.); (M.G.R.); (C.S.W.M.)
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Pedreros-Rosales C, Jara A, Lorca E, Mezzano S, Pecoits-Filho R, Herrera P. Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond. Toxins (Basel) 2023; 15:531. [PMID: 37755957 PMCID: PMC10535648 DOI: 10.3390/toxins15090531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.
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Affiliation(s)
- Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción 4070386, Chile
- Nephrology Service, Hospital Las Higueras, Talcahuano 4270918, Chile
| | - Aquiles Jara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Eduardo Lorca
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
| | - Sergio Mezzano
- Instituto de Medicina, Facultad de Medicina, Universidad Austral, Valdivia 5110566, Chile
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI 48108, USA
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Patricia Herrera
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
- Nephrology Service, Hospital del Salvador, Santiago 8320000, Chile
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4
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Hemodiafiltration: Technical and Medical Insights. Bioengineering (Basel) 2023; 10:bioengineering10020145. [PMID: 36829639 PMCID: PMC9952158 DOI: 10.3390/bioengineering10020145] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Despite the significant medical and technical improvements in the field of dialytic renal replacement modalities, morbidity and mortality are excessively high among patients with end-stage kidney disease, and most interventional studies yielded disappointing results. Hemodiafiltration, a dialysis method that was implemented in clinics many years ago and that combines the two main principles of hemodialysis and hemofiltration-diffusion and convection-has had a positive impact on mortality rates, especially when delivered in a high-volume mode as a surrogate for a high convective dose. The achievement of high substitution volumes during dialysis treatments does not only depend on patient characteristics but also on the dialyzer (membrane) and the adequately equipped hemodiafiltration machine. The present review article summarizes the technical aspects of online hemodiafiltration and discusses present and ongoing clinical studies with regards to hard clinical and patient-reported outcomes.
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Paglialonga F, Monzani A, Prodam F, Smith C, De Zan F, Canpolat N, Agbas A, Bayazit A, Anarat A, Bakkaloglu SA, Askiti V, Stefanidis CJ, Azukaitis K, Bulut IK, Borzych-Dużałka D, Duzova A, Habbig S, Krid S, Licht C, Litwin M, Obrycki L, Ranchin B, Samaille C, Shenoy M, Sinha MD, Spasojevic B, Vidal E, Yilmaz A, Fischbach M, Schaefer F, Schmitt CP, Edefonti A, Shroff R. Nutritional and Anthropometric Indices in Children Receiving Haemodiafiltration vs Conventional Haemodialysis - The HDF, Heart and Height (3H) Study. J Ren Nutr 2023; 33:17-28. [PMID: 35870690 DOI: 10.1053/j.jrn.2022.07.005] [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] [Received: 02/25/2022] [Revised: 05/26/2022] [Accepted: 07/03/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The "HDF-Heart-Height" study showed that haemodiafiltration (HDF) is associated with improved growth compared to conventional haemodialysis (HD). We report a post-hoc analysis of this study assessing the effect of extracorporeal dialysis therapies on nutritional indices. METHODS 107 children were included in the baseline cross-sectional analysis, of whom 79 (43 HD, 36 HDF) completed the 12-month follow-up. Height (Ht), optimal 'dry' weight (Wt), and body mass index (BMI) standard deviations scores (SDS), waist-to-hip ratio, des-acyl ghrelin (DAG), adiponectin, leptin, insulin-like growth factor-1 (IGF-1)-SDS and insulin were measured. RESULTS The levels of nutritional indices were comparable between HDF and HD patients at baseline and 12-month. On univariable analyses Wt-SDS positively correlated with leptin and IGF-1-SDS, and negatively with DAG, while Ht-SDS of the overall cohort positively correlated with IGF1-SDS and inversely with DAG and adiponectin. On multivariable analyses, higher 12-month Ht-SDS was inversely associated with baseline DAG (beta = -0.13 per 500 higher; 95%CI -0.22, -0.04; P = .004). Higher Wt-SDS at 12-month was positively associated with HDF modality (beta = 0.47 vs HD; 95%CI 0.12-0.83; P = .01) and inversely with baseline DAG (beta = -0.18 per 500 higher; 95%CI -0.32, -0.05; P = .006). Growth Hormone (GH) treated patients receiving HDF had higher annualized increase in Ht SDS compared to those on HD. CONCLUSIONS In children on HD and HDF both Wt- and Ht-SDS independently correlated with lower baseline levels of the anorexygenic hormone DAG. HDF may attenuate the resistance to GH, but further studies are required to examine the mechanisms linking HDF to improved growth.
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Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Alice Monzani
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Flavia Prodam
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy; Endocrinology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Colette Smith
- Institute of Global Health, University College London, London, UK
| | - Francesca De Zan
- University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
| | | | - Ayse Agbas
- Cerrahpasa School of Medicine, Istanbul, Turkey
| | | | | | | | | | | | - Karolis Azukaitis
- Clinic of Pediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | | | | | | | | | | | | | - Bruno Ranchin
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Bron, France
| | | | - Mohan Shenoy
- Royal Manchester Children's Hospital, Manchester, UK
| | - Manish D Sinha
- Kings College London Evelina London Children's Hospital, London, UK
| | | | - Enrico Vidal
- Division of Pediatrics, Department of Medicine, University of Udine, Italy
| | - Alev Yilmaz
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | | | - Franz Schaefer
- Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | | | - Alberto Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
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Tiranathanagul K, Khemnark N, Takkavatakarn K, Limjariyakul M, Mahatanan N, Chariyavilaskul P, Wittayalertpanya S, Susantitaphong P, Eiam-Ong S. Comparative efficacy between hemodialysis using super high-flux dialyzer with hemoperfusion and high-volume postdilution online hemodiafiltration in removing protein bound and middle molecule uremic toxins: A cross-over randomized controlled trial. Artif Organs 2022; 46:775-785. [PMID: 35028951 DOI: 10.1111/aor.14161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hemodialysis (HD) using super high-flux dialyzer (HD + SHF) comparably removed uremic toxins to high-volume postdilution online hemodiafiltration (olHDF). Integration of hemoperfusion (HP) to HD + SHF (HD + SHF + HP) might provide superior uremic toxin removing capability to high-volume postdilution olHDF. METHOD The present study was conducted in thrice-a-week HD patients to compare the efficacy in removing indoxyl sulfate (IS), beta-2 microglobulin (β2 M), and urea between high-volume postdilution ol-HDF and HD + SHF + HP, comprising HD + SHF as the main treatment plus HD + SHF + HP 1/week in the first 4 weeks and 1/2 weeks in the second 4 weeks. RESULTS Ten prevalent HD patients with blood flow rate (BFR) above 400 ml/min were randomized into two sequences of 8-week treatment periods of HD + SHF + HP and later high-volume postdilution olHDF or vice versa. When compared with high-volume postdilution olHDF (convective volume of 26.02 ± 1.8 L/session), HD + SHF + HP provided comparable values of percentage reduction ratio of IS (52.0 ± 11.7 vs. 56.3 ± 7.5%, p = 0.14) and β2 M (83.7 ± 4.9 vs. 84.0 ± 4.3%, p = 0.37) and slightly lower urea reduction ratio. Despite greater dialysate albumin loss (p = 0.008), there was no significant change in serum albumin level in HD + SHF + HP group. CONCLUSIONS HD + SHF + HP could not provide superior efficacy in removing uremic toxins to high-volume postdilution olHDF. The use of low BFR of 200 ml/min during the first 2 h of HD + SHF + HP session, according to the instruction of manufacturer, might impair the efficacy of the HD + SHF part in removing uremic toxins.
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Affiliation(s)
- Khajohn Tiranathanagul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Chulalongkorn University, Bangkok, Thailand
| | - Nutchaya Khemnark
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Chulalongkorn University, Bangkok, Thailand
| | - Maneerut Limjariyakul
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nunta Mahatanan
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Chulalongkorn University, Bangkok, Thailand.,Department of Nursing, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pajaree Chariyavilaskul
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Chulalongkorn University, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society and Chulalongkorn University, Bangkok, Thailand
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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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Mendrala K, Kosiński S, Podsiadło P, Pasquier M, Mazur P, Paal P, Gajniak D, Darocha T. The efficiency of continuous renal replacement therapy for rewarming of patients in accidental hypothermia--An experimental study. Artif Organs 2021; 45:1360-1367. [PMID: 34219241 DOI: 10.1111/aor.14032] [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: 03/10/2021] [Revised: 05/31/2021] [Accepted: 06/25/2021] [Indexed: 11/27/2022]
Abstract
Severe accidental hypothermia carries high mortality and morbidity and is often treated with invasive extracorporeal methods. Continuous veno-venous hemodiafiltration (CVVHDF) is widely available in intensive care units. We sought to provide theoretical basis for CVVHDF use in rewarming of hypothermic patients. CVVHDF system was used in the laboratory setting. Heat balance and transferred heat units were evaluated for the system without using blood. We used 5L of crystalloid solution at the temperature of approximately 25°C, placed in a thermally insulated tank (representing the "central compartment" of a hypothermic patient). Time of warming the central compartment from 24.9 to 30.0°C was assessed with different flow combinations: "blood" (central compartment fluid) 50 or 100 or 150 mL/min, dialysate solution 100 or 1500 mL/h, and substitution fluid 0 or 500 mL/h. The total circulation time was 1535 minutes. There were no differences between heat gain values on the filter depending on blood flow (P = .53) or dialysate flow (P = .2). The mean heating time for "blood" flow rates 50, 100, and 150 mL/min was 113.7 minutes (95% CI, 104.9-122.6 minutes), 83.3 minutes (95% CI, 76.2-90.3 minutes), and 74.7 minutes (95% CI, 62.6-86.9 minutes), respectively (P < .01). The respective median rewarming rate for different "blood" flows was 3.6°C/h (IQR, 3.0-4.2°C/h), 4.8 (IQR, 4.2-5.4°C/h), and 5.4 (IQR, 4.8-6.0°C/h), respectively (P < .01). The dialysate flow did not affect the warming rate. Based on our experimental model, CVVHDF may be used for extracorporeal rewarming, with the rewarming rates increasing achieved with higher blood flow rates.
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Affiliation(s)
- Konrad Mendrala
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Paweł Podsiadło
- Institute of Medical Sciences, Jan Kochanowski University, Kielce, Poland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.,Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitaller Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Dariusz Gajniak
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
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9
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Tyagi A, Ng YW, Tamtaji M, Abidi IH, Li J, Rehman F, Hossain MD, Cai Y, Liu Z, Galligan PR, Luo S, Zhang K, Luo Z. Elimination of Uremic Toxins by Functionalized Graphene-Based Composite Beads for Direct Hemoperfusion. ACS APPLIED MATERIALS & INTERFACES 2021; 13:5955-5965. [PMID: 33497185 DOI: 10.1021/acsami.0c19536] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Conventional absorbents for hemoperfusions suffer from low efficiency and slow absorption with numerous side effects. In this research, we developed cellulose acetate (CA) functionalized graphene oxide (GO) beads (∼1.5-2 mm) that can be used for direct hemoperfusion, aiming at the treatment of kidney dysfunction. The CA-functionalized GO bead facilitates adsorption of toxins with high biocompatibility and high-efficiency of hemoperfusion while maintaining high retention for red blood cell, white blood cells, and platelets. Our in vitro results show that the toxin concentration for creatinine reduced from 0.21 to 0.12 μM (p < 0.005), uric acid from 0.31 to 0.15 mM (p < 0.005), and bilirubin from 0.36 to 0.09 mM (p < 0.005), restoring to normal levels within 2 h. Our in vivo study on rats (Sprague-Dawley, n = 30) showed that the concentration for creatinine reduced from 83.23 to 54.87 μmol L-1 (p < 0.0001) and uric acid from 93.4 to 54.14 μmol L-1 (p < 0.0001), restoring to normal levels within 30 min. Results from molecular dynamics (MD) simulations using free-energy calculations reveal that the presence of CA on GO increases the surface area for adsorption and enhances penetration of toxins in the binding cavities because of the increased electrostatic and van der Waals force (vdW) interactions. These results provide critical insight to fabricate graphene-based beads for hemoperfusion and to have the potential for the treatment of blood-related disease.
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Affiliation(s)
- Abhishek Tyagi
- State Key Laboratory of Precision Electronic Manufacturing Technology and Equipment, School of Electromechanical Engineering, Guangdong University of Technology, Guangzhou 510006, China
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Yik Wong Ng
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Mohsen Tamtaji
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Irfan Haider Abidi
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Jingwei Li
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Faisal Rehman
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Md Delowar Hossain
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Yuting Cai
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Zhenjing Liu
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Patrick Ryan Galligan
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Shaojuan Luo
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
- School of Chemical Engineering and Light Industry, Guangdong University of Technology, Guangzhou 510006, China
| | - Kai Zhang
- State Key Laboratory of Precision Electronic Manufacturing Technology and Equipment, School of Electromechanical Engineering, Guangdong University of Technology, Guangzhou 510006, China
| | - Zhengtang Luo
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, and Hong Kong Branch of Chinese National Engineering Research Center for Tissue Restoration and Reconstruction, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
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Beberashvili I, Ptashkin E, Azar A, Hamad RA, Koren S, Stav K, Efrati S. Obestatin levels in response to a meal and association with subsequent appetite sensations in maintenance hemodialysis patients. Clin Nutr 2020; 39:3199-3205. [DOI: 10.1016/j.clnu.2020.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 12/19/2019] [Accepted: 02/10/2020] [Indexed: 01/10/2023]
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Canaud B, Vienken J, Ash S, Ward RA. Hemodiafiltration to Address Unmet Medical Needs ESKD Patients. Clin J Am Soc Nephrol 2018; 13:1435-1443. [PMID: 29511057 PMCID: PMC6140578 DOI: 10.2215/cjn.12631117] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hemodiafiltration combines diffusive and convective solute removal in a single therapy by ultrafiltering 20% or more of the blood volume processed using a high-flux hemodialyzer and maintaining fluid balance by infusing sterile nonpyrogenic replacement fluid directly into the patient's blood. In online hemodiafiltration, the large volumes of replacement fluid required are obtained by online filtration of standard dialysate through a series of bacteria- and endotoxin-retaining filters. Currently available systems for online hemodiafiltration are on the basis of conventional dialysis machines with added features to safely prepare and infuse replacement fluid and closely control fluid balance. Hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis, and recently completed randomized, controlled clinical trials suggest better patient survival with online hemodiafiltration compared with standard high-flux hemodialysis when a high convection volume is delivered. Hemodiafiltration is also associated with improvements in other clinical outcomes, such as a reduction in intradialytic hypotension, and it is now used routinely to treat >100,000 patients, mainly in Europe and Japan.
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Affiliation(s)
- Bernard Canaud
- Center of Excellence Medical, Fresenius Medical Care, Bad Homburg, Germany
- University of Montpellier, Research and Training Unit Medicine, Montpellier, France
| | | | - Stephen Ash
- Indiana University Health Arnett Hospital, Lafayette, Indiana
- HemoCleanse Technologies, LLC, Lafayette, Indiana
- Ash Access Technology, Inc., Lafayette, Indiana; and
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Lu W, Jiang GR. Randomised, open-label, multicentre trial comparing haemodialysis plus haemoperfusion versus haemodialysis alone in adult patients with end-stage renal disease (HD/HP vs HD): study protocol. BMJ Open 2018; 8:e022169. [PMID: 30056391 PMCID: PMC6067402 DOI: 10.1136/bmjopen-2018-022169] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Haemodialysis (HD) is the cornerstone treatment for patients with end-stage renal disease (ESRD). However, highly protein bound or large molecular weight uremic toxins such as phenolic and indolic compounds and homocysteine, which are associated with adverse outcomes such as cardiovascular disease of patients with ESRD, are difficult to remove via HD but can be effectively eliminates by haemoperfusion (HP). The proposed trial (referred to as HD/HP vs HD below) is a randomised, open-label, multicentre trial comparing HD plus HP versus HD alone in adult patients with ESRD. The primary endpoint measure is all-cause mortality. METHODS AND ANALYSIS We plan to enrol 1364 maintenance HD patients from 11 medical centres in Shanghai. Participants will be randomised to receive HD plus HP or HD alone at a 1:1 ratio after 1-month run-in period. In both arms, patients will receive low-flux HD at a frequency of two times a week and haemodiafiltration at a frequency of once a week. In the intervention group, subjects also received HP once every 2 weeks. Follow-up is scheduled at 3, 6, 12, 18 and 24 months after randomisation, and will consist the following: routine physical examinations, standard lab panels (blood routine, liver/residual kidney functions, tests of the coagulation system, etc), dialysis adequacy (standard Kt/V), chest X-ray, ECG, echocardiography, heart function rating. Adverse events will be assessed according to the international conference on harmonisation guidelines. The primary outcome is 24-month all-cause mortality. Secondary outcomes will include cardiovascular-related mortality, the occurrence of major cardiovascular events and the quality of life. ETHICS AND DISSEMINATION The study protocol has been approved by the Ethical Committees of all 11 participating centres. Clinical Research Unit of Xin Hua Hospital will oversee the study. The results will be presented at national and international academic meetings, and submitted to peer-reviewed journals for publications. TRIAL REGISTRATION NUMBER NCT03227770; Pre-results.
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Affiliation(s)
- Wei Lu
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Geng-Ru Jiang
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Maduell F. Hemodiafiltration versus conventional hemodialysis: Should “conventional” be redefined? Semin Dial 2018; 31:625-632. [DOI: 10.1111/sdi.12715] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Francisco Maduell
- Department of Nephrology; Hospital Clínic Barcelona; Barcelona Spain
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Roumelioti ME, Trietley G, Nolin TD, Ng YH, Xu Z, Alaini A, Figueroa R, Unruh ML, Argyropoulos CP. Beta-2 microglobulin clearance in high-flux dialysis and convective dialysis modalities: a meta-analysis of published studies. Nephrol Dial Transplant 2017; 33:1025-1039. [DOI: 10.1093/ndt/gfx311] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 10/04/2017] [Indexed: 01/01/2023] Open
Affiliation(s)
- Maria-Eleni Roumelioti
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Gregory Trietley
- Department of Pharmacy and Therapeutics, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Yue-Harn Ng
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Zhi Xu
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Ahmed Alaini
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Rocio Figueroa
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Mark L Unruh
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
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Canaud B, Chénine L, Leray-Moraguès H, Patrier L, Rodriguez A, Gontier-Picard A, Moréna M. [Online hemodiafiltration: Practical aspects, safety and efficacy]. Nephrol Ther 2017; 13:189-201. [PMID: 28483384 DOI: 10.1016/j.nephro.2017.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Purification of high molecular uremic toxins by conventional hemodialysis is limited. It remains associated with a high morbidity and excessively high mortality. Online hemodiafiltration using a high permeability hemodiafilter, an ultrapure dialysate, and which tends to maximize substitution volumes, provides a high efficiency and low bio-incompatibility renal supplementation. Regular use of online hemodiafiltration is associated with reduced morbidity (reduction of intradialytic hypotension episodes, improved blood pressure control, reduced inflammatory profile, better anemia correction and prevention of β2-microglobulin-associated amyloidosis). Recently, several cohort studies have shown that hemodiafiltration with high substitution volume was associated with a significant reduction in mortality. Randomized studies have been conducted in Europe to confirm these facts. The high safety of online hemodiafiltration has been confirmed in clinical practice by prospective studies. Online hemodiafiltration has reached its full maturity phase and is expected to represent the new standard of renal replacement therapy.
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Affiliation(s)
- Bernard Canaud
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Association pour l'installation à domicile des épurations rénales (Aider), 746, rue de la Croix-de-Lavit, 34192 Montpellier, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France.
| | - Leïla Chénine
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - Hélène Leray-Moraguès
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Association pour l'installation à domicile des épurations rénales (Aider), 746, rue de la Croix-de-Lavit, 34192 Montpellier, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - Laure Patrier
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France
| | - Annie Rodriguez
- Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - A Gontier-Picard
- Néphrologie, dialyse et soins intensifs, hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34925 Montpellier cedex 5, France; Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
| | - Marion Moréna
- Institut de recherche et formation en dialyse (IRFD), hôpital Lapeyronie, CHRU de Montpellier, 375, avenue du Doyen-Giraud, 34295 Montpellier, France
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Li WH, Yin YM, Chen H, Wang XD, Yun H, Li H, Luo J, Wang JW. Curative effect of neutral macroporous resin hemoperfusion on treating hemodialysis patients with refractory uremic pruritus. Medicine (Baltimore) 2017; 96:e6160. [PMID: 28328802 PMCID: PMC5371439 DOI: 10.1097/md.0000000000006160] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/03/2017] [Accepted: 01/26/2017] [Indexed: 11/26/2022] Open
Abstract
This study aims to investigate the efficacy and safety of neutral macroporous resin hemoperfusion in treating maintenance hemodialysis (MHD) patients with refractory uremic pruritus (RUP).Ninety patients were enrolled and were randomly divided into 3 groups: control group, experiment 1 group, and experiment 2 group. Clinical symptom scores of skin itching were recorded before and at 4 and 8 weeks after the treatment. In addition, serum parathyroid hormone (PTH), calcium (Ca), phosphorus (P), and C-reactive protein (CRP) were detected; and the calcium-phosphorus product ([Ca] × [P]) was calculated to compare the curative effect.VSA score, modified Duo pruritus score, and CRP: these indices decreased to some extent at 4 and 8 weeks after treatment in the 2 experiment groups, compared with pretreatment (P < 0.05); and differences among these 3 groups were statistically significant (P < 0.05). PTH, P, and [Ca] × [P]: these indices decreased to some extent at 4 and 8 weeks after treatment in the 2 experiment groups, compared with pretreatment (P < 0.05); and differences between the control and experiment 1 groups, as well as between the control and experiment 2 groups, were statistically significant (P < 0.05). However, the difference between the experiment 1 and experiment 2 groups were not statistically significant (P < 0.05).The effects of HA330 and HA130 resin hemoperfusion apparatus on secondary hyperparathyroidism and the disorder of calcium and phosphorus metabolism are similar. The mechanism may be related to its strong adsorption effect, and its capacity to widely remove inflammatory mediators, immune mediators, and endotoxins.
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Argyropoulos C, Roumelioti ME, Sattar A, Kellum JA, Weissfeld L, Unruh ML. Dialyzer Reuse and Outcomes of High Flux Dialysis. PLoS One 2015; 10:e0129575. [PMID: 26057383 PMCID: PMC4461247 DOI: 10.1371/journal.pone.0129575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 05/11/2015] [Indexed: 11/23/2022] Open
Abstract
Background The bulk of randomized trial evidence for the expanding use of High Flux (HF) hemodialysis worldwide comes from two randomized controlled trials, one of which (HEMODIALYSIS, HEMO) allowed, while the other (Membrane Outcomes Permeability, MPO) excluded, the reuse of membranes. It is not known whether dialyzer reuse has a differential impact on outcomes with HF vs low flyx (LF) dialyzers. Methods Proportional Hazards Models and Joint Models for longitudinal measures and survival outcomes were used in HEMO to analyze the relationship between β2-microglobulin (β2M) concentration, flux, and reuse. Meta-analysis and regression techniques were used to synthesize the evidence for HF dialysis from HEMO and MPO. Findings In HEMO, minimally reused (< 6 times) HF dialyzers were associated with a hazard ratio (HR) of 0.67 (95% confidence interval, 95%CI: 0.48–0.92, p = 0.015), 0.64 (95%CI: 0.44 – 0.95, p = 0.03), 0.61 (95%CI: 0.41 – 0.90, p = 0.012), 0.53 (95%CI: 0.28 – 1.02, p = 0.057) relative to minimally reused LF ones for all cause, cardiovascular, cardiac and infectious mortality respectively. These relationships reversed for extensively reused membranes (p for interaction between reuse and flux < 0.001, p = 0.005) for death from all cause and cardiovascular causes, while similar trends were noted for cardiac and infectious mortality (p of interaction between reuse and flux of 0.10 and 0.08 respectively). Reduction of β2M explained only 1/3 of the effect of minimally reused HF dialyzers on all cause mortality, while non-β2M related factors explained the apparent attenuation of the benefit with more extensively reused dialyzers. Meta-regression of HEMO and MPO estimated an adjusted HR of 0.63 (95% CI: 0.51–0.78) for non-reused HF dialyzers compared with non-reused LF membranes. Conclusions This secondary analysis and synthesis of two large hemodialysis trials supports the widespread use of HF dialyzers in clinical hemodialysis over the last decade. A mechanistic understanding of the effects of HF dialysis and the reuse process on dialyzers may suggest novel biomarkers for uremic toxicity and may accelerate membrane technology innovations that will improve patient outcomes.
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Affiliation(s)
- Christos Argyropoulos
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
- * E-mail:
| | - Maria-Eleni Roumelioti
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
| | - Abdus Sattar
- Department of Epidemiology and Biostatistics School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - John A. Kellum
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lisa Weissfeld
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Biostatistics University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark L. Unruh
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
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Alix PM, Guebre-Egziabher F, Soulage CO. Leptin as an uremic toxin: Deleterious role of leptin in chronic kidney disease. Biochimie 2014; 105:12-21. [PMID: 25010649 DOI: 10.1016/j.biochi.2014.06.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 06/30/2014] [Indexed: 12/27/2022]
Abstract
White adipose tissue secretes a large variety of compounds named adipokines amongst which, leptin exhibits pleiotropic metabolic actions. Leptin is an anorexigenic hormone, secreted in proportion of fat mass, with additional effects on the regulation of inflammation, cardiovascular system, immunity, hematopoiesis and bone metabolism. Chronic kidney disease (CKD) is characterized by an increase of plasma leptin concentration that may be explained by a lack of renal clearance. Hyperleptinemia plays a key role in the pathogenesis of complications associated with CKD such as cachexia, protein energy wasting, chronic inflammation, insulin resistance, cardiovascular damages and bone complications. Leptin is also involved in the progression of renal disease through its pro-fibrotic and pro-hypertensive actions. Most of the adverse effects of leptin have been documented both experimentally and clinically. Leptin may therefore be considered as an uremic toxin in CKD. The aim of this review is to summarize the pathophysiological and clinical role of leptin in in vitro studies, experimental models, as well as in patients suffering from CKD.
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Affiliation(s)
- Pascaline M Alix
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, F-69621 Villeurbanne, France; Hospices Civils de Lyon, Department of Nephrology, Hôpital E Herriot, Lyon F-69003, France.
| | - Fitsum Guebre-Egziabher
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, F-69621 Villeurbanne, France; Hospices Civils de Lyon, Department of Nephrology, Hôpital E Herriot, Lyon F-69003, France
| | - Christophe O Soulage
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, F-69621 Villeurbanne, France
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Susantitaphong P, Siribamrungwong M, Jaber BL. Convective therapies versus low-flux hemodialysis for chronic kidney failure: a meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2013; 28:2859-74. [PMID: 24081858 DOI: 10.1093/ndt/gft396] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although convective therapies have gained popularity for the optimal removal of uremic solutes, their benefits and potential risks have not been fully elucidated. We conducted a meta-analysis of all randomized controlled trials comparing convective therapies with low-flux hemodialysis in patients with chronic kidney failure. METHODS We performed a literature search using MEDLINE (inception-December 2012), Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, scientific abstracts from meetings and bibliographies of retrieved articles. Randomized controlled trials comparing the effect of convective therapies including high-flux hemodialysis, hemofiltration or hemodiafiltration versus low-flux hemodialysis were included. Random-effects model meta-analyses were used to examine continuous and binary outcomes. RESULTS Sixty-five (29 crossover and 36 parallel-arm) trials were identified (n = 12 182). Convective therapies resulted in a decrease in all-cause mortality [relative risk (RR) 0.88; 95% confidence interval (CI) 0.76, 1.02, P = 0.09], cardiovascular mortality (RR 0.84; 95% CI 0.71, 0.98, P = 0.03), all-cause hospitalization (RR 0.91; 95% CI 0.82, 1.01; P = 0.08) and therapy-related hypotension (RR 0.55, 95% CI 0.35, 0.87, P = 0.01). Convective therapies also resulted in an increase in the clearance of several low-molecular-weight (urea, creatinine and phosphate), middle-sized (β-2 microglobulin and leptin) and protein-bound (homocysteine, advanced glycation end-products and pentosidine) solutes and a decrease in inflammatory markers (interleukin-6). There was no impact of convective therapies on cardiac morphological and functional parameters, and blood pressure and anemia parameters. CONCLUSIONS Although convective therapies are associated with improved clearance of uremic solutes, the potential long-term benefits of specific convective modalities require further study.
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Affiliation(s)
- Paweena Susantitaphong
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St. Elizabeth's Medical Center, Boston, MA, USA
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Imamović G, Hrvačević R, Kapun S, Marcelli D, Bayh I, Grassmann A, Scatizzi L, Maslovarić J, Canaud B. Survival of incident patients on high-volume online hemodiafiltration compared to low-volume online hemodiafiltration and high-flux hemodialysis. Int Urol Nephrol 2013; 46:1191-200. [PMID: 24057682 DOI: 10.1007/s11255-013-0526-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 07/19/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemodiafiltration is becoming a preferred treatment modality for dialysis patients in many countries. The volume of substitution fluid delivered has been indicated as an independent mortality risk factor. The aim of this study is to compare patient survival on three different treatment modalities: high-flux hemodialysis, low-volume online HDF (oHDF) and high-volume oHDF. METHODS Incident hemodialysis and oHDF patients treated in 13 NephroCare centers in Bosnia and Herzegovina, Serbia and Slovenia between January 1, 2007, and December 31, 2011, were included in this epidemiological cohort study. High-volume oHDF was defined as substitution volume higher than the median substitution volume infused, otherwise low-volume. Main predictor was treatment modality at baseline and in time-dependent model. Other predictors were age, gender, diabetes mellitus, cerebrovascular accident, arrhythmia, hemoglobin and C-reactive protein. RESULTS Four hundred and forty-two patients were included in the study. Median substitution fluid volume was 20.4 L. Mean difference between the oHDF groups in substitution fluid volume was 8.3 ± 5.2 L [95 % confidence intervals (95 % CI) 7.1-9.5, p < 0.0001]. The unadjusted hazard ratios (HR) with 95 % CI compared to high-flux HD were 0.87 (0.5-1.5) for low-volume oHDF and 0.29 (0.13-0.63) for high-volume oHDF. After the adjustment for covariates, the HR for patients on low-volume oHDF remained statistically insignificant compared to high-flux HD (0.84; 95 % CI 0.46-1.53), while patients on high-volume oHDF showed a marked and significantly lower HR (0.29; 95 % CI 0.13-0.68) than patients on high-flux HD in baseline model. While this effect failed to reach significance in the time-dependent model (HR 0.477; 95 % CI 0.196-1.161), possibly due to an inadequate sample size here, the consistency of results in both models supports the robustness of the findings. After switching from high-flux hemodialysis to oHDF, mean hemoglobin and albumin levels did not change significantly. Mean erythropoietin resistance index (ERI) and erythropoiesis stimulating agents (ESA) consumption decreased significantly (p = 0.02, p = 0.03, respectively). CONCLUSIONS The median substitution volume used in these three countries for post-dilutional oHDF is 20.4 L. oHDF is associated with significant reductions in ERI and ESA consumption. Only high-volume oHDF is associated with improved survival compared to high-flux hemodialysis.
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Affiliation(s)
- Goran Imamović
- Fresenius Medical Care, Sarajevo, Bosnia and Herzegovina,
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Combination of maintenance hemodialysis with hemoperfusion: a safe and effective model of artificial kidney. Int J Artif Organs 2011; 34:339-47. [PMID: 21534244 DOI: 10.5301/ijao.2011.7748] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate whether the combination of maintenance hemodialysis (MHD) with hemoperfusion (HP) could improve the clearance rate of middle and large molecule uremic toxins so as to improve the quality of life of MHD patients and reduce their mortality rate. METHODS This study was a prospective, randomized, controlled clinical trial. 100 MHD patients were selected and then randomly divided into two groups after four weeks of run-in period. Group 1 received HD alone 2 times a week and the combined treatment of HD with HP (HD+HP) once a week, whereas Group 2 was given HD alone 3 times a week. This study was followed up for a mean of 2 years. The primary outcome was the death of patients. Secondary end points included normal clinical data, leptin, high sensitive C-reactive protein (hsCRP), interleukin-6 (IL-6), ß(2) microglobulin (ß(2)-MG), immunoreactive parathyroid hormone (iPTH), tumor necrosis factor-α (TNF-α) and the index of dimensions of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 Chinese Edition ). RESULTS At the end of the two-year observation, the serum concentration of leptin, hsCRP, iPTH, IL-6, ß(2)-MG and TNF-α, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), cardiothoracic ratio, left ventricular mass index (LVMI), the EPO doses and the types of antihypertensive drugs used were lower with Group 1 than with Group 2 (p<0.05); Group 1 had higher hemoglobin (Hb), ejection fraction (EF), and body mass index (BMI) (p<0.05). No statistical difference between the two groups was observed in terms of serum albumin, serum iron (SI), total iron binding capacity (TIBC), cardiac output (CO), Kt/V, early/atrial mitral inflow velocities (E/A) (p>0.05). Besides, the SF-36 indicated that the total score of overall dimentions of Group 1 was higher than Group 2 (p<0.05) and the quality of life of Group 1 was evidently better than Group 2. The Kaplan-Meier Survival Curves for the 2-year observation period showed that patients in Group 1 had obvious survival advantage while Log-rank test results showed p<0.05. No serious adverse incidents occurred during the HD+HP treatment. CONCLUSIONS HD+HP was superior to HD in regularly eliminating middle and large molecule uremic toxins accumulated in the body. These findings suggest a potential role for HD+HP in the treatment to improve the quality of life and survival rate of MHD patients.
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Hallbauer J, Kreusch S, Klemm A, Wolf G, Rhode H. Long-term serum proteomes are quite similar under high- and low-flux hemodialysis treatment. Proteomics Clin Appl 2010; 4:953-61. [DOI: 10.1002/prca.201000051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 08/11/2010] [Accepted: 09/07/2010] [Indexed: 11/06/2022]
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Gracia-Iguacel C, Gallar P, Qureshi AR, Ortega O, Mon C, Ortiz M, Villarreal I, Garcia-Lacalle C, Olieta A, Sánchez M, Herrero JC, Vigil A, Lindholm B, Carrero JJ. Vitamin D Deficiency in Dialysis Patients: Effect of Dialysis Modality and Implications on Outcome. J Ren Nutr 2010; 20:359-67. [DOI: 10.1053/j.jrn.2010.03.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Indexed: 12/19/2022] Open
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Merino A, Portolés J, Selgas R, Ojeda R, Buendia P, Ocaña J, Bajo MA, del Peso G, Carracedo J, Ramírez R, Martín-Malo A, Aljama P. Effect of different dialysis modalities on microinflammatory status and endothelial damage. Clin J Am Soc Nephrol 2010; 5:227-34. [PMID: 20056757 DOI: 10.2215/cjn.03260509] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES We studied the relationship between microinflammation and endothelial damage in chronic kidney disease (CKD) patients on different dialysis modalities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Four groups of CKD stage 5 patients were studied: 1) 14 nondialysis CKD patients (CKD-NonD); 2) 15 hemodialysis patients (HD); 3) 12 peritoneal dialysis patients with residual renal function >1 ml/min (PD-RRF >1); and 4) 13 peritoneal dialysis patients with residual renal function <or=1 ml/min (PD-RRF <or=1). Ten healthy subjects served as controls. CD14(+)CD16(+) cells and apoptotic endothelial microparticles (EMPs) were measured by flow cytometry. Serum vascular endothelial growth factor (VEGF) was measured by ELISA. RESULTS CKD-NonD and HD patients had a higher percentage of CD14(+)CD16(+) monocytes than PD groups and controls. CD14(+)CD16(+) was similar in the PD groups, regardless of their RRF, and controls. The four uremic groups displayed a marked increase in apoptotic EMPs and VEGF compared with controls. Apoptotic EMPs and VEGF were significantly higher in HD patients than in CKD-NonD and both PD groups. However, there were no significant differences between CKD-NonD and the two PD groups. There was a correlation between CD14(+)CD16(+) and endothelial damage in CKD-NonD and HD patients, but not in PD and controls. CONCLUSIONS There was an increase in CD14(+)CD16(+) only in CKD-NonD and HD patients. In these patients, there was a relationship between increased CD14(+)CD16(+) and endothelial damage. These results strongly suggest that other factors unrelated to the microinflammatory status mediated by CD14(+)CD16(+) are promoting the endothelial damage in PD, regardless of their RRF.
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Affiliation(s)
- Ana Merino
- Unidad de Investigación, Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, Spain
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Les alternatives à l’hémodialyse conventionnelle. Nephrol Ther 2007. [DOI: 10.1016/s1769-7255(07)78755-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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