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AlMojalled RM, Almabadi RM, Alghamdi AA, Alnugali RZ. Correlation of Serum Albumin Levels With Laboratory Parameters in Automated Peritoneal Dialysis and Continuous Ambulatory Peritoneal Dialysis Patients: A Prospective Cohort Study. Cureus 2023; 15:e47364. [PMID: 38021540 PMCID: PMC10657481 DOI: 10.7759/cureus.47364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Peritoneal dialysis (PD) is a treatment option for end-stage renal disease (ESRD) patients, with automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) being the two main modalities. APD has reported benefits such as reduced peritonitis rates, improved ultrafiltration, and enhanced quality of life. However, some studies have found potential negative consequences of APD, and the impact on survival outcomes is limited and contradictory. Selecting the appropriate PD modality for ESRD patients should be individualized based on various factors, including nutritional status, demographic factors, laboratory findings, and other outcomes. PD patients are at high risk of malnutrition, and serum albumin is commonly used as a marker of nutritional status. Continuous monitoring of laboratory values may be beneficial for identifying nutritional deficiencies in a timely manner. Methodology This prospective cohort study aimed to compare APD and CAPD modalities in relation to serum albumin levels, demographic factors, and other laboratory parameters. The sample consisted of patients with ESRD treated with PD, who were divided into two groups per baseline albumin level. The study collected data on demographic, clinical, and laboratory characteristics, as well as comorbidities. The data were analyzed using SPSS version 26 (IBM Corp., Armonk, NY, USA), and statistical tests, such as the chi-square test and repeated-measures analysis of variance (ANOVA), were conducted to determine significant associations and differences between variables. Results The study included a total of 85 patients with ESRD who required PD as a treatment modality. Among them, 71 patients were undergoing APD, and 14 patients were undergoing CAPD. The study found that there were no significant differences in demographic factors, laboratory parameters, or medical history parameters between APD and CAPD patients with different albumin levels. The patients were followed up for six months and laboratory parameters were evaluated. Repeated-measures ANOVA showed that there were no significant variations in both APD and CAPD patients. However, Spearman's rank correlation test revealed statistically important correlations between albumin and some laboratory parameters in both APD and CAPD patients at different assessment stages, including hemoglobin, sodium, transferrin, uric acid, phosphate, total protein, cholesterol, and triglycerides (p < 0.05). Conclusions Serum albumin levels appeared to be unaffected by the choice of PD modality. There were significant correlations between serum albumin levels and specific laboratory findings, including total protein, across all assessment stages for both APD and CAPD patients. These findings underscore the importance of continuous laboratory monitoring for PD patients.
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Affiliation(s)
| | - Reem M Almabadi
- Department of Nutrition and Dietetics, King Fahad Armed Forces Hospital, Jeddah, SAU
| | - Ahlam A Alghamdi
- Department of Health Education, King Fahad Armed Forces Hospital, Jeddah, SAU
| | - Razan Z Alnugali
- Department of Family Medicine, King Fahad Armed Forces Hospital, Jeddah, SAU
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2
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García-Prieto A, de la Flor JC, Coll E, Iglesias E, Reque J, Valga F. Expanded hemodialysis: what's up, Doc? Clin Kidney J 2023; 16:1071-1080. [PMID: 37398691 PMCID: PMC10310509 DOI: 10.1093/ckj/sfad033] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Indexed: 10/06/2023] Open
Abstract
In recent years there has been an increasing interest in expanded hemodialysis (HDx), an emerging renal replacement therapy based on the use of medium cut-off membranes (MCO). Thanks to the internal architecture of these types of membranes, with a higher pore size and smaller fiber inner diameter to favor internal filtration rate, they can increase the removal of larger middle molecules in conventional hemodialysis. Secondarily, several reports suggest that this therapy potentially improve the outcomes for end-stage renal disease patients. However, HDx has not been defined yet and the characteristics of MCO membranes are not well stablished. The aim of this narrative review is to define HDx and summarize the dialyzers that have been used so far to perform this therapy, collect the evidence available on its efficacy and clinical outcomes compared with other hemodialysis techniques and settle the bases for its optimal prescription.
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Affiliation(s)
- Ana García-Prieto
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Elisabet Coll
- Nephrology Department, Fundación Puigvert, Barcelona, Spain
| | - Elena Iglesias
- Nephrology Department, Complejo Hospitalario Universitario de Orense, Ourense, Spain
| | - Javier Reque
- Nephrology Department, Hospital General Universitario de Castellón, Castellón, Spain
| | - Francisco Valga
- Nephrology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
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3
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Belmouaz M, Bauwens M, Hauet T, Bossard V, Jamet P, Joly F, Chikhi E, Joffrion S, Gand E, Bridoux F. Comparison of the removal of uraemic toxins with medium cut-off and high-flux dialysers: a randomized clinical trial. Nephrol Dial Transplant 2020; 35:328-335. [PMID: 31578564 DOI: 10.1093/ndt/gfz189] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/21/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Accumulation of middle-weight uraemic toxins in haemodialysis (HD) patients results in increased morbidity and mortality. Whether medium cut-off HD (MCO-HD) improves removal of middle-weight uraemic toxins remains to be demonstrated. METHODS This cross-over prospective study included 40 patients randomly assigned to receive either 3 months of MCO-HD followed by 3 months of high-flux HD (HF-HD), or vice versa. The primary endpoint was myoglobin reduction ratio (RR) after 3 months of MCO-HD. Secondary endpoints were the effect of MCO-HD on other middle-weight toxins and protein-bound toxins, and on parameters of nutrition, inflammation, anaemia and oxidative stress. RESULTS Compared with HF-HD, MCO-HD provided higher mean RR of myoglobin (36 ± 8 versus 57 ± 13%, P < 0.0001), beta2-microglobulin (68 ± 6 versus 73 ± 15%, P = 0.04), prolactin (32 ± 13 versus 59 ± 11%, P < 0.0001), fibroblast growth factor 23 (20 ± 21 versus 41 ± 22%, P = 0.0002), homocysteine (43 ± 7 versus 46 ± 9%, P = 0.03) and higher median RR of kappa [54 (48-58) versus 70 (63-74)%, P < 0.0001] and lambda free light chain (FLC) [15 (9-22) versus 44 (38-49)%, P < 0.0001]. Mean ± SD pre-dialysis levels of beta2-microglobulin (28.4 ± 5.6 versus 26.9 ± 5.1 mg/L, P = 0.01) and oxidized low-density lipoprote (6.9 ± 4.4 versus 5.5 ± 2.5 pg/mL, P = 0.04), and median (interquartile range) kappa FLC [145 (104-203) versus 129 (109-190) mg/L, P < 0.03] and lambda FLC [106 (77-132) versus 89 (62-125) mg/L, P = 0.002] were significantly lower. Mean albumin levels decreased significantly (38.2 ± 4.1 versus 36.9 ± 4.3 g/L, P = 0.004), without an effect on nutritional status as suggested by unchanged normalized protein catabolic rate and transthyretin level. CONCLUSIONS Compared with HF-HD, MCO-HD provides higher myoglobin and other middle molecules RR and is associated with moderate hypoalbuminemia. The potential benefits of this strategy on long-term clinical outcomes deserve further evaluation.
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Affiliation(s)
- Mohamed Belmouaz
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Marc Bauwens
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Thierry Hauet
- Department of Biochemistry, Poitiers University Hospital, Poitiers, France.,Institut National de la Sante et de la Recherche Médicale (INSERM), U1082 (IRTOMIT), Poitiers University Hospital, Poitiers, France
| | - Valentin Bossard
- Department of Biochemistry, Poitiers University Hospital, Poitiers, France
| | - Pierre Jamet
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Florent Joly
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Elise Chikhi
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Sandrine Joffrion
- Department of Biochemistry, Poitiers University Hospital, Poitiers, France.,Institut National de la Sante et de la Recherche Médicale (INSERM), U1082 (IRTOMIT), Poitiers University Hospital, Poitiers, France
| | - Elise Gand
- Department of Biostatistics, Centre d'Investigation Clinique CIC 1402, Poitiers University Hospital, Poitiers, France
| | - Frank Bridoux
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
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4
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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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5
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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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Lim PS, Lin Y, Chen M, Xu X, Shi Y, Bowry S, Canaud B. Precise Quantitative Assessment of the Clinical Performances of Two High-Flux Polysulfone Hemodialyzers in Hemodialysis: Validation of a Blood-Based Simple Kinetic Model Versus Direct Dialysis Quantification. Artif Organs 2017; 42:E55-E66. [PMID: 29193165 DOI: 10.1111/aor.13011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/26/2017] [Accepted: 07/19/2017] [Indexed: 12/25/2022]
Abstract
Highly permeable dialysis membranes with better design filters have contributed to improved solute removal and dialysis efficacy. However, solute membrane permeability needs to be well controlled to avoid increased loss of albumin that is considered to be detrimental for dialysis patients. A novel high-flux dialyzer type (FX CorDiax; Fresenius Medical Care) incorporating an advanced polysulfone membrane modified with nano-controlled spinning technology to enhance the elimination of a broader spectrum of uremic toxins has been released. The aim of this study was to compare in the clinical setting two dialyzer types having the same surface area, the current (FX dialyzer) and the new dialyzer generation (FX CorDiax), with respect to solute removal capacity over a broad spectrum of markers, including assessment of albumin loss based on a direct dialysis quantification method. We performed a crossover study following an A1-B-A2 design involving 10 patients. Phase A1 was 1 week of thrice-weekly bicarbonate hemodialysis with the FX dialyzer, 4 h per treatment; phase B was performed with a similar treatment regimen but with a new FX CorDiax dialyzer and finally the phase A2 was repeated with FX dialyzer as the former phase. Solute removal markers of interest were assessed from blood samples taken before and after treatment and from total spent dialysate collection (direct dialysis quantification) permitting a mass transfer calculation (mg/session into total spent dialysate/ultrafiltrate). On the blood side, there were no significant differences in the solute percent reduction between FX CorDiax 80 and FX 80. On the dialysate side, no difference was observed regarding eliminated mass of different solutes including β2 -microglobulin (143.1 ± 33.6 vs. 138.3 ± 41.9 mg, P = 0.8), while the solute mass removal of total protein (1.65 ± 0.51 vs. 2.14 ± 0.75 g, P = 0.04), and albumin (0.41 ± 0.21 vs. 1.22 ± 0.51 g, P < 0.001) were significantly less for FX CorDiax 80 compared to the FX 80 dialyzer. The results of this cross-over study indicate that the new FX CorDiax dialyzer has highly effective removal of middle molecules, without any concomitant increase in total protein and albumin loss. The clinical relevance and potential benefit of this finding needs to be determined.
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Affiliation(s)
- Paik-Seong Lim
- Division of Renal Medicine, Tungs Taichung Metroharbour Hospital, Taiwan
| | - Yuyu Lin
- Division of Renal Medicine, Tungs Taichung Metroharbour Hospital, Taiwan
| | - Minfeng Chen
- Division of Renal Medicine, Tungs Taichung Metroharbour Hospital, Taiwan
| | - Xiaoqi Xu
- Fresenius Medical Care Asia Pacific, Hong Kong
| | - Yun Shi
- Fresenius Medical Care Asia Pacific, Hong Kong
| | - Sudhir Bowry
- Fresenius Medical Care Deutschland EMEA, Bad Homburg, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland EMEA, Bad Homburg, Germany
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7
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Kirsch AH, Lyko R, Nilsson LG, Beck W, Amdahl M, Lechner P, Schneider A, Wanner C, Rosenkranz AR, Krieter DH. Performance of hemodialysis with novel medium cut-off dialyzers. Nephrol Dial Transplant 2017; 32:165-172. [PMID: 27587605 PMCID: PMC5837492 DOI: 10.1093/ndt/gfw310] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/15/2016] [Indexed: 11/14/2022] Open
Abstract
Background. Compared to high-flux dialysis membranes, novel medium cut-off (MCO) membranes show greater permeability for larger middle molecules. Methods. In two prospective, open-label, controlled, randomized, crossover pilot studies, 39 prevalent hemodialysis (HD) patients were studied in four dialysis treatments as follows: study 1, three MCO prototype dialyzers (AA, BB and CC with increasing permeability) and one high-flux dialyzer in HD; and study 2, two MCO prototype dialyzers (AA and BB) in HD and high-flux dialyzers in HD and hemodiafiltration (HDF). Primary outcome was lambda free light chain (λFLC) overall clearance. Secondary outcomes included overall clearances and pre-to-post-reduction ratios of middle and small molecules, and safety of MCO HD treatments. Results. MCO HD provided greater λFLC overall clearance [least square mean (standard error)] as follows: study 1: MCO AA 8.5 (0.54), MCO BB 11.3 (0.51), MCO CC 15.0 (0.53) versus high-flux HD 3.6 (0.51) mL/min; study 2: MCO AA 10.0 (0.58), MCO BB 12.5 (0.57) versus high-flux HD 4.4 (0.57) and HDF 6.2 (0.58) mL/min. Differences between MCO and high-flux dialyzers were consistently significant in mixed model analysis (each P < 0.001). Reduction ratios of λFLC were greater for MCO. Clearances of α1-microglobulin, complement factor D, kappa FLC (κFLC) and myoglobin were generally greater with MCO than with high-flux HD and similar to or greater than clearances with HDF. Albumin loss was moderate with MCO, but greater than with high-flux HD and HDF. Conclusions. MCO HD removes a wide range of middle molecules more effectively than high-flux HD and even exceeds the performance of high-volume HDF for large solutes, particularly λFLC.
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Affiliation(s)
- Alexander H Kirsch
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Raphael Lyko
- Division of Nephrology, Department of Medicine, University Hospital, Würzburg, Germany
| | | | - Werner Beck
- Gambro Dialysatoren GmbH, Baxter Renal Therapeutic Area, Hechingen, Germany
| | - Michael Amdahl
- Baxter Healthcare Corporation, Life Science & Operations, Round Lake, IL, USA
| | - Petra Lechner
- Department of Internal Medicine, LKH Hochsteiermark, Bruck, Austria
| | - Andreas Schneider
- Division of Nephrology, Department of Medicine, University Hospital, Würzburg, Germany
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital, Würzburg, Germany
| | - Alexander R Rosenkranz
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Detlef H Krieter
- Division of Nephrology, Department of Medicine, University Hospital, Würzburg, Germany
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Medium cut-off membranes - closer to the natural kidney removal function. Int J Artif Organs 2017; 40:328-334. [PMID: 28574113 PMCID: PMC6159847 DOI: 10.5301/ijao.5000603] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 01/31/2023]
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9
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Kneis C, Beck W, Boenisch O, Klefisch F, Deppisch R, Zickler D, Schindler R. Elimination of Middle-Sized Uremic Solutes with High-Flux and High-Cut-Off Membranes: A Randomized in vivo Study. Blood Purif 2013; 36:287-94. [DOI: 10.1159/000356224] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 10/04/2013] [Indexed: 12/19/2022]
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10
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Pellicano R, Polkinghorne KR, Kerr PG. Reduction in β2-Microglobulin With Super-flux Versus High-flux Dialysis Membranes: Results of a 6-Week, Randomized, Double-blind, Crossover Trial. Am J Kidney Dis 2008; 52:93-101. [DOI: 10.1053/j.ajkd.2008.02.296] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Accepted: 02/12/2008] [Indexed: 11/11/2022]
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Ward RA. Protein-Leaking Membranes for Hemodialysis: A New Class of Membranes in Search of an Application? J Am Soc Nephrol 2005; 16:2421-30. [PMID: 15975998 DOI: 10.1681/asn.2005010070] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A new class of membranes that leak protein has been developed for hemodialysis. These membranes provide greater clearances of low molecular weight proteins and small protein-bound solutes than do conventional high-flux dialysis membranes but at the cost of some albumin loss into the dialysate. Protein-leaking membranes have been used in a small number of clinical trials. The results of these trials suggest that protein-leaking membranes improve anemia correction, decrease plasma total homocysteine concentrations, and reduce plasma concentrations of glycosylated and oxidized proteins. However, it is not clear yet that routine use of protein-leaking membranes is warranted. Specific uremic toxins that are removed by protein-leaking membranes but not conventional high-flux membranes have not been identified. It is also unclear whether protein-leaking membranes offer benefits beyond those obtained with conventional high-flux membranes used in convective therapies, such as hemofiltration and hemodiafiltration. Finally, the amount of albumin loss that can be tolerated by hemodialysis patients in a long-term therapy has yet to be determined. Protein-leaking membranes offer a new approach to improving outcomes in hemodialysis, but whether their benefits will outweigh their disadvantages will require more basic and clinical research.
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Affiliation(s)
- Richard A Ward
- Kidney Disease Program, Department of Medicine, University of Louisville, 615 S. Preston Street, Louisville, KY 40202-1718, USA.
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12
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Krieter DH, Canaud B. High permeability of dialysis membranes: what is the limit of albumin loss? Nephrol Dial Transplant 2003; 18:651-4. [PMID: 12637630 DOI: 10.1093/ndt/gfg054] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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