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Molina P, Goicoechea M, Huarte E, Maduell F, Valero A, Martín-Malo A. Hemodiafiltration with endogenous reinfusion of the regenerated ultrafiltrate (HFR): towards a convective, diffusive, and adsorptive dialysis. Nefrologia 2023; 43:688-702. [PMID: 38176980 DOI: 10.1016/j.nefroe.2023.12.003] [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: 05/08/2023] [Accepted: 06/28/2023] [Indexed: 01/06/2024] Open
Abstract
Hemodiafiltration with endogenous reinfusion of the ultrafiltrate (HFR) is a dialysis technique characterized by a resin cartridge with adsorptive properties that combines the mechanisms of diffusion, convection, and adsorption in a single therapeutic regimen. After nearly 20 years of clinical experience with HFR, this article reviews the accumulated evidence with this technique, considering whether adsorption reduction, as a third purification mechanism, should be the next step in the treatment of hemodialysis patients. HFR, beyond producing an extensive removal of uremic toxins, has demonstrated to reduce the loss of nutrients and other physiological components during the dialysis session as compared to online hemodiafiltration, ameliorating the inflammatory state and oxidative stress in this population. In addition to its ease of use, the technique is also highly biocompatible and can be used in patients with a compromised vascular access. Based on these observations, HFR appears to be an especially useful therapy for high-comorbidity patients, including those with frailty, malnutrition, or cardiovascular disease. In this review, we, as a consensus panel of nephrologists experienced with HFR, survey existing literature and summarize our views on when to use this technique, which patients may be best suited for HFR, and how to effectively prescribe and monitor this modality of dialysis in daily clinical practice.
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Affiliation(s)
- Pablo Molina
- Servicio de Nefrología, Hospital Universitari Dr. Peset, Universitat de València, FISABIO, Valencia, Spain.
| | - Marian Goicoechea
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emma Huarte
- Servicio de Nefrología, Hospital de San Pedro, Logroño, Spain
| | - Francisco Maduell
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Alejandro Valero
- Servicio de Nefrología, Hospital Universitari Dr. Peset, Universitat de València, FISABIO, Valencia, Spain
| | - Alejandro Martín-Malo
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Red Nacional de Investigación en Nefrología (REDinREN), Instituto de Salud Carlos III, Spain
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2
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Molina P, Ojeda R, Blanco A, Alcalde G, Prieto-Velasco M, Aresté N, Buades JM, Simó VE, Goicoechea M, Pérez-Morales RE, Sánchez-Álvarez E, Sánchez-Villanueva R, Montesa M, Arenas MD. Etiopathogenesis of chronic kidney disease-associated pruritus: putting the pieces of the puzzle together. Nefrologia 2023; 43:48-62. [PMID: 37173258 DOI: 10.1016/j.nefroe.2023.03.015] [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: 03/29/2022] [Accepted: 06/28/2022] [Indexed: 05/15/2023] Open
Abstract
Defined as the unpleasant sensation that causes the desire to scratch, pruritus is the most common skin symptom associated with uremia and appears in almost half of patients with advanced chronic kidney disease (CKD). Beyond its direct impact on quality of life, CKD-associated pruritus (CKD-aP) is an independent predictor of mortality that also has a synergistic effect with other quality of life-related symptoms, such as insomnia, depression, and anxiety. Although different mechanisms have been proposed to explain the origin of Pa-ERC, its etiopathogenesis is still not fully understood. Since new therapeutic targets have been identified and several clinical trials have recently shown promising results, our current understanding of the interrelationships has expanded significantly and the pathophysiological mechanisms underlying CKD-aP are now considered to be multifactorial. The potential triggers of pruritus in patients with CKD are discussed in this review, including hypotheses about skin xerosis, accumulation of uremic toxins, dysregulation of the immune system and systemic inflammation, uremic neuropathy, and imbalances in the endogenous opioid system. Other non-uremic causes of pruritus are also discussed, with the aim of guiding the physicians to apply an adequate aetiopathogenic approach to CKD-aP in their day-to-day clinical practice.
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Affiliation(s)
- Pablo Molina
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain.
| | - Raquel Ojeda
- Servicio de Nefrología, Hospital Universitario Renia Sofía, Córdoba, Spain
| | - Ana Blanco
- Fresenius Medical Care, Centro de Diálisis Alcobendas, Madrid, Spain; Servicio de Nefrología, Hospital Quirón Ruber Juan Bravo, Madrid, Spain
| | - Guillermo Alcalde
- Servicio de Nefrología, BIOARABA, Hospital Universitario Araba, Osakidetza, Universidad del País Vasco, Vitoria-Gasteiz, Álava, Spain
| | | | - Nuria Aresté
- Servicio de Nefrología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Juan Manuel Buades
- Servicio de Nefrología, Hospital Universitario Son Llàtzer, Institut d'Investigació Sanitària de les Illes Balears (IdISBa), Palma, Spain
| | - Vicent Esteve Simó
- Servicio de Nefrologia, Hospital Terrassa, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
| | - Marian Goicoechea
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Elena Pérez-Morales
- Servicio de Nefrología. Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Emilio Sánchez-Álvarez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Red de Investigación Renal (REDINREN), Gijón, Asturias, Spain
| | | | - María Montesa
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain
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3
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Etiopatogenia del prurito asociado a la enfermedad renal crónica: recomponiendo las piezas del puzle. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.06.004] [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] Open
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4
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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5
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Monzón T, Valga F, Henríquez F, Alonso F, Parodis Y, Hillebrand S, Pérez GA. Use HFR-supra for inflammatory bowel disease: A case report. Nefrologia 2021; 41:710-711. [PMID: 36165165 DOI: 10.1016/j.nefroe.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/15/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
- Tania Monzón
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain.
| | - Francisco Valga
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Fernando Henríquez
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Francisco Alonso
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Yanet Parodis
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Sebastian Hillebrand
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Gloria Antón Pérez
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
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6
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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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7
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Magnani S, Atti M. Uremic Toxins and Blood Purification: A Review of Current Evidence and Future Perspectives. Toxins (Basel) 2021; 13:toxins13040246. [PMID: 33808345 PMCID: PMC8066023 DOI: 10.3390/toxins13040246] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022] Open
Abstract
Accumulation of uremic toxins represents one of the major contributors to the rapid progression of chronic kidney disease (CKD), especially in patients with end-stage renal disease that are undergoing dialysis treatment. In particular, protein-bound uremic toxins (PBUTs) seem to have an important key pathophysiologic role in CKD, inducing various cardiovascular complications. The removal of uremic toxins from the blood with dialytic techniques represents a proved approach to limit the CKD-related complications. However, conventional dialysis mainly focuses on the removal of water-soluble compounds of low and middle molecular weight, whereas PBTUs are strongly protein-bound, thus not efficiently eliminated. Therefore, over the years, dialysis techniques have been adapted by improving membranes structures or using combined strategies to maximize PBTUs removal and eventually prevent CKD-related complications. Recent findings showed that adsorption-based extracorporeal techniques, in addition to conventional dialysis treatment, may effectively adsorb a significant amount of PBTUs during the course of the sessions. This review is focused on the analysis of the current state of the art for blood purification strategies in order to highlight their potentialities and limits and identify the most feasible solution to improve toxins removal effectiveness, exploring possible future strategies and applications, such as the study of a synergic approach by reducing PBTUs production and increasing their blood clearance.
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8
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Monzón T, Valga F, Henríquez F, Alonso F, Parodis Y, Hillebrand S, Pérez GA. Use HFR-supra for inflammatory bowel disease: A case report. Nefrologia 2021; 41:S0211-6995(21)00053-9. [PMID: 33771382 DOI: 10.1016/j.nefro.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/15/2020] [Indexed: 10/21/2022] Open
Affiliation(s)
- Tania Monzón
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, España.
| | - Francisco Valga
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| | - Fernando Henríquez
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| | - Francisco Alonso
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| | - Yanet Parodis
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| | - Sebastian Hillebrand
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| | - Gloria Antón Pérez
- Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gran Canaria, Las Palmas, España
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9
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Donati G, Cappuccilli M, Di Filippo F, Nicoletti S, Ruggeri M, Scrivo A, Angeletti A, La Manna G. The Use of Supra-Hemodiafiltration in Traumatic Rhabdomyolysis and Acute Kidney Injury: A Case Report. Case Rep Nephrol Dial 2021; 11:26-35. [PMID: 33708797 PMCID: PMC7923720 DOI: 10.1159/000507424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/22/2020] [Indexed: 01/06/2023] Open
Abstract
Oliguric acute kidney injury due to traumatic rhabdomyolysis can be potentially lethal if the proper medical therapy combined with extracorporeal detoxification is not performed. Different extracorporeal techniques are available to overcome this syndrome. Here, we report the first case of removal of myoglobin and successful recovery from acute kidney injury in an elderly septic patient using supra-hemodiafiltration with endogenous reinfusion technique (HFR-Supra) combined with the medical therapy.
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Affiliation(s)
- Gabriele Donati
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Maria Cappuccilli
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Federica Di Filippo
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Simone Nicoletti
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Marco Ruggeri
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Anna Scrivo
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Angeletti
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology Dialysis and Renal Transplantation Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St Orsola Hospital, University of Bologna, Bologna, Italy
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10
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Challenges of reducing protein-bound uremic toxin levels in chronic kidney disease and end stage renal disease. Transl Res 2021; 229:115-134. [PMID: 32891787 DOI: 10.1016/j.trsl.2020.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 12/11/2022]
Abstract
The prevalence of chronic kidney disease (CKD) in the worldwide population is currently estimated between 11% and 13%. Adequate renal clearance is compromised in these patients and the accumulation of a large number of uremic retention solutes results in an irreversible worsening of renal function which can lead to end stage renal disease (ESRD). Approximately three million ESRD patients currently receive renal replacement therapies (RRTs), such as hemodialysis, which only partially restore kidney function, as they are only efficient in removing mainly small, unbound solutes from the circulation while leaving larger and protein-bound uremic toxins (PBUTs) untouched. The accumulation of PBUTs in patients highly increases the risk of cardiovascular events and is associated with higher mortality and morbidity in CKD and ESRD. In this review, we address several strategies currently being explored toward reducing PBUT concentrations, including clinical and medical approaches, therapeutic techniques, and recent developments in RRT technology. These include preservation of renal function, limitation of colon derived PBUTs, oral sorbents, adsorbent RRT technology, and use of albumin displacers. Despite the promising results of the different approaches to promote enhanced removal of a small percentage of the more than 30 identified PBUTs, on their own, none of them provide a treatment with the required efficiency, safety and cost-effectiveness to prevent CKD-related complications and decrease mortality and morbidity in ESRD.
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11
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Liu Y, Peng X, Hu Z, Yu M, Fu J, Huang Y. Fabrication of a novel nitrogen-containing porous carbon adsorbent for protein-bound uremic toxins removal. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 121:111879. [PMID: 33579500 DOI: 10.1016/j.msec.2021.111879] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/15/2020] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
Protein-bound uremic toxins (PBUTs), the presence of which in the blood is an important risk factor for the progression of chronic kidney disease (CKD), have not been cleared efficiently via traditional hemodialysis methods until now. In this study, biosafe and efficient nitrogen-containing porous carbon adsorbent (NPCA) beads for the clearance of PBUTs were prepared from porous acrylonitrile/divinylbenzene cross-linked copolymer beads followed by pyrolysis. The resulting NPCA beads were characterized via SEM, XPS and nitrogen adsorption/desorption tests. The results demonstrated that the NPCA beads possessed a mesoporous/microporous hierarchical structure with rich nitrogen functional groups on their surfaces and realized efficient PBUTs adsorption in human plasma. More importantly, the efficacy of PBUTs removal was substantially higher than those of commercial adsorbents that are commonly used in clinical uremia treatments. The NPCA beads also exhibited satisfactory removal efficacy towards middle-molecular-weight uremic toxins. The PBUTs removal mechanism of the NPCA beads is ascribed to effective competition between nitrogen-containing NPCA and proteins for PBUT binding. According to hemocompatibility assays, the NPCA beads possessed satisfactory in vitro hemocompatibility. This nitrogen-containing porous carbon adsorbent is an attractive and promising material for blood purification applications in the treatment of clinical uremia.
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Affiliation(s)
- Yunhong Liu
- College of Chemical Engineering and Materials Science, Quanzhou Normal University, Quanzhou 362000, China
| | - Xinyan Peng
- College of Chemical Engineering and Materials Science, Quanzhou Normal University, Quanzhou 362000, China.
| | - Zhudong Hu
- School of Materials Science and Energy Engineering, Foshan University, Foshan 528000, China
| | - Mingguang Yu
- School of Materials Science and Energy Engineering, Foshan University, Foshan 528000, China
| | - Jijun Fu
- School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou 511436, China
| | - Yugang Huang
- School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou 511436, China
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12
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Scaparrotta G, Gobbi L, Calò LA. Switching to HFR Supra resolved refractory itch and quality of life in a chronic dialysis with liver transplant patient. Artif Organs 2020; 45:320-321. [PMID: 33009689 DOI: 10.1111/aor.13811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Giuseppe Scaparrotta
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Laura Gobbi
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Lorenzo A Calò
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine, University of Padova, Padova, Italy
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13
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Chen X, Shen B, Cao X, Xiang F, Zou J, Ding X. Acute effect of one session of hemodiafiltration with endogenous reinfusion on uremic toxins and inflammatory mediators. Int J Artif Organs 2020; 43:437-443. [PMID: 31942823 DOI: 10.1177/0391398819899102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aims: To investigate the acute effects of hemodiafiltration with endogenous infusion on the elimination of uremic toxins and inflammatory mediators in patients with end-stage renal disease. Materials and methods: A total of 37 end-stage renal disease patients undergoing chronic hemodialysis received a single hemodiafiltration with endogenous infusion dialysis treatment. The acute effects of one hemodiafiltration with endogenous infusion session on uremic toxins and inflammatory mediators were assessed by comparing the pre- and post-hemodiafiltration with endogenous infusion concentrations. Results: Hemoglobin and albumin were stable during hemodiafiltration with endogenous infusion therapy. The mean reduction ratios of β2-microglobulin, p-cresyl sulfate, and indoxyl sulfate were 43.60%, 40.91%, and 43.64%, respectively. Tumor necrosis factor-α also decreased significantly at a mean rate of 28.10%, while the concentrations of interleukin-6 and high-sensitivity C-reactive protein remained unchanged after one session of hemodiafiltration with endogenous infusion. Conclusion: The hemodiafiltration with endogenous infusion system is a new dialysis technique that combines diffusion, convection, and adsorption processes. It allows for extensive solute removal, including protein-bound uremic toxins and some pro-inflammatory cytokines, but does not cause nutrient loss and inflammatory response during the treatment. Although the effect after a single hemodiafiltration with endogenous infusion session is limited, it may be improved by repeated and long-term treatment.
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Affiliation(s)
- Xiaohong Chen
- Shanghai Institute of Kidney and Dialysis, Shanghai, China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai, China
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical Center of Kidney, Shanghai, China
| | - Bo Shen
- Shanghai Institute of Kidney and Dialysis, Shanghai, China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai, China
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical Center of Kidney, Shanghai, China
| | - Xuesen Cao
- Shanghai Institute of Kidney and Dialysis, Shanghai, China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai, China
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical Center of Kidney, Shanghai, China
| | - Fangfang Xiang
- Shanghai Institute of Kidney and Dialysis, Shanghai, China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai, China
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical Center of Kidney, Shanghai, China
| | - Jianzhou Zou
- Shanghai Institute of Kidney and Dialysis, Shanghai, China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai, China
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical Center of Kidney, Shanghai, China
| | - Xiaoqiang Ding
- Shanghai Institute of Kidney and Dialysis, Shanghai, China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai, China
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical Center of Kidney, Shanghai, China
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14
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Monzón T, Parodis Y, Valga F, Henríquez F, Antón Pérez G. Uso de HFR-supra para el tratamiento de porfiria cutánea tarda en paciente en hemodiálisis crónica. Nefrologia 2019; 39:216-218. [DOI: 10.1016/j.nefro.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/02/2018] [Indexed: 11/30/2022] Open
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15
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Riccio E, Sabbatini M, Bruzzese D, Grumetto L, Marchetiello C, Amicone M, Andreucci M, Guida B, Passaretti D, Russo G, Pisani A. Plasma p-cresol lowering effect of sevelamer in non-dialysis CKD patients: evidence from a randomized controlled trial. Clin Exp Nephrol 2017; 22:529-538. [PMID: 29159529 DOI: 10.1007/s10157-017-1504-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/31/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The accumulation of p-cresol, a metabolic product of aromatic amino acids generated by intestinal microbiome, increases the cardiovascular risk in chronic kidney disease (CKD) patients. Therefore, therapeutic strategies to reduce plasma p-cresol levels are highly demanded. It has been reported that the phosphate binder sevelamer (SEV) sequesters p-cresol in vitro, while in vivo studies on dialysis patients showed controversial results. Aim of our study was to evaluate the effect of SEV on p-cresol levels in non-dialysis CKD patients. METHODS This was a single-blind, randomized placebo-controlled trial (Registration number NCT02199444) carried on 69 CKD patients (stage 3-5, not on dialysis), randomly assigned (1:1) to receive either SEV or placebo for 3 months. Total p-cresol serum levels were evaluated at baseline (T0), and 1 (T1) and 3 months (T3) after treatment start. The primary end-point was to evaluate the effect of SEV on p-cresol levels. RESULTS Compared to baseline (T0, 7.4 ± 2.7 mg/mL), p-cresol mean concentration was significantly reduced in SEV patients after one (- 2.06 mg/mL, 95% CI - 2.62 to - 1.50 mg/mL; p < 0.001) and 3 months of treatment (- 3.97 mg/mL, 95% CI - 4.53 to - 3.41 mg/mL; p < 0.001); no change of plasma p-cresol concentration was recorded in placebo-treated patients. Moreover, P and LDL values were reduced after 3 months of treatment by SEV but not placebo. CONCLUSIONS In conclusion, our study represents the first evidence that SEV is effective in reducing p-cresol levels in CKD patients in conservative treatment, and confirms its beneficial effects on inflammation and lipid pattern.
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Affiliation(s)
- Eleonora Riccio
- Department of Nephrology, Second University of Naples, Naples, Italy.
| | - Massimo Sabbatini
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Dario Bruzzese
- Chair of Statistics, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Lucia Grumetto
- Department of Pharmacy, School of Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Cristina Marchetiello
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Maria Amicone
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Michele Andreucci
- Unit of Nephrology, Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Bruna Guida
- Division of Physiology, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Davide Passaretti
- Department of Economics and Law, University of Cassino and Southern Lazio, Cassino, Italy
| | - Giacomo Russo
- Department of Pharmacy, School of Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Antonio Pisani
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
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Tessitore N, Poli A, Bedogna V, Corazza L, Campostrini N, Atti M, Sereni L, Castagna A, Girelli D, Pessolano G, Lupo A. A single dialysis session of hemodiafiltration with sorbent-regenerated endogenous ultrafiltrate reinfusion (HFR) removes hepcidin more efficiently than bicarbonate hemodialysis: a new approach to containing hepcidin burden in dialysis patients? J Nephrol 2017; 31:297-306. [PMID: 28353202 DOI: 10.1007/s40620-017-0383-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/22/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Most hemodialysis patients have high Hepcidin-25 levels, which may be involved in the pathogenesis of several uremic complications related to an altered iron biology. The hemodialysis procedure itself can influence Hepcidin-25 levels by removing Hepcidin-25 and maybe stimulating its production due to a pro-inflammatory effect. METHODS To assess the relationship between dialysis-related inflammation and intradialysis changes in Hepcidin-25, we performed a crossover trial in 28 hemodialysis patients to compare the effects on serum levels of Hepcidin-25 and inflammatory markers activated during dialysis [Tumor Necrosis Factor-α (TNF-α), Interleukin-6, C-reactive protein (CRP), Pentraxin-3] of a single dialysis session using a technique capable of reducing inflammation, HFR (Hemo Filtrate Reinfusion: a hemodiafiltration system combining convection, diffusion and adsorption) or bicarbonate-dialysis using either the same low-flux membrane as in the diffusion stage of HFR (LFBD) or a high-flux membrane (HFBD). RESULTS HFR achieved a greater reduction in Hepcidin-25 levels than both LFBD [-72% (95% CI: -11 to -133), p = 0.022] and HFBD [-137% (95% CI: -2 to -272), p = 0.047], conceivably due to both a greater removal (because of its convective/adsorptive component) and a lower inflammation-related Hepcidin-25 production. HFR also led to a greater decrease in TNF-α than LFBD [-277% (95% CI: -59 to -494), p = 0.014], while the two methods induced similar changes in Interleukin-6, CRP and Pentraxin-3 levels. CONCLUSIONS Our findings suggest that a single bicarbonate-dialysis session can upregulate Hepcidin-25 synthesis and that HFR can fully overcome this effect, enabling a greater Hepcidin-25 removal during dialysis. Adequately-designed studies are needed, however, to establish whether the beneficial effect of HFR emerging from our study could reduce Hepcidin-25 (and TNF-α) burden and improve clinically-relevant outcomes. TRIAL REGISTRATION ISRCTN15957905.
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Affiliation(s)
- Nicola Tessitore
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy.
| | - Albino Poli
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Valeria Bedogna
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
| | | | - Natascia Campostrini
- Internal Medicine Section, Department of Medicine, University of Verona, Verona, Italy
| | | | | | - Annalisa Castagna
- Internal Medicine Section, Department of Medicine, University of Verona, Verona, Italy
| | - Domenico Girelli
- Internal Medicine Section, Department of Medicine, University of Verona, Verona, Italy
| | - Giuseppina Pessolano
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Antonio Lupo
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
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Abad S, Vega A, Quiroga B, Arroyo D, Panizo N, Reque JE, López-Gómez JM. Toxinas unidas a proteínas: valor añadido en su eliminación con altos volúmenes convectivos. Nefrologia 2016; 36:637-642. [DOI: 10.1016/j.nefro.2016.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 04/06/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
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18
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Palleschi S, Ghezzi PM, Palladino G, Rossi B, Ganadu M, Casu D, Cossu M, Mattana G, Pinna AM, Contu B, Ghisu T, Monni A, Gazzanelli L, Mereu MC, Logias F, Passaghe M, Amore A, Bolasco P. Vitamins (A, C and E) and oxidative status of hemodialysis patients treated with HFR and HFR-Supra. BMC Nephrol 2016; 17:120. [PMID: 27566671 PMCID: PMC5002141 DOI: 10.1186/s12882-016-0315-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 07/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodiafiltration with on-line endogenous reinfusion (HFR) is an extracorporeal dialytic method that combines diffusion, convection and adsorption. HFR-Supra (HFR-S) is a second-generation system with increased convective permeability and adsorption capability. Previous studies suggested that HFR reduces oxidative stress compared to standard haemodialysis. The principal aim of the present study was to compare antioxidant vitamins behavior and oxidative status of hemodialysis patients treated with HFR and HFR-S. METHODS The study was designed as a multicenter, randomized, crossover trial. Forty-one patients were recruited from 19 dialysis centers and after a 4-month washout stabilization period in on-line hemodiafiltration (ol-HDF), each patient was randomized to a sequence of treatments (HFR-S followed by HFR or viceversa) with each treatment applied over 6 months. Plasma levels of Advanced Oxidation Protein Products, Total Antioxidant Status, vitamins C, A and E and their ligands (Retinol Binding Protein and total lipids) were measured at baseline and at the end of each treatment period. RESULTS Results show that the higher convective permeability of HFR-S with respect to HFR did not produce additional beneficial effects on the patients' oxidative status, a slight decrease of both Vitamin A and Retinol Binding Protein being the only difference registered in the long-term. However, as compared to ol-HDF, both the re-infusive techniques allowed to reduce the intradialytic loss of Vitamin C and, in the long-term, improve the patients' oxidative status and increase Retinol Binding Protein plasma values. No significant differences were found between the Vitamin C concentration of pre- and post cartridge UF neither in HFR-S nor in HFR showing that the sorbent resin does not adsorb Vitamin C. CONCLUSION HFR-S and HFR are almost equivalent in term of impact on antioxidant vitamins and oxidative status of hemodialysis patients. Nonetheless, as compared to ol-HDF, both treatments produced a sensible sparing of Vitamin C and may represent a new approach for reducing oxidative stress and related complications in dialysis patients. Long-term effects of re-infusive treatments on patients' cardiovascular morbidity and mortality need to be evaluated. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01492491 , retrospectively registered in 10 December 2011.
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Affiliation(s)
- Simonetta Palleschi
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Paolo M. Ghezzi
- Medical Scientific Consultant of Bellco s.r.l. Company, Mirandola, Italy
| | | | - Barbara Rossi
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Piergiorgio Bolasco
- Territorial Unit of Nephrology and Dialysis , ASL 8 of Cagliari, Cagliari, Italy
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Esquivias-Motta E, Martín-Malo A, Buendia P, Álvarez-Lara MA, Soriano S, Crespo R, Carracedo J, Ramírez R, Aljama P. Hemodiafiltration With Endogenous Reinfusion Improved Microinflammation and Endothelial Damage Compared With Online-Hemodiafiltration: A Hypothesis Generating Study. Artif Organs 2016; 41:88-98. [DOI: 10.1111/aor.12704] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 12/28/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Elvira Esquivias-Motta
- Nephrology Unit, Reina Sofía University Hospital; Córdoba
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
| | - Alejandro Martín-Malo
- Nephrology Unit, Reina Sofía University Hospital; Córdoba
- Instituto de Salud Carlos III (RETICs Red Renal); Madrid
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
| | - Paula Buendia
- Instituto de Salud Carlos III (RETICs Red Renal); Madrid
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
| | - Maria A Álvarez-Lara
- Nephrology Unit, Reina Sofía University Hospital; Córdoba
- Instituto de Salud Carlos III (RETICs Red Renal); Madrid
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
| | - Sagrario Soriano
- Nephrology Unit, Reina Sofía University Hospital; Córdoba
- Instituto de Salud Carlos III (RETICs Red Renal); Madrid
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
| | - Rodolfo Crespo
- Nephrology Unit, Reina Sofía University Hospital; Córdoba
| | - Julia Carracedo
- Instituto de Salud Carlos III (RETICs Red Renal); Madrid
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
| | - Rafael Ramírez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
- Biologia de Sistemas Department; Alcala de Henares University; Madrid Spain
| | - Pedro Aljama
- Nephrology Unit, Reina Sofía University Hospital; Córdoba
- Instituto de Salud Carlos III (RETICs Red Renal); Madrid
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Fundación de Investigaciones Biomédicas de Córdoba (FIBICO); Córdoba
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Solano FG, Bellei E, Cuoghi A, Caiazzo M, Bruni F. Radical improvement of signs and symptoms in systemic lupus erythematosus when treated with hemodiafiltration with endogenous reinfusion dialysis. Case Rep Nephrol Dial 2015; 5:106-12. [PMID: 26034748 PMCID: PMC4448051 DOI: 10.1159/000381395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Lupus nephritis is one of the most serious complications of systemic lupus erythematosus (SLE). In the kidney, immune complexes and autoantibodies activate mesangial cells that secrete cytokines that can further amplify inflammatory processes. We present the case of a 42-year-old woman with lupus nephritis accompanied by periods of exacerbation of SLE, with necrotic-like skin lesions, psoriatic arthritis without skin psoriasis, purpura of the lower limb, petechial rash, joint pain, fever, eyelid edema with bilateral conjunctival hyperemia and itching. The patient underwent a dialytic treatment of hemodiafiltration with endogenous reinfusion. The technique uses the super-high-flux membrane Synclear 02 (SUPRA treatment) coupled with an adsorbent cartridge that has affinity for many toxins and mediators. Fever and joint pain were immediately reduced after treatment and, subsequently, there was a notable reduction of the skin damage. Prednisone and immunosuppressive drugs were gradually reduced until complete suspension. High-performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometer was performed for identification of proteins captured by a resin bed during a dialysis session of the patient. This technique identified several biomarkers of kidney injuries, uremic toxins, fragments of immunoglobulins, antigens involved in antiphospholipid syndrome and a new marker (α-defensin) that correlated significantly with disease activity. The removal of these different proteins could possibly provide an explanation of the improvement in the patient's symptoms and the normalization of her SLE. SUPRA coupled with an adsorption may be a promising new technique for the treatment of lupus nephritis.
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Affiliation(s)
| | - Elisa Bellei
- Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena ; Science and Technology Park for Medicine-TMP, Democenter Foundation, Italy
| | - Aurora Cuoghi
- Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena ; Science and Technology Park for Medicine-TMP, Democenter Foundation, Italy
| | | | - Francesco Bruni
- Nephrology and Dialysis, Civil Hospital Madonna del Soccorso, San Benedetto del Tronto
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Sabatino A, Regolisti G, Brusasco I, Cabassi A, Morabito S, Fiaccadori E. Alterations of intestinal barrier and microbiota in chronic kidney disease. Nephrol Dial Transplant 2014; 30:924-33. [PMID: 25190600 DOI: 10.1093/ndt/gfu287] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 08/04/2014] [Indexed: 12/27/2022] Open
Abstract
Recent studies have highlighted the close relationship between the kidney and the gastrointestinal (GI) tract--frequently referred to as the kidney--gut axis--in patients with chronic kidney disease (CKD). In this regard, two important pathophysiological concepts have evolved: (i) production and accumulation of toxic end-products derived from increased bacterial fermentation of protein and other nitrogen-containing substances in the GI tract, (ii) translocation of endotoxins and live bacteria from gut lumen into the bloodstream, due to damage of the intestinal epithelial barrier and quantitative/qualitative alterations of the intestinal microbiota associated with the uraemic milieu. In both cases, these gut-centred alterations may have relevant systemic consequences in CKD patients, since they are able to trigger chronic inflammation, increase cardiovascular risk and worsen uraemic toxicity. The present review is thus focused on the kidney-gut axis in CKD, with special attention to the alterations of the intestinal barrier and the local microbiota (i.e. the collection of microorganisms living in a symbiotic coexistence with their host in the intestinal lumen) and their relationships to inflammation and uraemic toxicity in CKD. Moreover, we will summarize the most important clinical data suggesting the potential for nutritional modulation of gut-related inflammation and intestinal production of noxious by-products contributing to uraemic toxicity in CKD patients.
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Affiliation(s)
- Alice Sabatino
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Regolisti
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Hospital, Parma, Italy
| | - Irene Brusasco
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Hospital, Parma, Italy
| | - Aderville Cabassi
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Hospital, Parma, Italy
| | - Santo Morabito
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Hospital, Parma, Italy
| | - Enrico Fiaccadori
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Hospital, Parma, Italy
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