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Schiffl H. Innovations of renal replacement techniques at the intersection of clinical trial and real-world data. Int Urol Nephrol 2024; 56:1195-1196. [PMID: 37581689 PMCID: PMC10853322 DOI: 10.1007/s11255-023-03738-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Helmut Schiffl
- Department of Medicine IV, Hospital of the LMU Munich, Ziemssenstr. 3, 80336, Munich, Germany.
- Medizinische Klinik und Poliklinik IV, Universitätsklinikum der LMU München, Ziemssenstr. 3, 80336, Munich, Germany.
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Zakrzewska A, Biedunkiewicz J, Komorniczak M, Jankowska M, Jasiulewicz K, Płonka N, Biedunkiewicz B, Małgorzewicz S, Tarasewicz A, Puchalska-Reglińska E, Siebert J, Dębska-Ślizień A, Tylicki L. Intradialytic Tolerance and Recovery Time in Different High-Efficiency Hemodialysis Modalities. J Clin Med 2024; 13:326. [PMID: 38256460 PMCID: PMC10816973 DOI: 10.3390/jcm13020326] [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: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
There are several forms of maintenance high-efficiency hemodialysis (HD), including hemodiafiltrations (HDF) in different technical modes and expanded HD, using dialyzers with medium cut-off membranes. The aim of the study was to assess the intradialytic tolerance and length of dialysis recovery time (DRT) in these modalities. This is an exploratory, crossover study in maintenance HD patients with low comorbidity and no clinical indications for the use of high-efficiency HD, who were exposed to five intermittent dialyses in random order: high-flux hemodialysis (S-HD), expanded HD (HDx), pre-dilution HDF (PRE-HDF), mix-dilution HDF (MIX-HDF) and post-dilution HDF (POST-HDF). Twenty-four dialysis sessions of each method were included in the analysis. Dialysis parameters, including blood flow rate, dialysis fluid flow rate and temperature, and pharmacological treatment were constant. Average total convection volume for post-HDF, pre-HDF and mix-HDF were 25.6 (3.8), 61.5 (7.2) and 47.1 (11.4) L, respectively. During all therapies, patients were monitored for the similarity of their hydration statuses using bioimpedance spectroscopy, and for similar variability over time in systemic blood pressure and cardiac output, while peripheral resistance was monitored using impedance cardiography. The lowest frequency of all intradialytic adverse events were observed during HDx. Delayed DRT was the shortest during PRE-HDF. Patients were also more likely to report immediate recovery while receiving PRE-HDF. These differences did not reach statistical significance; however, the study results suggest that intradialytic tolerance and DRT may depend on the dialysis method used. This supports the need of taking into account patient preferences and quality of life while individualizing high-efficiency therapy in HD patients.
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Affiliation(s)
- Agnieszka Zakrzewska
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Jan Biedunkiewicz
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Michał Komorniczak
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Magdalena Jankowska
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Katarzyna Jasiulewicz
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Natalia Płonka
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Bogdan Biedunkiewicz
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Sylwia Małgorzewicz
- Department of Clinical Nutrition, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
| | - Agnieszka Tarasewicz
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | | | - Janusz Siebert
- Department of Family Medicine, University Center for Cardiology, Medical University of Gdansk, 80-211 Gdansk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
| | - Leszek Tylicki
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland (M.K.); (M.J.); (K.J.); (B.B.)
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Cho AJ, Park HC, Kim DH, Choi HB, Song GH, Kim H, Kim SH, Choi G, Kim JK, Song YR, Yoon JW, Lee YK. Impact of needle type on substitution volume during online hemodiafiltration: plastic cannulae versus metal needles. Kidney Res Clin Pract 2023; 42:117-126. [PMID: 36328989 PMCID: PMC9902740 DOI: 10.23876/j.krcp.21.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/17/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Plastic cannulae have attracted increasing interest as an alternative to traditional metal needles with the aim of reducing cannulation-related complications. We investigated whether the substitution volumes during hemodiafiltration differ using these two types of needles in dialysis patients. METHODS An intervention study involving 26 hemodialysis patients was conducted in Korea between March and September in 2021. Patients first received online hemodiafiltration using traditional metal needles, and thereafter plastic cannulae were used in a stepwise protocol. Repeated-measures design and linear mixed-effect models were used to compare substitution volumes between the two needle types with the same inner diameter. RESULTS The mean patient age was 62.7 years, and their mean dialysis vintage was 95.2 months. Most patients (92.3%) had an arteriovenous fistula as the vascular access. The substitution volume increased as blood flow and needle size increased for both plastic cannulae and metal needles. The substitution volume was significantly higher with 17-gauge (G) plastic cannulae than with 16-G metal needles at blood flow rates of 280, 300, and 330 mL/min. Similar results were obtained for 15-G metal needles and 16-G plastic cannulae at a blood flow rate of 330 mL/min. However, the patient ratings of pain on a visual analogue scale were higher for plastic cannulae. CONCLUSION Higher substitution volumes were obtained at the same prescribed blood flow rate with plastic cannulae than with metal needles during online hemodiafiltration. Plastic cannulae are an option for achieving high-volume hemodiafiltration for patients with low blood flow rates.
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Affiliation(s)
- AJin Cho
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Do Hyoung Kim
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Han Byul Choi
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Gi Hyun Song
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Hyunsuk Kim
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Seok-hyung Kim
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Gwangho Choi
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Young Rim Song
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Jong-Woo Yoon
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea,Jong-Woo Yoon Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon 24253, Republic of Korea. E-mail:
| | - Young-Ki Lee
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea,Hallym University Kidney Research Institute, Seoul, Republic of Korea,Correspondence: Young-Ki Lee Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea. E-mail:
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Dellepiane S, Marengo M, D'Arezzo M, Donati G, Fabbrini P, Lacquaniti A, Ronco C, Cantaluppi V. The Next Evolution of HemoDialysis eXpanded: From a Delphi Questionnaire-Based Approach to the Real Life of Italian Dialysis Units. Blood Purif 2022; 51:943-952. [PMID: 35231902 PMCID: PMC9808684 DOI: 10.1159/000522038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/17/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Impact assessment of new technologies in chronic hemodialysis (HD) is challenging due to HD patient frailty, the complexity of HD clinical trials and practice variability among countries. Among the most recent HD innovations, medium cut-off (MCO) dialyzers present an optimized membrane geometry that provides enhanced clearances for middle and large molecular weight uremic toxins (UT). These toxins are poorly cleared by available HD techniques and largely contribute to patient morbidity and mortality. The aim of this paper is to assess the available clinical evidence about MCO membranes and to identify the next steps needed to generate conclusive data on their use in HD. METHODS With this purpose, we first reviewed and compared the current HD technologies aimed to improve the clearance of middle and large UT; subsequently, we used a Delphi questionnaire to identify and discuss the consensus about MCO efficacy within a large sample of the Italian Nephrology community. RESULTS AND CONCLUSIONS Our investigation gathered a significant degree of consensus on the beneficial role of MCO membrane and expanded HD. Finally, we used our results to propose future trial designs and clinical investigations aimed to improve evidence quality about the use of these membranes in the present clinical scenario of dialysis units.
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Affiliation(s)
- Sergio Dellepiane
- Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Mario D'Arezzo
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti − Ancona University Hospital, Ancona, Italy
| | - Gabriele Donati
- Nephrology Dialysis and Renal Transplantation Unit, St. Orsola University Hospital, Bologna, Italy
| | - Paolo Fabbrini
- Nephrology and Dialysis Unit, San Gerardo Hospital and Milano Bicocca University, Monza, Italy
| | | | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy,Division of Nephrology, Dialysis and Kidney Transplantation Unit, International Renal Research Institute Vicenza (IRRIV), “San Bortolo” Hospital, Vicenza, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), “Maggiore della Carità” University Hospital, Novara, Italy,*Vincenzo Cantaluppi,
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Shin SK, Jo YI. Why should we focus on high-volume hemodiafiltration? Kidney Res Clin Pract 2022; 41:670-681. [PMID: 35286790 PMCID: PMC9731779 DOI: 10.23876/j.krcp.21.268] [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: 11/14/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 07/26/2024] Open
Abstract
Though noticeable technological advances related to hemodialysis (HD) have been made, unfortunately, the survival rate of dialysis patients has yet to improve significantly. However, recent research findings reveal that online hemodiafiltration (HDF) significantly improves patient survival in comparison to conventional HD. Accordingly, the number of patients receiving online HDF is increasing. Although the mechanism driving the benefit has not yet been fully elucidated, survival advantages are mainly related to the lowering of cardiovascular mortality. High cardiovascular mortality among HD patients is seemingly attributable to the cardiovascular changes that occur in response to renal dysfunction and the HD-induced myocardial stress and injury, and online HDF appears to improve such secondary cardiovascular changes. Interestingly, patient survival improves only if the convection volume is supplied sufficiently over a certain level during online HDF treatment. In other words, survival improvement from online HDF is related to convection volume. Therefore, there is a growing interest in high-volume HDF in terms of improving the survival rate. The survival improvement will require a minimum convection volume of 23 L or more per 4-hour session for postdilution HDF. To obtain an optimal high convection volume in online HDF, several factors, such as the treatment time, blood flow rate, filtration fraction, and dialyzer, need to be considered. High-volume HDF can be performed easily and safely in routine clinical practice. Therefore, when the required equipment is available, performing high-volume HDF will help to improve the survival rate of dialysis patients.
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Affiliation(s)
- Sug-Kyun Shin
- Division of Nephrology, Department of Internal Medicine, NHIS Ilsan Hospital, Goyang, Republic of Korea
| | - Young-Il Jo
- Division of Nephrology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
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Murea M, Flythe JE, Anjay R, Emaad ARM, Gupta N, Kovach C, Vachharajani TJ, Kalantar-Zadeh K, Casino FG, Basile C. Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one. Curr Opin Nephrol Hypertens 2022; 31:92-99. [PMID: 34846314 DOI: 10.1097/mnh.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group. RECENT FINDINGS Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy. SUMMARY Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Rastogi Anjay
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdel-Rahman M Emaad
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Nupur Gupta
- Indiana University Health, Indianapolis, Indiana
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti
- Dialysis Centre SM2, Policoro, Italy
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Ficociello LH, Busink E, Sawin D, Winter A. Global real-world data on hemodiafiltration: An opportunity to complement clinical trial evidence. Semin Dial 2022; 35:440-445. [PMID: 35439847 PMCID: PMC9790215 DOI: 10.1111/sdi.13085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 12/30/2022]
Abstract
Hemodiafiltration (HDF) is a renal replacement therapy that utilizes both diffusive clearance and convective transport to achieve greater clearance of middle-molecular-weight solutes. Among other factors, important prerequisites for the implementation of HDF include access to high-flux dialyzers, achievement of high blood flow rates, and availability of high volumes of sterile substitution/replacement fluids. Online hemodiafiltration (OL-HDF) is an established kidney replacement therapy, frequently used in many countries. Although in the United States, some prerequisites (e.g., access to high-flux dialyzers and achievement of high blood flow rates) for OL-HDF treatment are readily available; however, a machine capable of generating the online solution for OL-HDF is currently not available. As the clinical experience with HDF accumulates globally, it is worth examining the evidence for this kidney replacement therapy as used in routine clinical care. Such real-world evidence is increasingly recognized as valuable by clinicians and may inform regulatory decisions. In this review, we will focus on emerging global real-world data derived from routine clinical practices and examine how these data may complement those derived from clinical trials.
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Affiliation(s)
| | - Ellen Busink
- Health Economics, Market Access and Political Affairs EMEAFresenius Medical Care Deutschland GmbHBad HomburgGermany
| | | | - Anke Winter
- Global Medical OfficeFresenius Medical CareBad HomburgGermany
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8
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Canaud B, Blankestijn PJ, Grooteman MPC, Davenport A. Why and how high volume hemodiafiltration may reduce cardiovascular mortality in stage 5 chronic kidney disease dialysis patients? A comprehensive literature review on mechanisms involved. Semin Dial 2021; 35:117-128. [PMID: 34842306 DOI: 10.1111/sdi.13039] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
Online hemodiafiltration (HDF) is an established renal replacement modality for patients with end stage chronic kidney disease that is now gaining rapid clinical acceptance worldwide. Currently, there is a growing body of evidence indicating that treatment with HDF is associated with better outcomes and reduced cardiovascular mortality for dialysis patients. In this comprehensive review, we provide an update on the potential mechanisms which may improve survival in HDF treated patients. The strongest evidence is for better hemodynamic stability and reduced endothelial dysfunction associated with HDF treatments. Clinically, this is marked by a reduced incidence of intradialytic hypotensive episodes, with a better hemodynamic response to ultrafiltration, mediated by an increase in total peripheral vascular resistance and extra-vascular fluid recruitment, most likely driven by the negative thermal balance associated with online HDF therapy. In addition, endothelial function appears to be improved due to a combination of a reduction of the inflammatory and oxidative stress complex syndrome and exposure to circulating cardiovascular uremic toxins. Reports of reversed cardiovascular remodeling effects with HDF may be confounded by volume and blood pressure management, which are strongly linked to center clinical practices. Currently, treatment with HDF appears to improve the survival of dialysis patients predominantly due to a reduction in their cardiovascular burden, and this reduction is linked to the sessional convection volume exchanged.
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Affiliation(s)
- Bernard Canaud
- Department of Nephrology, Montpellier University, Montpellier, France.,Global Medical Office, FMC, Deutschland, Bad Homburg, Germany
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Muriel P C Grooteman
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital. University College London, London, UK
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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10
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Park HC, Lee YK. Who is the winner, pre-, post-, or mixed-dilution hemodiafiltration? Kidney Res Clin Pract 2021; 40:332-334. [PMID: 34510854 PMCID: PMC8476302 DOI: 10.23876/j.krcp.21.172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hayne Cho Park
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Republic of Korea
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Park KS, Kang EW, Chang TI, Jo W, Park JT, Yoo TH, Kang SW, Han SH. Mixed versus predilution hemodiafiltration effects on convection volume and small and middle molecule clearance in hemodialysis patients: a prospective randomized controlled trial. Kidney Res Clin Pract 2021; 40:445-456. [PMID: 34370930 PMCID: PMC8476308 DOI: 10.23876/j.krcp.21.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/31/2021] [Indexed: 12/05/2022] Open
Abstract
Background The use of newly developed mixed-dilution hemodiafiltration (HDF) can supplement the weaknesses of pre- and postdilution HDF. However, it is unclear whether mixed-HDF performs well compared to predilution HDF. Methods We conducted a prospective, open-labeled, randomized controlled trial from two hemodialysis centers in Korea. Between January 2017 and September 2019, 60 patients who underwent chronic hemodialysis were randomly assigned at a 1:1 ratio to receive either predilution HDF (n = 30) or mixed-HDF (n = 30) for 6 months. We compared convection volume, changes in small- and medium-sized molecule clearance, high-sensitive C-reactive protein (hs-CRP) level, and dialysis-related parameters between the two dialysis modalities. Results A mean effective convection volume of 41.0 ± 10.3 L/session in the predilution HDF group and 51.5 ± 9.0 L/session in the mixed-HDF group was obtained by averaging values of three time-points. The difference in effective convection volume between the groups was 10.5 ± 1.3 L/session. This met the preset noninferiority criteria, suggesting that mixed-HDF was noninferior to predilution HDF. Moreover, the β2-microglobulin reduction rate was greater in the mixed-HDF group than in the predilution HDF group, while mixed-HDF provided greater transmembrane pressure. There were no significant between-group differences in Kt/V urea levels, changes in predialysis hs-CRP levels, proportions of overhydration, or blood pressure values. Symptomatic intradialytic hypotension episodes and other adverse events occurred similarly in the two groups. Conclusion Use of mixed-HDF was comparable to predilution HDF in terms of delivered convection volume and clinical parameters. Moreover, mixed-HDF provided better β2-microglobulin clearance than predilution HDF.
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Affiliation(s)
- Kyoung Sook Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ea Wha Kang
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Wonji Jo
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
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12
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Lee Y, Jang MJ, Jeon J, Lee JE, Huh W, Choi BS, Park CW, Chin HJ, Kang CL, Kim DK, Han SS, Joo KW. Cardiovascular Risk Comparison between Expanded Hemodialysis Using Theranova and Online Hemodiafiltration (CARTOON): A Multicenter Randomized Controlled Trial. Sci Rep 2021; 11:10807. [PMID: 34031503 PMCID: PMC8144214 DOI: 10.1038/s41598-021-90311-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022] Open
Abstract
Expanded hemodialysis (HDx) with medium cutoff (MCO) membranes, which remove middle-to-large molecules well, may be a good option to replace online hemodiafiltration (online-HDF). To provide more evidence, this randomized controlled trial compared several cardiovascular parameters between patients undergoing HDx and online-HDF. Eighty patients undergoing thrice-weekly hemodialysis were randomly assigned to receive either HDx with a Theranova membrane (n = 43) or online-HDF (n = 37). The primary endpoints were changes in brachial-ankle pulse wave velocity (baPWV), echocardiographic parameters, and coronary artery calcium (CAC) scores over 1 year, and the secondary endpoints included blood cardiovascular biomarkers, mortality, and patient-reported outcomes. A linear mixed model and log-rank test were used to estimate the group differences. 65 patients had completed the trial. The changes in baPWV and echocardiographic parameters did not differ between the two groups. The CAC scores remained stable in the online-HDF group, whereas an increasing trend was shown in the HDx group (P = 0.012). Other endpoints, including cardiovascular and all-cause mortalities, were similar between the two groups. The changes in cardiovascular parameters did not differ between HDx with an MCO membrane and online-HDF. However, attention may be needed in patients with high CAC scores or scores with an increasing tendency when online-HDF is replaced with HDx with an MCO membrane.
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Affiliation(s)
- Yeonhee Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Myoung-Jin Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
| | - Chae Lin Kang
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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13
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Kim DH, Lee YK, Park HC, Kim J, Yun KS, Cho AJ, Noh JW, Kim H, Kim SH, Yoon JW. Stepwise achievement of high convection volume in post-dilution hemodiafiltration: A prospective observational study. Semin Dial 2021; 34:368-374. [PMID: 33774852 DOI: 10.1111/sdi.12966] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 03/01/2021] [Indexed: 12/28/2022]
Abstract
High-volume online hemodiafiltration (HDF) has been reported to reduce the patient's mortality. However, achieving a high convection volume is challenging. In this prospective study, we investigated the feasibility of achieving high-volume HDF with ≥21 L substitution volume via modification of blood flow rate (BFR), needle size, and dialysis membrane. In 30 patients undergoing hemodialysis, we followed a stepwise protocol and gradually increased the BFR (280→300→330 ml/min; steps 1, 2, and 3) and needle size (16→15 G; step 4). After changing dialyzer surface area (1.8 m2 →2.5 m2 ), the BFR and needle size were similarly increased stepwise (steps 5, 6, 7, and 8). The mean substitution volume was 18.7 ± 2.2 L at step 1 and it significantly increased to 25.1 ± 2.6 L by step 8. A substitution volume of 21 L was achieved by 13.3% of patients in step 1 and by 96.7% after step 8. The substitution volume was higher for the dialyzer with a large surface area and for the larger needle (15 G). Between steps 1 and 8, the Kt/V and β2 microglobulin reduction ratios also improved significantly. High-volume HDF is feasible through a stepwise increase in the BFR, needle size, and surface area of the dialysis membrane.
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Affiliation(s)
- Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Juhee Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Kyu Sang Yun
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung-Woo Noh
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyunsuk Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Seok-Hyung Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jong-Woo Yoon
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
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14
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Rambabova Bushljetik I, Trajceska L, Biljali S, Balkanov T, Dejanov P, Spasovski G. Efficacy of Medium Cut-Off Dialyzer and Comparison with Standard High-Flux Hemodialysis. Blood Purif 2020; 50:492-498. [PMID: 33291102 DOI: 10.1159/000511983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND A new medium cut-off (MCO) membranes has been designed to achieve better removal capacities for middle and large middle molecules in hemodialysis (HD) treatment. AIM The aim of this study was to evaluate the removal efficacy of Theranova® in standard HD in comparison with standard high-flux HD. METHODS Four HD patients (M/F 1/4) were included in 12-week observational pilot study in HD with Theranova® 400 and Theranova® 500 dialyzers. Each patient was assessed 4 times, T0 with high-flux dialyzers, T1 at 1 month, T2 at second month, and T3 at third month, by measuring pre- and post-HD samples of urea, Cr, β2-microglobilin (β2M), myoglobin, albumin, free light chains kappa (FLC-k), and free light chains lambda (FLC-λ). RESULTS The data showed a higher average removal rate for all the uremic toxins with Theranova® dialyzers for β2M, myoglobin, FLC-k, and FLC-λ (62.7, 56.9, 63.5, and 54.6%, respectively) during the 3 months. Albumin retention was observed and did not change between T0 and T3 (p = 0.379). CONCLUSION Compared to high-flux membranes, MCO membranes show greater permeability for middle molecules in midterm report.
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Affiliation(s)
| | - Lada Trajceska
- University Clinic for Nephrology, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Sefedin Biljali
- Clinical Biochemistry, University Ss. Cyril and Methodius Skopje, Skopje, North Macedonia
| | - Trajan Balkanov
- Institute of Clinical Pharmacology, University Ss. Cyril and Methodius Skopje, Skopje, North Macedonia
| | - Petar Dejanov
- University Clinic for Nephrology, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Goce Spasovski
- University Clinic for Nephrology, University Ss. Cyril and Methodius, Skopje, North Macedonia
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15
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Huang C, Ren J, Ji F, Muyldermans S, Jia L. Nanobody-Based high-performance immunosorbent for selective beta 2-microglobulin purification from blood. Acta Biomater 2020; 107:232-241. [PMID: 32092428 DOI: 10.1016/j.actbio.2020.02.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 12/18/2022]
Abstract
Removing β2-microglobulin (β2M) from blood circulation is considered to be the most effective method to delay the occurrence of dialysis-related amyloidosis (DRA). The ideal extracorporeal β2M removal system should be cost-effective, highly specific and having a high capacity. However, the traditional technologies based on size exclusion do not have an adequate specificity, and alternative immunosorbents have limited applications due to low capacity and their high cost. Nanobodies (Nbs), the smallest functional recombinant antibody fragments, offer several advantages to overcome these obstacles. In this study, an anti-β2M Nb with a C-terminal thiol-tag was successfully prepared from E. coli for site-directed and oriented immobilization and usage as capture ligand in a β2M-selective immunosorbent. The prepared immunosorbent showed a high binding capacity of up to 7 mg β2M per mL resin, which is 17 times higher than that of previous studies using single-chain variable antibody fragments (scFv). Furthermore, an exceptional high specificity has been demonstrated as other human serum proteins were not adsorbed during dynamic adsorption experiments. About 80% of the original binding capacity of the immunosorbent was restored after four consecutive easy regenerations, whereas 90% of the original capacity was retained after 1-month storage of the resin. Moreover, the mathematical model fitted very well the in vitro perfusion. The results with this pioneering immunosorbent confirm its possible clinical application and is expected to reach the required clinical effect of immunoadsorption therapy. STATEMENT OF SIGNIFICANCE: Dialysis-related amyloidosis (DRA), associated with the accumulation of β2-microglobulin (β2M), is a serious complication of end-stage kidney disease. Removing β2M from blood circulation by extracorporeal blood purification is considered to be the most effective method to delay the occurrence of DRA. However, the existing methods are incapable to eliminate sufficient quantities of β2M from circulation, either because of lack of specificity, high cost or for low capacity. In this manuscript, we provide a practical and economic immunosorbent based on anti-β2M nanobody for DRA. The prepared immunosorbent was reusable and storable, and demonstrated high specificity and realized a high binding capacity of up to 7 mg β2M per mL resin, which is 17 times higher than that of the previous studies.
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16
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Kim TH, Kim SH, Kim TY, Park HY, Jung KS, Lee MH, Jhee JH, Lee JE, Choi HY, Park HC. Removal of large middle molecules via haemodialysis with medium cut-off membranes at lower blood flow rates: an observational prospective study. BMC Nephrol 2019; 21:2. [PMID: 31892319 PMCID: PMC6937993 DOI: 10.1186/s12882-019-1669-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Online haemodiafiltration (OL-HDF) may improve middle molecular clearance in contrast to conventional haemodialysis (HD). However, OL-HDF requires higher convective flows and cannot sufficiently remove large middle molecules. This study evaluated the efficacy of a medium cut-off (MCO) dialyser in removing large middle molecular uraemic toxins and compared it with that of conventional high-flux (HF) dialysers in HD and predilution OL-HDF. Methods Six clinically stable HD patients without residual renal function were investigated. Dialyser and treatment efficacies were examined during a single midweek treatment in three consecutive periods: 1) conventional HD using an HF dialyser, 2) OL-HDF using the same HF dialyser, and 3) conventional HD using an MCO dialyser. Treatment efficacy was assessed by calculating the reduction ratio (RR) for β2-microglobulin (β2M), myoglobin, κ and λ free light chains (FLCs), and fibroblast growth factor (FGF)-23 and measuring clearance for FLCs. Results All three treatments showed comparable RRs for urea, phosphate, creatinine, and uric acid. MCO HD showed greater RRs for myoglobin and λFLC than did HF HD and predilution OL-HDF (myoglobin: 63.1 ± 5.3% vs. 43.5 ± 8.9% and 49.8 ± 7.3%; λFLC: 43.2 ± 5.6% vs. 26.8 ± 4.4% and 33.0 ± 9.2%, respectively; P < 0.001). Conversely, predilution OL-HDF showed the greatest RR for β2M, whereas MCO HD and HF HD showed comparable RRs for β2M (predilution OL-HDF vs. MCO HD: 80.1 ± 4.9% vs. 72.6 ± 3.8%, P = 0.01). There was no significant difference among MCO HD, HF HD, and predilution OL-HDF in the RRs for κFLC (63.2 ± 6.0%, 53.6 ± 15.5%, and 61.5 ± 7.0%, respectively; P = 0.37), and FGF-23 (55.5 ± 20.3%, 34.6 ± 13.1%, and 35.8 ± 23.2%, respectively; P = 0.13). Notably, MCO HD showed improved clearances for FLCs when compared to HF HD or OL-HDF. Conclusions MCO HD showed significantly greater RR of large middle molecules and achieved improved clearance for FLCs than conventional HD and OL-HDF, without the need for large convection volumes or high blood flow rates. This would pose as an advantage for elderly HD patients with poor vascular access and HD patients without access to OL-HDF. Trial registration Clinical Research Information Service (CRIS): KCT 0003009. The trial was prospectively registered on the 21 Jul 2018.
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Affiliation(s)
- Tae Hoon Kim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, 17046, Republic of Korea
| | - Seok-Hyung Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, 24253, Republic of Korea
| | - Tae Yeon Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Hae Yeul Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Kwon Soo Jung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Moon Hyoung Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jong Hyun Jhee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jung Eun Lee
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, 17046, Republic of Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea.,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Hyeong Cheon Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea. .,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.
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