1
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Karabelas AJ. On the total albumin losses during haemocatharsis. J Artif Organs 2024; 27:91-99. [PMID: 38238597 PMCID: PMC11126488 DOI: 10.1007/s10047-023-01430-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/16/2023] [Indexed: 05/26/2024]
Abstract
Excessive albumin losses during HC (haemocatharsis) are considered a potential cause of hypoalbuminemia-a key risk factor for mortality. This review on total albumin losses considers albumin "leaking" into the dialysate and losses due to protein/membrane interactions (i.e. adsorption, "secondary membrane formation" and denaturation). The former are fairly easy to determine, usually varying at the level of ~ 2 g to ~ 7 g albumin loss per session. Such values, commonly accepted as representative of the total albumin losses, are often quoted as limits/standards of permissible albumin loss per session. On albumin mass lost due to adsorption/deposition, which is the result of complicated interactions and rather difficult to determine, scant in vivo data exist and there is great uncertainty and confusion regarding their magnitude; this is possibly responsible for neglecting their contribution to the total losses at present. Yet, many relevant in vitro studies suggest that losses of albumin due to protein/membrane interactions are likely comparable to (or even greater than) those due to leaking, particularly in the currently favoured high-convection HDF (haemodiafiltration) treatment. Therefore, it is emphasised that top research priority should be given to resolve these issues, primarily by developing appropriate/facile in vivo test-methods and related analytical techniques.
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Affiliation(s)
- Anastasios J Karabelas
- Chemical Process and Energy Resources Institute, Centre for Research and Technology-Hellas, 6th Km Charilaou - Thermi Road, Thermi - Thessaloniki, GR 57001, Greece.
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2
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Tashiro M, Okada K, Tanaka Y, Michiwaki H, Shima H, Inoue T, Doi T, Minakuchi J. Impact of Albumin Leakage on the Mortality of Patients Receiving Hemodialysis or Online Hemodiafiltration. J Clin Med 2024; 13:1865. [PMID: 38610630 PMCID: PMC11012308 DOI: 10.3390/jcm13071865] [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: 02/21/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Online hemodiafiltration (OHDF) has a lower mortality rate than hemodialysis (HD). We aimed to investigate the impact of the albumin leakage on the mortality of patients receiving HD or OHDF. Methods: In this single-center study, consecutive patients receiving renal replacement therapy between January and April 2018 were retrospectively registered. Using (1:1) propensity score matching, 3-year all-cause mortality was compared between patients receiving HD and OHDF, and the impact of albumin leakage on the mortality rate in both groups was investigated. Results: Of the 460 patients, 137 patients receiving HD were matched with an equal number of patients receiving OHDF. OHDF was associated with higher albumin leakage (p < 0.001) and a lower mortality than HD (log-rank test, p < 0.001). Albumin leakage was associated with mortality in patients receiving HD (per 1 g increase, hazard ratio (HR): 0.495, 95% confidence interval (CI): 0.275-0.888) and patients receiving OHDF (per 1 g increase, HR: 0.734, 95% CI: 0.588-0.915). Patients receiving HD, with the highest albumin leakage tertile (>3 g), had a similar mortality rate to patients receiving OHDF, with similar albumin leakage. Conclusions: The negative relationship between albumin leakage and mortality suggests the benefit of removing middle- to -large-molecular-weight substances to improve survival.
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Affiliation(s)
- Manabu Tashiro
- Department of Nephrology, Kawashima Hospital, 6-1 Kitasakoichiban-Cho, Tokushima-City 770-0011, Japan; (K.O.); (H.S.); (T.I.); (T.D.); (J.M.)
| | - Kazuyoshi Okada
- Department of Nephrology, Kawashima Hospital, 6-1 Kitasakoichiban-Cho, Tokushima-City 770-0011, Japan; (K.O.); (H.S.); (T.I.); (T.D.); (J.M.)
| | - Yusaku Tanaka
- Department of Clinical Engineering, Kawashima Hospital, 6-1 Kitasakoiciban-Cho, Tokushima-City 770-0011, Japan; (Y.T.); (H.M.)
| | - Hiroyuki Michiwaki
- Department of Clinical Engineering, Kawashima Hospital, 6-1 Kitasakoiciban-Cho, Tokushima-City 770-0011, Japan; (Y.T.); (H.M.)
| | - Hisato Shima
- Department of Nephrology, Kawashima Hospital, 6-1 Kitasakoichiban-Cho, Tokushima-City 770-0011, Japan; (K.O.); (H.S.); (T.I.); (T.D.); (J.M.)
| | - Tomoko Inoue
- Department of Nephrology, Kawashima Hospital, 6-1 Kitasakoichiban-Cho, Tokushima-City 770-0011, Japan; (K.O.); (H.S.); (T.I.); (T.D.); (J.M.)
| | - Toshio Doi
- Department of Nephrology, Kawashima Hospital, 6-1 Kitasakoichiban-Cho, Tokushima-City 770-0011, Japan; (K.O.); (H.S.); (T.I.); (T.D.); (J.M.)
| | - Jun Minakuchi
- Department of Nephrology, Kawashima Hospital, 6-1 Kitasakoichiban-Cho, Tokushima-City 770-0011, Japan; (K.O.); (H.S.); (T.I.); (T.D.); (J.M.)
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3
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Pedreros-Rosales C, Jara A, Lorca E, Mezzano S, Pecoits-Filho R, Herrera P. Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond. Toxins (Basel) 2023; 15:531. [PMID: 37755957 PMCID: PMC10535648 DOI: 10.3390/toxins15090531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.
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Affiliation(s)
- Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción 4070386, Chile
- Nephrology Service, Hospital Las Higueras, Talcahuano 4270918, Chile
| | - Aquiles Jara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Eduardo Lorca
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
| | - Sergio Mezzano
- Instituto de Medicina, Facultad de Medicina, Universidad Austral, Valdivia 5110566, Chile
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI 48108, USA
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Patricia Herrera
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
- Nephrology Service, Hospital del Salvador, Santiago 8320000, Chile
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4
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Nenadović M, Nikolić A, Stanojević-Pirković M, Trbojević-Stanković J, Nikolić T, Petrović D, Djulejić V. Assessment of the Influence of Asymmetric Triacetate Cellulose Membrane on the Rate of Removal of Middle Molecular Weight Uremic Toxins in Patients Treated with Postdilution Online Hemodiafiltration. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND: Postdilution online hemodiafiltration (OL-HDF) effectively removes uremic toxins of middle molecular weight from the blood of patients with end-stage chronic kidney disease. The rate of removal of uremic toxins depends on the type of dialysis membrane, blood flow rate (Qb), net ultrafiltration flow rate (Qnuf), and total convective volume (Vconv).
AIM: The aim of this study was to examine the efficacy of asymmetric triacetate cellulose dialysis membrane in patients on post-dilution OL-HDF.
METHODS: Thirty-five patients treated with post-dilution OL-HDF hemodiafiltration for at least 3 months were examined. The main parameters for assessing the efficiency of removal of uremic toxins of middle molecular weight are the concentration of β2-microglobulin (β2-M) and interleukin-6 (IL-6) in serum before and after a single session of post-dilution OL-HDF. The followings were used for statistical analysis: Kolmogorov–Smirnov test, Student’s T test for bound samples and Wilcoxon test.
RESULTS: The average Vconv was 20.90 ± 3.30 liters/session. The β2-M reduction index during a single session of postdilution OL-HDF was 71.10 ± 6.39%, the IL-6 reduction index was 43.75 ± 15.60%, and the albumin reduction index was 4.55 ± 2.31%.
CONCLUSION: The asymmetric triacetate cellulose dialysis membrane effectively removes β2-M and IL-6 during a single session of postdilution OL-HDF. The β2-M reduction index is ∼70%, the IL-6 reduction index is ∼40%, and albumin loss is <4.0 g/4 h. The examined dialysis membrane and dialysis modality prevent the development of amyloidosis associated with dialysis, microinflammation and reduce the risk of developing atherosclerotic cardiovascular diseases in the population of patients treated with regular hemodiafiltration.
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5
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Guedes M, Vernooij RWM, Davenport A, Kuhlmann MK, Aregger F, Pecoits-Filho R. Clinical performance, intermediate and long-term outcomes of high-volume hemodiafiltration in patients with kidney failure. Semin Dial 2022; 35:420-426. [PMID: 35689437 DOI: 10.1111/sdi.13105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/05/2022] [Indexed: 12/20/2022]
Abstract
Hemodiafiltration (HDF), in which both convective and diffusion methods are combined, yields an increased overall solute clearance compared with hemodialysis (HD), specifically for medium and larger molecular weight uremic toxins. Due to uncertainty in the treatment effects, the nephrology community still perceives the implementation of HDF and the achievement of high convective volume as complex. In this article, we review practical aspects of the implementation of HDF that can effectively deliver a high-volume HDF therapy and assure clinical performance to most patients. We also present an overview of the impact of high-volume HDF (compared to HD) on a series of relevant biochemical, patient-reported, and clinical outcomes, including uremic toxin removal, phosphate, Inflammation and oxidative stress, hemodynamic stability, cardiac outcomes, nutritional effects, health-related quality of life, morbidity, and mortality.
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Affiliation(s)
- Murilo Guedes
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, Division of Medicine, University College London, London, UK
| | - Martin K Kuhlmann
- Department of Internal Medicine - Nephrology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Fabienne Aregger
- Department of Internal Medicine - Nephrology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil.,Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
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6
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Mohajerani F, Clark WR, Ronco C, Narsimhan V. Mass Transport in High-Flux Hemodialysis: Application of Engineering Principles to Clinical Prescription. Clin J Am Soc Nephrol 2022; 17:749-756. [PMID: 35277434 PMCID: PMC9269577 DOI: 10.2215/cjn.09410721] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An understanding of the processes underlying mass transfer is paramount for the attainment of adequate solute removal in the dialytic treatment of patients with kidney failure. In this review, engineering principles are applied to characterize the physical mechanisms behind the two major modes of mass transfer during hemodialysis, namely diffusion and convection. The manner in which flow rate, dialyzer geometry, and membrane microstructure affect these processes is discussed, with concepts such as boundary layers, effective membrane diffusivity, and sieving coefficients highlighted as critical considerations. The objective is to improve clinicians' understanding of these concepts as important factors influencing the prescription and delivery of hemodialysis therapy.
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Affiliation(s)
- Farzad Mohajerani
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Nephrology Department, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Vivek Narsimhan
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana
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7
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Effets biologiques et cliniques, et résultats au long cours du traitement par ol-HDF des patients adultes insuffisants rénaux chroniques. Nephrol Ther 2022. [DOI: 10.1016/s1769-7255(22)00035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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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9
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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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10
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Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach. Nutrients 2020; 12:nu12030785. [PMID: 32188148 PMCID: PMC7146606 DOI: 10.3390/nu12030785] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022] Open
Abstract
Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.
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11
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Cuvelier C, Tintillier M, Migali G, Van Ende C, Pochet JM. Albumin losses during hemodiafiltration: all dialyzers are not created equal - a case report. BMC Nephrol 2019; 20:392. [PMID: 31660886 PMCID: PMC6819538 DOI: 10.1186/s12882-019-1567-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/26/2019] [Indexed: 12/03/2022] Open
Abstract
Background Online hemodiafiltration (OL-HDF) is associated with better removal of both small and middle molecules and might improve survival compared to conventional hemodialysis (HD). Nevertheless, hemodiafiltration (HDF) can lead to an increase in albumin loss across the dialyzer, especially with high permeability membrane and high convective volume (CV). We present the case of a patient treated by OL-HDF who developed severe hypoalbuminemia resulting from massive albumin loss into dialysate. Case presentation A 71-year-old woman with ESRD started renal replacement therapy in December 2016. She was treated by high volume post-dilution OL-HDF, 4 h, 3 times per week. The dialyzer was the Phylther HF20SD (a 2.0m2 heat sterilized high flux (HF) polyphenylene membrane from Bellco). At the initiation of dialysis, the serum albumin was 4.0 g/dl. During the following months, the patient developed severe hypoalbuminemia. The lowest value observed was 2.26 g/dl in July 2017. Diagnostic workup excluded nephrotic syndrome, hepatic failure and malabsorption. The patient was shifted from OL-HDF to standard HF HD, keeping the same dialyzer and dialysis schedule. During the following months, we observed a progressive correction of the hypoalbuminemia (3.82 g/dl at last follow-up). To precise the impact of the epuration technique on the albumin losses in this patient, we measured the amount of albumin in dialysate during one session with the Phylther HF20SD on OL-HDF and one session with the same filter but on standard HD. The CV was 29.0 l for the HDF session. The total albumin losses were 23.6 g on OL-HDF and 4.6 g on HD. Conclusion OL-HDF can lead to significant albumin loss into the dialysate, especially with high permeability membrane and high CV. When prescribing post-dilutional OL-HDF, the choice of the dialyzer membrane should be made with caution. Users of the steam sterilized polyphenylene membrane, the Phylther SD, should be informed of the risk of large albumin loss with this membrane during post-dilution OL-HDF.
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Affiliation(s)
- Charles Cuvelier
- CHU UCL Namur, Internal Medicine and Nephrology Departement, Université catholique de Louvain, Sainte-Elisabeth site, 15 Place Louise Godin, Namur, Belgium.
| | - Michel Tintillier
- CHU UCL Namur, Internal Medicine and Nephrology Departement, Université catholique de Louvain, Sainte-Elisabeth site, 15 Place Louise Godin, Namur, Belgium
| | - Gabriela Migali
- CHU UCL Namur, Internal Medicine and Nephrology Departement, Université catholique de Louvain, Sainte-Elisabeth site, 15 Place Louise Godin, Namur, Belgium
| | - Charlotte Van Ende
- CHU UCL Namur, Internal Medicine and Nephrology Departement, Université catholique de Louvain, Sainte-Elisabeth site, 15 Place Louise Godin, Namur, Belgium
| | - Jean-Michel Pochet
- CHU UCL Namur, Internal Medicine and Nephrology Departement, Université catholique de Louvain, Sainte-Elisabeth site, 15 Place Louise Godin, Namur, Belgium
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12
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van Gelder MK, Abrahams AC, Joles JA, Kaysen GA, Gerritsen KGF. Albumin handling in different hemodialysis modalities. Nephrol Dial Transplant 2019; 33:906-913. [PMID: 29106652 DOI: 10.1093/ndt/gfx191] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/20/2017] [Indexed: 11/14/2022] Open
Abstract
Hypoalbuminemia is a major risk factor for morbidity and mortality in dialysis patients. With increasing interest in highly permeable membranes and convective therapies to improve removal of middle molecules, transmembrane albumin loss increases accordingly. Currently, the acceptable upper limit of albumin loss for extracorporeal renal replacement therapies is unknown. In theory, any additional albumin loss should be minimized because it may contribute to hypoalbuminemia and adversely affect the patient's prognosis. However, hypoalbuminemia-associated mortality may be a consequence of inflammation and malnutrition, rather than low albumin levels per se. The purpose of this review is to give an overview of albumin handling with different extracorporeal renal replacement strategies. We conclude that the acceptable upper limit of dialysis-related albumin loss remains unknown. Whether enhanced middle molecule removal outweighs the potential adverse effects of increased albumin loss with novel highly permeable membranes and convective therapies is yet to be determined.
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Affiliation(s)
- Maaike K van Gelder
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George A Kaysen
- Department of Medicine Division of Nephrology, University of California, Davis, CA, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, CA, USA
| | - Karin G F Gerritsen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Msaad R, Essadik R, Mohtadi K, Meftah H, Lebrazi H, Taki H, Kettani A, Madkouri G, Ramdani B, Saïle R. Predictors of mortality in hemodialysis patients. Pan Afr Med J 2019; 33:61. [PMID: 31448023 PMCID: PMC6689835 DOI: 10.11604/pamj.2019.33.61.18083] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/05/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Mortality in patients with chronic renal failure is high compared to the general population. The objective of our study is to evaluate the predictive factors related to mortality in hemodialysis. Methods This is a retrospective study involving 126 hemodialysis patients in the Nephrology Department of Ibn Rochd Hospital, Casablanca. Data were collected between January 2012 and January 2016. For each of our patients, we analyzed demographic, clinical, biological and anthropometric data. The Kaplan-Meier method and the log-rank test were used to evaluate and compare survival curves. To evaluate the effect of predictors of mortality, we used the proportional Cox hazard model. Results The analysis of the results showed that the surviving patients were younger than the deceased patients (43.07±13.52 years versus 53.09±13.56 years, p=0.001). Also, the latter has a significantly lower albumin and prealbumin levels (p=0.01 and p=0.04 respectively). Overall survival was 80.2%. Cox regression analysis at age (HR=1.26, p<0.0002), inflammation (HR=1.15, p<0.03), AIP> 0.24 (HR=2.1, p<0.002) and cardiovascular disease (RR=2.91, p<0.001) were associated with global and cardiovascular mortality. Conclusion Our study showed that the mortality rate is high in our cohort. In addition, cardiovascular diseases, under nutrition and inflammation are predictive factors for mortality. Treatment and early management of these factors are essential for reducing morbidity and mortality.
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Affiliation(s)
- Rajaa Msaad
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Rajaa Essadik
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Karima Mohtadi
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Hasnaa Meftah
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Halima Lebrazi
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Hassan Taki
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Anass Kettani
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Ghizlane Madkouri
- Department of Nephrology-Transplantation and Hemodialysis of the University Hospital Center Ibn Rochd of Casablanca, Casablanca, Morocco
| | - Benyounes Ramdani
- Department of Nephrology-Transplantation and Hemodialysis of the University Hospital Center Ibn Rochd of Casablanca, Casablanca, Morocco
| | - Rachid Saïle
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
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Hulko M, Haug U, Gauss J, Boschetti-de-Fierro A, Beck W, Krause B. Requirements and Pitfalls of Dialyzer Sieving Coefficients Comparisons. Artif Organs 2018; 42:1164-1173. [PMID: 30281162 PMCID: PMC6585607 DOI: 10.1111/aor.13278] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 11/12/2022]
Abstract
Sieving coefficients reported in dialyzer data sheets and instructions for use (IFUs) indicate the potential of different solutes to pass across a particular membrane. Despite being measured in vitro, sieving coefficient data are often used as a predictor of the clinical performance of dialyzers. Although standards for the measurement of sieving coefficients exist, the stated methodologies do not offer sufficient guidance to ensure comparability of test results between different dialyzers. The aim of this work was to investigate the relationship between sieving coefficients and published clinical performance indicators for two solutes, albumin loss and beta‐2 microglobulin (β2M) reduction ratio (RR), and to assess the impact of different in vitro test parameters on sieving coefficient values for albumin, β2M, and myoglobin. Clinical albumin loss and β2M RR for commercially available dialyzers used in hemodialysis (HD) and post‐dilution hemodiafiltration (HDF) were extracted from the literature and plotted against sieving coefficients reported in data sheets and IFUs. Albumin, β2M, and myoglobin sieving coefficients of a selection of dialyzers were measured per the ISO 8637 standard. The impact of in vitro testing conditions was assessed by changing blood flow rate, ultrafiltration (UF) rate, sampling time, and origin of test plasma. Results showed variation in albumin loss and β2M RR for the same sieving coefficient across different dialyzers in HD and HDF. Changes in blood flow rates, UF rates, sampling time, and test plasma (bovine vs. human) caused marked differences in sieving coefficient values for all investigated solutes. When identical testing conditions were used, sieving coefficient values for the same dialyzer were reproducible. Testing conditions have a marked impact on the measurement of sieving coefficients, and values should not be compared unless identical conditions are used. Further, variability in observed clinical data in part reflects the lack of definition of test conditions.
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Affiliation(s)
| | - Ulrike Haug
- Research & Development, Baxter International Inc
| | - Julia Gauss
- Research & Development, Baxter International Inc
| | | | - Werner Beck
- Global Medical Affairs, Baxter International Inc., Hechingen, Germany
| | - Bernd Krause
- Research & Development, Baxter International Inc
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15
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Piccoli GB, Cabiddu G, Moio MR, Fois A, Cao R, Molfino I, Kaniassi A, Lippi F, Froger L, Pani A, Biolcati M. Efficiency and nutritional parameters in an elderly high risk population on hemodialysis and hemodiafiltration in Italy and France: different treatments with similar names? BMC Nephrol 2018; 19:171. [PMID: 29986663 PMCID: PMC6038182 DOI: 10.1186/s12882-018-0948-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/14/2018] [Indexed: 12/29/2022] Open
Abstract
Background Choice of dialysis is context sensitive, explored for PD and extracorporeal dialysis, but less studied for haemodialysis (HD) and hemodiafiltration (HDF), both widely employed in Italy and France; reasons of choice and differences in prescriptions may impact on dialysis-related variables, particularly relevant in elderly, high-comorbidity patients. Methods The study involved two high-comorbidity in-hospital cohorts, treated in Centers with similar characteristics, in Italy (Cagliari) and France (Le Mans). All patients (204) agreed to participate. Stable cases on thrice-weekly dialysis, with at least 2 months follow-up were selected (180 patients, Males 59.4%, median age 71 years, vintage 4.3 years, Charlson index 9). Univariate and multivariate correlations between baseline data, HD-HDF, dialysis efficiency and nutritional markers were assessed. Results In Le Mans HDF was mainly chosen to increase efficiency (large surface dialysers, high convective volume; 76.3% of the patients), in Cagliari to improve tolerance (smaller surfaces, lower convective volume; 59% of patients). Kt/V was similar in HD and HDF, and in both settings(median Kt/V Daugirdas 2: 1.6); in the setting of high efficiency no correlation was found between Kt/V, BMI, urea, creatinine, n-PCR and phosphate. The relationship between Kt/V and albumin was divergent: a weak consensual increase was present in Cagliari, a decrease in Le Mans, suggesting a role of albumin losses with high convective volumes. In the multivariate analysis, after adjustment for other covariates (including comorbidity and type of treatment) low albumin level < 3.5 g/dl was highly correlated with setting of study: Le Mans (OR: 7.155 (2.955–17.324)). The multivariate analysis confirmed a role of type of treatment, with higher risk of low albumin levels in HDF (OR: 3.592 (1.466–8.801)), and of comorbidity (Charlson index> = 7 (OR: 3.153 (1.311–7.582)), MIS index> = 7 (OR: 5.916 (2.457–14.241)). Conclusions The different prescriptions of HD and HDF may have similar effects on dialysis efficiency, but diverging effects on crucial nutritional markers, such as albumin levels, probably more evident in high-comorbidity populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy. .,Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.
| | | | - Maria Rita Moio
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France
| | | | | | - Ida Molfino
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.,University of Naples, Naples, Italy
| | - Ana Kaniassi
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | - Francoise Lippi
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | - Ludivine Froger
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | | | - Marilisa Biolcati
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
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17
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Medium cut-off membranes - closer to the natural kidney removal function. Int J Artif Organs 2017; 40:328-334. [PMID: 28574113 PMCID: PMC6159847 DOI: 10.5301/ijao.5000603] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 01/31/2023]
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18
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Nagai K, Tsuchida K, Ishihara N, Minagawa N, Ichien G, Yamada S, Hirose D, Michiwaki H, Kanayama HO, Doi T, Minakuchi J. Implications of Albumin Leakage for Survival in Maintenance Hemodialysis Patients: A 7-year Observational Study. Ther Apher Dial 2017; 21:378-386. [PMID: 28452109 DOI: 10.1111/1744-9987.12526] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/17/2016] [Accepted: 12/26/2016] [Indexed: 11/27/2022]
Abstract
Albumin leakage during hemodialysis (HD) presents a clinical dilemma. However, protein-binding uremic toxins are suggested to be responsible for increased mortality. No one has investigated the relationship between albumin leakage and mortality. Therefore, the purpose of this observational study was to analyze the association of albumin leakage with mortality in 690 HD patients who survived one year after enrollment. They were divided to three groups who received HD with large (3 g or more per HD session), middle (1 to 3 g) or small (less than 1 g) amount of albumin leakage, respectively. A propensity score analysis minimizing indication bias was performed. Consequently, in a 7-year observation period, 212 patients died. Albumin leakage 3 g or more per HD session provided better prognosis than albumin leakage less than 3 g per HD session. In conclusion, clinically acceptable large albumin leakage provides beneficial effects on mortality in maintenance HD patients.
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Affiliation(s)
- Kojiro Nagai
- Department of Nephrology, Tokushima University Graduate School, Tokushima, Japan
| | - Kenji Tsuchida
- Department of Kidney Disease (Dialysis & Transplantation), Kawashima Hospital, Tokushima, Japan
| | - Noriyuki Ishihara
- Department of Kidney Disease (Dialysis & Transplantation), Kawashima Hospital, Tokushima, Japan
| | | | | | - Satoshi Yamada
- Department of Kidney Disease (Dialysis & Transplantation), Kawashima Hospital, Tokushima, Japan
| | - Daisuke Hirose
- Department of Kidney Disease (Dialysis & Transplantation), Kawashima Hospital, Tokushima, Japan
| | - Hiroyuki Michiwaki
- Department of Kidney Disease (Dialysis & Transplantation), Kawashima Hospital, Tokushima, Japan
| | - Hiro-Omi Kanayama
- Urology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Toshio Doi
- Department of Nephrology, Tokushima University Graduate School, Tokushima, Japan
| | - Jun Minakuchi
- Department of Kidney Disease (Dialysis & Transplantation), Kawashima Hospital, Tokushima, Japan
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Piccoli GB, Moio MR, Fois A, Sofronie A, Gendrot L, Cabiddu G, D'Alessandro C, Cupisti A. The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach. Nutrients 2017; 9:E372. [PMID: 28394304 PMCID: PMC5409711 DOI: 10.3390/nu9040372] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/25/2022] Open
Abstract
The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Maria Rita Moio
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Antioco Fois
- Nefrologia, Ospedale Brotzu, 09100 Cagliari, Italy.
| | - Andreea Sofronie
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
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Weng CH, Hsu CW, Hu CC, Yen TH, Huang WH. Association Between Hemodiafiltration and Hypoalbuminemia in Middle-Age Hemodialysis Patients. Medicine (Baltimore) 2016; 95:e3334. [PMID: 27082584 PMCID: PMC4839828 DOI: 10.1097/md.0000000000003334] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The advantage of hemodiafiltration (HDF) is well known. One of the disadvantages of HDF is loss of serum albumin, but this issue is still obscure. Some risk factors associated with mortality were age dependent. Studies on serum albumin/hypoalbuminemia and HDF in different age stratification were limited. The aim of this cross-sectional study was to assess the role of HDF and other clinical variables on serum albumin values in maintenance hemodialysis (MHD) patients of different age groups. We recruited a total of 1216 patients on MHD. Patients were divided into 4 groups by age stratification of youth (<30 years old), young-middle age (30-44 years old), middle age (45-64 years old), and old age (≥65 years old). Biochemical, hematological, nutritional, inflammatory parameters, and receiving HDF or not were recorded. The associations between age groups, HDF, and variables mentioned above were analyzed. Only in middle-age group, patients with HDF was significantly (P = 0.013) associated with serum albumin <4 g/dL. In middle-age group, a multivariate-forward logistic regression analysis showed that male sex (2.169 [1.029, 4.574], P = 0.042), inflammation (4.167 [2.043, 8.498], P < 0.001), cardiovascular disease (2.92 [1.019, 8.402], P = 0.046), serum creatinine level (0.639 [0.538, 0.758], P < 0.001), and cholesterol level (0.984 [0.975, 0.993], P = 0.001) were associated with serum albumin level <3.6 g/dL. Hepatitis C virus infection (1.911 [1.186, 3.077], P = 0.008), HDF (2.143 [1.298, 3.540], P = 0.003), inflammation (2.309 [1.549, 3.440], P < 0.001), use of arterio-venous fistula (0.518 [0.327, 0.820], P = 0.005), Kt/V (0.395 [0.193, 0.809], P = 0.011), nonanuria (0.542 [0.337, 0.870], P = 0.011), serum creatinine level (0.744 [0.669, 0.828], P < 0.001), and cholesterol level (0.993 [0.987, 0.998], P = 0.013) were associated with serum albumin level <4 g/dL. HDF can predict serum albumin level <4 g/dL in middle-age HD patients. The effect of age needs to be taken into consideration when interpreting the correlation between hypoalbuminemia and HDF.
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Affiliation(s)
- Cheng-Hao Weng
- From the Department of Nephrology and Division of Clinical Toxicology (C-HW, C-WH, T-HY, W-HH), Chang Gung Memorial Hospital, Linkou Medical Center; Chang Gung University College of Medicine (C-HW, C-WH, C-CH, T-HY, W-HH), Taoyuan; and Department of Hepatogastroenterology and Liver Research Unit, Chang Gung Memorial Hospital (C-CH), Keelung, Taiwan
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