Abstract
Expanded hemodialysis (HDx), using medium cut‐off membrane, is a novel therapy that effectively clears middle molecules (MMs). We aimed to compare HDx to hemodiafiltration (HDF) in an open randomized clinical study. Patients currently on HDF (age 18–80 years; on HDF >3 months) were randomized to switch to HDx (N = 21) or continue HDF (N = 22) with a 24‐week follow‐up. Pre‐ to post‐dialysis reduction ratios (RR) and changes in pre‐dialysis levels over time were evaluated for MMs and clinical biomarkers. Use of erythropoiesis‐stimulating agents (ESAs) was assessed. HDx showed greater RR for YKL‐40 while RR appeared similar between groups for beta2‐microglobulin, FGF‐23, and free light chains. Intradialytic changes in inflammatory biomarkers (IL‐6, CRP, PTX3) did not differ between therapies. Changes from baseline to 12 and 24 weeks did not differ between groups for MMs, inflammatory markers, albumin, fibrinogen, hemoglobin, PTH, and phosphorus. Use of ESAs tended to decrease in HDx arm while remaining stable in HDF arm. HDx appeared safe with similar clinical effectiveness as HDF. With fewer requirements and resource needs, HDx provides an attractive alternative to HDF.
Highlights
Hemodiafiltration (HDF) enhances middle molecule (MM) removal by convection and shows survival benefit compared to high-flux hemodialysis
HDx showed greater reduction ratios (RR) for YKL-40 while RR appeared similar between groups for beta2-microglobulin, FGF-23, and free light chains
Changes from baseline to 12 and 24 weeks did not differ between groups for MMs, inflammatory markers, albumin, fibrinogen, hemoglobin, PTH, and phosphorus
Summary
Hemodiafiltration (HDF) enhances middle molecule (MM) removal by convection and shows survival benefit compared to high-flux hemodialysis. The choice of membrane becomes important for effective clearance of middle molecular uremic toxins (MMs), for which the membrane’s permeability properties are essential [1]. Recent research points at a significant role of large MMs, larger than 25 kDa, in the progression of comorbidities and poor outcome in dialysis patients [3, 4]. HDF enhances the removal of conventional and large MMs, as increased convection across the membrane helps to overcome limits in membrane permeability [6]. Analysis of pooled data from randomized controlled studies pointed at a survival benefit of HDF versus HD when HDF was applied in postdilution mode with high convective volume [7]. The mechanism of superior outcome has not been firmly established, it is commonly hypothesized that enhanced MM removal by HDF plays a key role
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