Online Hemodiafiltration Research Articles

Уровень N-терминального фрагмента прогормона мозгового натрийуретического пептида у пациентов с разным объемом замещения при on-line гемодиафильтрации

Уровень N-терминального фрагмента прогормона мозгового натрийуретического пептида у пациентов с разным объемом замещения при on-line гемодиафильтрации

Study of Biocompatibility of Membranes in Online Hemodiafiltration

Background: The biocompatibility of dialysis membranes is a determining factor in avoiding chronic microinflammation in patients under haemodialysis. Lower biocompatibility has been related to increased inflammatory status, which is known to be associated with cardiovascular events. Classically, cellulose membranes have been considered bioincompatible. A new-generation of asymmetric cellulose triacetate (CTA) membranes allows the performance of high convective transport techniques, but there have been no studies of their biocompatibility. The aim of the present study was to analyze and compare the biocompatibility characteristics of 4 membranes, including CTA, in online hemodiafiltration (OL-HDF) patients. Methods: We included 15 patients in ­OL-HDF. After a 2-week washout period with helixone membrane, each patient was treated with the 4 membranes (polyamide, polynephron, helixone and CTA) for 4 weeks in a randomized order. The other dialysis parameters were kept stable throughout the study. We studied changes in markers of the activation of the complement system, monocytes, platelets, and adhesion molecules with the 4 membranes, as well as inflammatory parameters. Results: Biocompatibility was similar among the membranes. There were no sustained differences in complement activation, measured by C3a and C5a levels, or in platelet activation, determined by levels of P-selectin and platelet-derived microparticles (CD41a+). No differences were observed in activated monocyte levels (CD14+/CD16+) or in plasma levels of interleukin (IL)-1, IL-6, IL-10 or high-sensitivity C-reactive protein, although tumour necrosis factor-α levels decreased when the patients were dialyzed with CTA. No significant differences were found in markers of endothelial damage, assessed by levels of plasminogen activator inhibitor-1 and adhesion molecules (intercellular adhesion molecule-1 and vascular cell adhesion molecule-1). Conclusion: The 4 membranes evaluated in this study in stable patients on OL-HDF, including the new-generation CTA, show similar biocompatibility with the methods applied.

Relationship of serum magnesium level with body composition and survival in hemodialysis patients.

A relationship between serum magnesium (Mg) and body composition parameters has not been reported in hemodialysis (HD) patients. We aimed to clarify whether serum Mg has any association with body composition parameters, or survival in HD patients. This study included 215 consecutive maintenance HD patients. Laboratory data collection and postdialysis body composition analysis were performed at baseline. The patients were divided based on baseline serum Mg level tertiles (low, medium, and high Mg groups). Kaplan-Meier survival, logistic regression analyses and Cox proportional hazard analyses were conducted. Among all patients, the median age and dialysis vintage were 73 (65-81) years and 44 (8-96) months, respectively. The serum Mg levels were < 2.3, 2.3-2.5, and > 2.5 mg/dL for the low (n = 67), middle (n = 76), and high (n = 72) Mg groups, respectively. Compared to other groups, low Mg group showed significantly higher age and C-reactive protein levels, but lower serum albumin, normalized protein catabolic rates and frequency of on-line hemodiafiltration. The low, middle, and high Mg groups differed significantly regarding body cell mass (fat-free mass without bone mineral mass and extracellular water) index (BCMI): [5.6 (4.2-6.8), 6.0 (4.8-8.1), 6.7 (4.9-7.5) kg/m2 , respectively] and overhydration/extracellular water ratio (OH/ECW) [11.7 (4.5-21.9), 4.8 (1.0-14.1), 8.5 (-0.5-15.0) %, respectively] but not regarding body mass index, lean tissue index, fat tissue index. Hypomagnesemia was significantly associated with BCMI [odds ratio (OR) [95% confidence interval (CI)]: 0.85 [0.73-1.00] and OH/ECW (OR [95% CI]: 1.03 [1.01-1.05]), respectively. Kaplan-Meyer 3-year survival rates were 53.6%, 69.7%, and 71.7% in low, middle, and high Mg groups, respectively. However, hypomagnesemia was not significantly associated with 3-year all-cause mortality independent of age, serum albumin and C-reactive protein. Hypomagnesemia was associated with lower BCMI, more pronounced OH/ECW and poorer Kaplan-Meier 3-year cumulative survival, but was not an independent risk factor for mortality in HD patients.

Predicting Residual Function in Hemodialysis and Hemodiafiltration—A Population Kinetic, Decision Analytic Approach

In this study, we introduce a novel framework for the estimation of residual renal function (RRF), based on the population compartmental kinetic behavior of beta 2 microglobulin (B2M) and its dialytic removal. Using this model, we simulated a large cohort of patients with various levels of RRF receiving either conventional high-flux hemodialysis or on-line hemodiafiltration. These simulations were used to estimate a novel population kinetic (PK) equation for RRF (PK-RRF) that was validated in an external public dataset of real patients. We assessed the performance of the resulting equation(s) against their ability to estimate urea clearance using cross-validation. Our equations were derived entirely from computer simulations and advanced statistical modeling and had extremely high discrimination (Area Under the Curve, AUC 0.888–0.909) when applied to a human dataset of measurements of RRF. A clearance-based equation that utilized predialysis and postdialysis B2M measurements, patient weight, treatment duration and ultrafiltration had higher discrimination than an equation previously derived in humans. Furthermore, the derived equations appeared to have higher clinical usefulness as assessed by Decision Curve Analysis, potentially supporting decisions for individualizing dialysis prescriptions in patients with preserved RRF.

Evaluation of the efficacy of a very high permeability dialyser and comparison with another high-flux dialyser in online haemodiafiltration.

Evaluation of the efficacy of a very high permeability dialyser and comparison with another high-flux dialyser in online haemodiafiltration.

Does subjective assessment of dialyzer appearance reflect dialyzer performance in online hemodiafiltration?

ABSTRACT Introduction: In post‐dilution online hemodiafiltration, a very thin balance subsists in preventing coagulation of the extracorporeal circuit (ECC) during treatment and bleeding in the patient, concerning dialyzer status and anticoagulation dose.The aim of this study was to assess whether there are clinical outcome differences between the visual aspect of the dialyzer's status in terms of clotted fibers at end of dialysis treatments, single‐pool urea kinetic modeling (spKt/V) and substitution volume (SubsVol). Methods: It is a multicenter, descriptive‐correlational study, involving 2829 patients during April 2016. Previous training was given to the Nursing staff to evaluate and classify both the dialyzer's and the venous chamber's appearance of the ECC venous line. Registration was performed at bedside immediately after the patient disconnection. Findings and discussion: Mean age was 68.96 years (SD = 13.75), 60.8% were men. The average hematocrit was 33.91% (SD = 3.45%). The average dry weight was 68.53 kg (SD = 13.27 kg). Mean unfractioned heparin (UFH) dose was 58.13 IU/kg. Only 32.4% of the patients had a clean dialyzer at the end of treatment. 19.4% of patients finished the treatment with more than 10% of clotted fibers. Patients with no residual blood (clean, 32.4%) presented a higher UFH dose (66.32 IU/kg) compared to overall average dose. UFH dose had a significant effect on dialyzer status. There were significant differences in average of spKt/V and SubsVol between the category clean and the other categories of dialyzer's status.Evaluating the dialyzer status represents an excellent opportunity to help the physicians to establish an ideal heparin dose. Only the category clean is significant to achieve the target. The nursing staff, by classifying the ECC appearance at patient's bedside and recording it in a centralized database, can be a major contributor to achieve an individualized and optimal UFH dose and subsequently better patient outcomes.

Analyse des risques et validation du procédé de production du liquide de substitution de la technique d’hémodiafiltration en ligne

IntroductionOnline hemodiafiltration is a technique of dialysis with many advantages, but its use is limited because of the lack of control of microbiological risks. This work conducts a risk analysis of the process for producing substitution liquid for online hemodiafiltration and validates this process from a microbiological point of view. Material and methodThe risk analysis was carried out following the approach of analysing failure modes, their effects and their criticalities. It identified the “worst case” of the production process being studied. For the validation of this process, we used the limulus amoebocytes lysate assay for bacterial endotoxins and the membrane filtration test for sterility control. ResultsWe identified 17 failure modes, 13 of which were acceptable. Failure modes that exceeded the acceptability threshold were defined as “worst cases”. Sterility monitoring and endotoxin testing, conducted in the “worst case”, verified the microbiological quality of the liquid produced to the required standards and subsequently validated the process used. DiscussionThis approach has resulted in the identification of as many failure modes as possible. Validating in “worst case” is an extreme challenge to the process and its success provides a sufficient basis to conclude that the technique is safe and, therefore, to validate the process. ConclusionThis work has enabled us to validate our production process in extreme cases to promote safer use of the technique.

Comparative Clinical Performance of Dialyzers Applied During High Volume Online Haemodiafiltration

Comparative Clinical Performance of Dialyzers Applied During High Volume Online Haemodiafiltration

Is high-volume post-dilution haemodiafiltration associated with risk of fluid volume imbalance? A national multicentre cross-sectional cohort study.

BackgroundFluid overload is frequent among hemodialysis (HD) patients. Dialysis therapy itself may favor sodium imbalance from sodium dialysate prescription. As on-line hemodiafiltration (OL-HDF) requires large amounts of dialysate infusion, this technique can expose to fluid accumulation in case of a positive sodium gradient between dialysate and plasma. To evaluate this risk, we have analyzed and compared the fluid status of patients treated with HD or OL-HDF in French NephroCare centers.MethodThis is a cross-sectional and retrospective analysis of prevalent dialysis patients. Data were extracted from the EUCLID5 data base. Patients were split in 2 groups (HD and OL-HDF) and compared as whole group or matched patients for fluid status criteria including predialysis relative fluid overload (RelFO%) status from the BCM®.Results2242 patients (age 71 years; female: 39%; vintage: 38 months; Charlson index: 6) were studied. 58% of the cohort were prescribed post-dilution OL-HDF. Comparing the HD and OL-HDF groups, there was no difference between HD and OL-HDF patients regarding the predialysis systolic BP, the interdialytic weight gain, the dialysate-plasma sodium gradient, and the predialysis RelFO%. The stepwise logistic regression did not find dialysis modality (HD or OL-HDF) associated with fluid overload or high predialysis systolic blood pressure. In OL-HDF patients, monthly average convective or weekly infusion volumes per session were not related with the presence of fluid overload.ConclusionsIn this cross-sectional study we did not find association between the use of post-dilution OL-HDF and markers of fluid volume excess. Aligned dialysis fluid sodium concentrations to patient predialysis plasma sodium and regular monitoring of fluid volume status by bioimpedance spectroscopy may have been helpful to manage adequately the fluid status in both OL-HDF and HD patients.

Overexposure to Bisphenol A and Its Chlorinated Derivatives of Patients with End-Stage Renal Disease during Online Hemodiafiltration.

The health safety conditions governing the practice of online hemodiafiltration (OL-HDF) do not yet incorporate the risks related to the presence of endocrine disruptors such as bisphenol A (BPA). The aim of this study was to assess, for the first time, the exposure to BPA but also to its chlorinated derivatives (ClxBPA) (100 times more estrogenic than BPA) during OL-HDF. We demonstrated that BPA is transmitted by the different medical devices used in OL-HDF: ultrafilters, dialysis concentrate cartridges (and not only dialyzers, as previously described). Moreover, BPA has been found in dialysis water as well as in ultrapure dialysate and replacement fluid due to contamination of water coming from municipal network. Indeed, due to contaminations provided by both ultrafilters and water, high levels of BPA were determined in the infused replacement fluid (1033 ng.L−1) from the beginning of the session. Thus, our results demonstrate that dialysis water must be considered as an important exposure source to endocrine disruptors, especially since other micropollutants such as ClxBPA have also been detected in dialysis fluids. While assessment of the impact of this exposure remains to be done, these new findings should be taken into account to assess exposure risks in end-stage renal disease patients.

Removal of Urea, β2-Microglobulin, and Indoxyl Sulfate Assessed by Absorbance and Fluorescence in the Spent Dialysate During Hemodialysis.

In this study, simultaneous removal assessment of marker molecules from three uremic toxin groups was performed during different hemodialysis treatment modalities using optical characteristics of spent dialysate. Results from optical measurements were compared with the results from chemical laboratory. Ten chronic dialysis patients, mean age 59 ± 15 years, were included in the study during 40 hemodialysis sessions. Low-flux hemodialysis (HD), high-flux hemodialysis (HF), and postdilutional online hemodiafiltration (HDF) with different settings were used. The reduction ratio (RR) and total removed solute (TRS) of three uremic solutes were determined: small molecular weight urea, middle molecular β2-microglobulin (B2M), and protein-bound indoxyl sulfate (IS). Concentrations of these solutes in the spent dialysate were measured by laboratory (lab) and optical (opt) methods, in the serum by laboratory methods, and calculated RR values in percentage were compared accordingly. Total removed solute was obtained from the total dialysate collection (TDC) using lab and opt methods. The highest RR values were found for urea and B2M, and the lowest for IS. The difference between RR of lab and opt results estimated as mean accuracy (BIAS) was ≤8.1% for all three solutes. Good correspondence between TRS lab vs. opt was achieved, resulting in strong linear correlation values R from 0.727 for urea to 0.971 for IS. Accuracy for TRS values as BIAS ± standard error (SE), comparing lab vs. opt, showed no statistical difference for any of the observed uremic solutes (P > 0.05). The accuracy of the optical method was not influenced by the dialysis modality (HD, HF, and HDF).

Utility of a blood volume monitor in the management of anemia in dialysis by computing the total hemoglobin mass.

The degree of interdialytic weight gain and ultrafiltration may influence anemia results in dialysis. The purpose of this study is to evaluate the utility of a blood volume monitor (BVM) in the management of renal anemia and its ability to avoid the variability of hematocrit (Hct) and hemoglobin values (Hb) depending on plasma volume through a simple method of monitoring the total hemoglobin mass (MtHb ). Predialysis blood samples for measurement were drawn at both the midweek treatment and the beginning-of-the-dialysis-week treatment in 30 patients. The MtHb was calculated as MtHb = Vb × Hb, where Vb is the absolute blood volume determined by online dialysate dilution using an online hemodiafiltration machine incorporating a relative BVM. The MtHb and the total red cell volume (VRBC ) as measured with the bolus method at the starting of the treatment were 540 ± 148 grams and 1544 ± 339 mL, respectively. There were significant differences between the Hb levels and between the hematocrit levels according to the time of dialysis. However, the MtHb remained constant. There was also an excellent correlation between the Hb measurements by the BVM and the blood sampling method (R = 0.89, P value <0.001). Our study suggests that BVM could be very useful in the management of anemia in dialysis by computing the total Hb mass in clinical practice and may support better and more appropriate assessments of the factors influencing circulating Hb.

High-Flux versus High-Retention-Onset Membranes: In vivo Small and Middle Molecules Kinetics in Convective Dialysis Modalities

Background: Patients undergoing maintenance hemodialysis (HD) exhibit increased levels of uremic toxins, which are associated with poor outcomes. Recently, new dialysis membranes have allowed clearance of solutes with higher molecular weight, without significant albumin losses high-retention-onset-HD (HRO-HD). Methods: Prospective crossover trial, in which 16 prevalent patients switched from high-flux HD (HF-HD) to online hemodiafiltration (olHDF) and HRO-HD for 4 weeks. The following variables were evaluated: pre- and post-dialysis serum concentrations of albumin, urea, phosphate (P), beta-2 microglobulin (β₂M), and total mass (TM) extraction and dialyzer clearance of urea, P, and β₂M. Results: Comparing HF-HD, olHDF, and HRO-HD, respectively, there were no differences regarding pre-dialysis serum concentrations of albumin (3.94 ± 0.36, 4.06 ± 0.22, and 3.93 ± 0.41 g/dL, p = 0.495), urea (166 ± 29, 167 ± 30, and 164 ± 27 mg/dL, p = 0.971), P (4.9 ± 2.1, 5.2 ± 1.6, and 4.9 ± 2.1 mg/dL, p = 0.879), and β₂M (31.3 ± 7.1, 32.6 ± 8.6, and 33.7 ± 5.9 µg/mL, p = 0.646). β₂M clearance was significantly lower in HF-HD in comparison to both olHDF and HRO-HD: 43 (37–53) versus 64 (48–85) mL/min, p = 0.013, and 69 (58–86) mL/min, p = 0.015, respectively. Post-dialysis β₂M serum concentration was higher in HF-HD in comparison to olHDF and HRO-HD: 11.6 (9.6–12.4) vs. 5.7 (4.5–7.0) µg/mL, p = 0.001, and 5.6 (5.3–7.6) µg/mL, p = 0.001, respectively. TM extraction of urea, P, and β₂M were similar across the 3 dialysis modalities. Conclusions: olHDF and HRO-HD were superior to HF-HD regarding β₂M clearance, leading to lower post-dialysis β₂M levels.

A Clinical Significance of Intermittent Infusion Hemodiafiltration Using Backfiltration of Ultrapure Dialysis Fluid Compared to Hemodialysis: A Multicenter Randomized Controlled Crossover Trial

Background: Intermittent infusion hemodiafiltration ­(I-HDF) using repeated infusion of ultrapure dialysis fluid through a dialysis membrane or sterile nonpyrogenic substitution fluid was developed to prevent a rapid decrease in blood pressure by increasing the patient’s circulating blood volume, to enhance the plasma refilling rate by improving peripheral circulation, and to enhance solute transfer from the extravascular space to the intravascular space by enhancing the plasma refilling rate. Furthermore, the effect of fouling caused by attachment of proteins to the membrane as a result of ultrafiltration can be reduced by backflushing of the membrane with the purified dialysate in I-HDF. Although there have been several clinical trials of I-HDF, there have been no comparisons of the clinical significance of and indications for ­I-HDF with those of conventional hemodialysis (HD). Objective: The aim of this multicenter randomized controlled crossover trial was to compare the clinical significance of ­I-HDF with that of HD in Japan. Method: Patients were randomized to receive HD, I-HDF, and HD (group A) or I-HDF, HD, and I-HDF (group B) in that order for 14 weeks each. The sample size of 70 was determined based on the operability and patient availability. Treatment outcomes were evaluated 5 and 14 weeks after the start of each treatment period. The patients received 4-h treatment sessions with no changes in session duration or anticoagulant therapy during the study. I-HDF was performed using a GC-110N dialysis machine. Two hundred milliliters of ultrapure dialysis fluid were infused at a rate of 150 mL/min by backfiltration every 30 min during treatment. The first and last infusions were performed 30 min after the start and 30 min before the end of treatment, respectively. The total estimated infusion volume per session was 1.4 L (i.e., 200 mL × 7 infusions). I-HDF is a type of online HDF with a small fluid replacement volume. An ABH-P polysulfone membrane hemodiafilter was used for ­I-HDF and a class 1 or 2 hemodialyzer with a polysulfone membrane not coated with vitamin E and approved by the Japanese reimbursement system was used for HD. The primary outcomes were the Short Form-36 version 2 summary scores for quality of life and the visual analog scale scores for clinical symptoms. Secondary outcomes were vital signs, number of interventions, and pre-treatment blood test results. These variables were evaluated 1 week before at the start of the study, and at 5 and 14 weeks after the start of each treatment period. The removal characteristics of the various solutes were evaluated when possible on the first day of each treatment period. All patients provided written informed consent to participate. Results: Thirty-two patients in group A and 32 patients in group B completed the trial. There were no differences in the primary or secondary outcomes between I-HDF and HD. Serum α₁-microglobulin (MG) levels at 14 weeks were significantly lower for I-HDF than for HD. During treatment, the removal rates for urea and creatinine, which are low molecular weight substances, were significantly lower during I-HDF than during HD. In contrast, the β₂-MG and α₁-MG removal rates were significantly higher during I-HDF than during HD. Furthermore, there was significantly less albumin leak during I-HDF than during HD. The solute removal results reflect the difference in pore size between the hemodiafilter used for I-HDF and the hemodialyzer used for HD and the difference in convective transport attributable to filtration between the 2 methods. Conclusions: These findings show that the removal rates of low molecular weight substances are significantly lower and those of medium to high molecular weight substances are significantly higher with I-HDF than with HD. They also indicate that there is significantly less albumin leak during I-HDF than during HD, meaning that I-HDF may be a particularly suitable dialysis modality for patients with malnutrition and the elderly in Japan.

Comparative study between Sustained Low Efficiency Hemodialysis and Online Hemodiafiltration in Critically Ill patients with Acute Kidney Injury

Background: acute kidney injury (AKI) has arisen as a global public health problem and associated with high morbidity and mortality where the AKI mortality is more than 50%. It is a serious complication frequently occurred in ICU In hospitalized patients, 15% of them developed AKI and around 40% of AKI patients were referred to ICU. Objective: The aim of this study was to compare between effect of Sustained Low Efficiency Hemodialysis and Online Hemodiafiltration in Critically Ill patients with Acute Kidney Injury. Patients and Methods: This prospective study included a total of forty (age and sex matched) patients with Acute Kidney Injury (AKI) who were critically ill, attending at Nephrology Unit, Bab El-Shaareya, Al-Azhar University Hospitals. The patients were divided into 2 groups; Group (A): 20 patients on Sustained Low Efficiency Hemodialysis (SLED) and Group (B): 20 patients on Online Hemodiafiltration (OLHDF) Results: there was no significant difference between the two groups as regard Intradialytic hypotension (2 patients (10 %) in group 1 and 5 patients in group 2 (25%) p-value = 0.2). There was no significant difference between the two groups as regard weaning from ventilator (4 patients (40%) in group 1 and 3 patients in group 2 (42.8%) p-value = 0.5). Conclusion: Online haemodiafiltration (OL-HDF) showed to be better than IHD-LI in many aspects but there was no statistically significant difference in mortality, allowing us to recommend as first choice OL-HDF of treatment proposed for critically ill patients with acute kidney injury.

MON-098 Losses of Amino Acid in the Pre- and Post-dilution of On-line HDF under the Same Reduction Rate of β2-microglobulin

We reported that amino acid loss occurred during pre-dilution on-line hemodiafiltration (Pre-HDF) was significantly less than those of hemodialysis. Since the amino acid kinetics during HDF therapy has not clearly been understood, we compared the amino acid losses that occur on performing Pre-HDF and post-dilution on-line HDF (Post-HDF) under the same reduction rate of β2-microglobulin (β2-MG) in the present study. We compared the total amino acid, total non-essential/essential/branched-chain amino acid amount into the total waste fluid, reduction rate of Urea, Cr and β2-MG and Kt/V (urea) between 9 patients undergoing Pre-HDF (7 males, 4 diabetic, mean age: 72.4±2.1 years) and the same patients receiving Post-HDF. The mean blood flow rate in the former and latter was 222±25 and 200±0 mL/min, respectively. The dialysate flow rate was 329±49 and 556±0 mL/min, respectively. The replacement fluid flow rate was 251±27 and 44±0 mL/min, respectively. The replacement fluid volume was 57±6 and 10±0 L, respectively. The reduction rate ofβ2-MG was same between the Pre-HDF and Post-HDF group (Pre-HDF: 80.9±4.0%, Post-HDF: 80.4±3.7%, P=0.545). In the Pre-HDF group, the total and total non-essential amino acid losses (4814.3±1055.6 and 3058.4±632.0 mg, respectively) were not significantly different from in the Post-HDF group (5257.3±698.9 and 3421.9±446.8 mg, respectively) (P=0.180 and 0.116, respectively). In the former, the total essential amino acid (1755.9±503.3 mg) was not significantly different from in the latter (1835.3±351.0 mg) (P=0.401) and also in the former, the branched-chain amino acid (780.2±224.2 mg) was not significantly in the latter (816.4±210.1 mg) (P=0.139). In the Pre-HDF group, the urea and Cr reduction rates were 69.5±7.4 and 63.2±6.7%, respectively. In the Post-HDF group, the values were 70.9±4.4 and 64.8±3.9%, respectively. The values showed no significant differences between the Pre-HDF and Post-HDF group (Urea: P=0.354, Cr: P=0.309). The Kt/V (urea) values in the former and latter were 1.46±0.28 and 1.45±0.19, respectively; there was no significant difference (p=0.862). Under the same reduction rate of β2-MG, the moderate volume Post-HDF (replacement fluid volume: around 10.0 L) is as favorable as the Pre-HDF as a blood purification method from the viewpoint of nutrition.

MON-114 COMPARISON OF ON-LINE HEMODIAFILTRATION AND HEMODIALYSIS ON THE REMOVAL RATE OF DRUGS

Recent data suggest that the removal rate of drugs is higher in predilution on-line hemodiafiltration(HDF) treatment because of the result in temporary reduction of serum protein binding rate. However, as far as searching, there are few studies comparing drug removal rates for Online-HDF and conventional hemodialysis therapy (HD). In this study, we compared the removal rate of drugs between in predilution on-line HDF and HD treatment.

SAT-040 HAEMODIAFILTRATION IMPROVES THE CARDIOVASCULAR RISK PROFILE AND PATIENT RELATED OUTCOME MEASURES COMPARED TO CONVENTIONAL HAEMODIALYSIS IN CHILDREN – THE HDF, HEART AND HEIGHT (3H) STUDY

Fluid overload, hypertension and cardiovascular disease are common in children on dialysis. In adults, haemodiafiltration (HDF) is shown to reduce cardiovascular mortality compared to conventional haemodialysis (HD), but causes for this are not clear and data in children are scarce. We performed a non-randomized parallel-arm clinical trial within the International Paediatric Haemodialysis Network registry to compare outcomes on HD versus post-dilution on-line HDF: the HDF, Heart and Height (3H) study. Co-primary outcome measures were annualised changes in carotid intima-media thickness standard deviation score (cIMT-SDS) and height-SDS. ClinicalTrials.gov: NCT02063776 190 children (from 28 centres in 10 countries across Europe and North America) were recruited, and 177 fulfilled inclusion criteria. 133 children (78 on HD and 55 on HDF) completed one-year follow-up. There was no difference between HD and HDF groups in age, gender, underlying renal disease, comorbidities, dialysis vintage, access type, blood flow or presence of residual renal function. There were 44 dropouts, mainly (79%) due to transplantation; there were no deaths. The median convective volume achieved in the HDF group was 13.33 (inter-quartile range 12.4 to 14.5) ml/m2/session. Annualised change in cIMT SDS was 10-fold lower in HDF compared to HD (0.013 vs 0.48; p=0.002; Figure 1). On propensity score analysis, after adjusting for potential confounders, children on HD had a +0.47 greater increase in annualised cIMT-SDS (95%CI 0.07-0.87; p=0.02) compared to those on HDF. The 24-hour mean arterial pressure (MAP)-SDS increased on HD but reduced on HDF. Serum β2-microglobulin, PTH and high-sensitivity CRP were lower and haemoglobin was higher in HDF patients at 1-year. Predictors of higher cIMT-SDS and MAP-SDS at 12-months (data adjusted for country and baseline values) were HD group, higher inter-dialytic weight gain and ultrafiltration rate and higher β2-microglobulin. Height-SDS increased in HDF but remained static in HD. Importantly, the type of vascular access, blood flow rate and residual renal function did not correlate with cIMT SDS, suggesting that convective clearance is a significant determinant of outcome. Patient related outcome measures that are primarily associated with fluid status, such as the post-dialysis recovery time, headaches, dizziness and cramps, were less frequent and less severe in HDF compared to HD patients. Lower inter-dialytic weight gain on HDF, implying lower ultrafiltration rates per session and greater hemodynamic stability, was strongly associated with fewer symptoms. HDF patients had improved school attendance and greater physical activity scores, but there was no difference in hospitalisation rates. A significant limitation of the study is that randomization was not possible due to small patient numbers. In conclusion, 3H, the largest paediatric dialysis study to date, has shown that HDF improves blood pressure and hemodynamic stability and increases the removal of middle-molecular weight uremic toxins that may, in turn, may halt the progression of vascular disease, improve growth rates and patient related outcome measures compared to conventional HD. Randomised trials to study to confirm these outcomes are required.

Online Hemodiafiltration Versus High-Flux Hemodialysis in Pediatric Patients.

Background Online haemodiafiltration (OL-HDF is associated with increased convective clearance compared to HD, even with a high flux membrane. The aim of this study was to compare the effect of OL-HDF and high-flux HD (HF-HD) on anemia, metabolic bone disease markers and dialysis efficiency. Patients and Methods In this prospective study, 16 children, on hemodialysis for at least three months, were shifted from HF-HD to OL-HDF for a period of 3 months on each modality. The mean age of patients was 10.31 ± 3.28 years, and the mean duration on HD was 57.50 ± 38.24 months. Blood pressure, hemoglobin (Hb), Calcium, phosphorus and Parathyroid hormone were measured after 3 months of HF-HD and again after 3 months of OL-HDF. Results In our study, dialysis efficiency expressed by Kt/V was significantly improved by OL-HDF (2.07±0.47) as compared to HF-HD (1.75±0.46); p value of 0.006. Significantly lower levels of Phosphorus and Parathyroid hormone (PTH) on HF-HD compared to OL-HDF were observed (4.25 ±1.3 to 4.92 ±1.9 mg/dl on OL-HDF, p value 0.04; and 404±476 to 749±79 g/dl, p value 0.001, respectively). The levels of Hb, hematocrit (HCT) and ferritin, Erythropoietin dose requirements were not significantly differnet. Systolic blood pressure values showed significant reduction on HF-HD (111.4 ±12.3 and 114.4 ±10.9 mmHg respectively, p value 0.013). Conclusions Over a period of three months, oHDF was not associated with better anemia management and nutrition when compared to HF-HD, while HDF proved to be more beneficial in dialysis efficiency. HF-HD was more effective in controlling BP and metabolic bone disease.

Changes in acute blood purification therapy in critical care: republication of the article published in the Japanese Journal of Artificial Organs.

Acute blood purification therapy is an essential artificial organ in critical care. In the review article, looking back on the history, we describe our present knowledge and techniques of acute blood purification therapy in critical care. The topics include continuous hemodiafiltration (CHDF), online HDF as an artificial liver support, blood purification therapy aiming to remove pathogenic substances of sepsis, a procedure for connecting a CRRT device into an extra-corporeal membrane oxygenation circuit, and replacement fluid for CHDF. We also raise remaining issues and clarify the future direction of acute blood purification therapy in critical care. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2017 (Vol. 46, No. 1, pp. 67-70), with adding some references.