Predilution Online Hemodiafiltration Research Articles

Experience with Tandem Pre-Dilution Online Hemodiafiltration and Centrifugal Plasma Exchange in Pretransplant Desensitization for Abo-Incompatible Kidney Transplantation: A Case Report

In the use of therapeutic plasma exchange (TPE) as antibody removal therapy for ABO-incompatible (ABOi) kidney transplantation, it is technically possible to perform online hemodiafiltration (OHDF) and TPE simultaneously for patients who are receiving OHDF. In this study, we report tandem therapy of pre-dilution OHDF and centrifugal plasma exchange (cTPE), instead of membrane plasma exchange, which is the mainstay of TPE in Japan. A total of 14 sessions of tandem cTPE and pre-dilution OHDF were performed as preoperative antibody removal therapy for 6 ABOi kidney transplant recipients. cTPE intra-circuit pressure, decreased antibody titer, and adverse events were evaluated. The study was carried out following the ethical standards of the Declaration of Helsinki and Istanbul. Donors were not prisoners or individuals who were coerced or paid. The tandem therapy was completed safely in 12 of the 14 sessions, with no problems such as pressure upper and lower limit alarms or circuit coagulation. In 2 sessions, the tandem therapy had to be interrupted due to coagulation on the dialysis circuit side. Antibody titers were reduced by a median of 3-fold for both IgG and IgM. There was no acute antibody-associated rejection. In preoperative apheresis therapy for ABOi kidney transplantation, tandem therapy of pre-dilution OHDF and cTPE may be a useful treatment option that can be performed safely and results in sufficient reduction of antibody levels.

Removal of α1-Microglobulin Using Post-Dilution Online Hemodiafiltration with Polymethylmethacrylate Membrane: An Open-Label, Single-Arm Study

Introduction: The removal of low- and medium-molecular-weight proteins has been improved with online hemodiafiltration (OL-HDF) and hemodialysis using high-flux membranes; however, the outcomes of patients with end-stage kidney disease (ESKD) undergoing dialysis treatment are still worse than in the general population. α₁-Microglobulin (α₁-m), with a molecular weight of 33,000 Da, may contribute to dialysis-related disorders and mortality. However, the removal is insufficient even with current OL-HDF using the polysulfone (PS) membrane, which is common in Japan. Polymethylmethacrylate (PMMA) membranes can remove medium- to high-molecular-weight proteins by adsorption. This study aimed to assess the efficacy of removing medium- to high-molecular-weight proteins, such as α₁-m and β₂-microglobulin (β₂-m), through post-dilution OL-HDF with PMMA (Post-PMMA). The assessment was conducted in comparison to pre-dilution OL-HDF with PS (Pre-PS), using an open-label, single-arm study. Methods: Seven patients with ESKD on Pre-PS underwent Post-PMMA with replacement volume of 30 mL/min (low flow) and 50 mL/min (high flow). Clearance and removal rates of α₁-m, β₂-m, small molecules, inflammatory cytokines, and albumin were measured at 60 and 240 min of treatment. Results: Clearance rates of α₁-m at 60 min were −2.8 ± 5.2 mL/min with Pre-PS, −0.4 ± 2.6 mL/min with Post-PMMA (low), and 0.6 ± 3.4 mL/min with Post-PMMA (high). The removal rate of α₁-m was higher in Post-PMMA than that in Pre-HDF-PS (Post-PMMA [high] 17.7 ± 5.9%, Post-PMMA [low] 15.0 ± 5.6%, and Pre-PS 4.1 ± 5.5%). Adsorption clearance of β₂-m was increased with Post-PMMA. Albumin leakage in Post-PMMA was not higher than that in Pre-PS. Conclusion: The removal rate of α₁-m with Post-PMMA was higher than that with Pre-PS. The PMMA membrane adsorbed β₂-m, suggesting the removal effect of medium- to high-molecular-weight proteins by the adsorption method. Since Post-PMMA effectively removes α₁-m without excessive albumin leakage, it will be useful for patients with ESKD, especially those with a poor nutritional status.

Efficacy of polymethylmethacrylate membrane hemodiafilter Filtryzer® PMF™-21A in improving pruritus in hemodialysis patients: a prospective interventional study

BackgroundHemodialysis-associated pruritus (HAP) occurs in 60–80% of hemodialysis patients. This significant complication not only decreases quality of life through sleep disturbance and depression, but also leads to poor survival outcomes. The polymethylmethacrylate (PMMA) membrane was the first synthetic polymer membrane for the hollow-fiber artificial kidney created in 1977. PMMA membrane dialyzers have been reported to be effective for improving various complaints, including pruritus, and nutritional status. In Japan, a PMMA membrane hemodiafilter Filtryzer® PMF™-A (PMF-A) was launched in November 2021 and subsequently became available for online hemodiafiltration (OHDF). This study aimed to determine whether PMF-A effectively improves pruritus in hemodialysis patients.MethodsParticipants were 20 patients (median age 74.5 years) on predilution OHDF (pre-OHDF) or postdilution OHDF (post-OHDF) using an Asymmetric Triacetate Membrane® hemodiafilter (FIX-210E eco or FIX-210S eco), who were experiencing pruritus of “very mild” or higher severity based on the Shiratori severity score either during the daytime or nighttime. After switching to post-OHDF with PMF-21A (substitution flow rate: 10 L/session), the substitution flow rate was gradually increased according to results of pruritus evaluation every 2 weeks over 3 months. The primary endpoint was the severity of pruritus evaluated using visual analogue scale (VAS) and the Shiratori severity score. Secondary endpoints included white blood cell count (WBC), hemoglobin level (Hb), platelet count (Plt), serum albumin level (Alb), high-sensitivity C-reactive protein (hsCRP), IL-6, dry weight (DW), and solute removal performance.ResultsThe median VAS score was significantly decreased 2 weeks after switching compared with baseline (44 mm) and remained significantly decreased at Week 12 (22 mm; p < 0.01). From baseline to Week 12, 16 patients (80%) showed improvement in VAS score. The percentage of patients with mild to moderate daytime pruritus according to the Shiratori severity score decreased significantly from 80.0% to 45.0% (p < 0.05), whereas no significant change was observed for nighttime pruritus (p = 0.267). Pre-dialysis serum β2-MG levels were significantly higher at Week 12 compared with baseline. No significant changes were observed in WBC, Hb, Plt, serum Alb, hsCRP, IL-6, or DW.ConclusionsOHDF with PMF-21A may be more effective in improving HAP.

Albumin Loss in Post-Dilution On-Line Hemodiafiltration Compared With Pre-Dilution On-Line Hemodiafiltration and Conventional Hemodialysis

Albumin Loss in Post-Dilution On-Line Hemodiafiltration Compared With Pre-Dilution On-Line Hemodiafiltration and Conventional Hemodialysis

Comparison of the pre-dilution and post-dilution methods for online hemodiafiltration.

Online hemodiafiltration (OL-HDF) is a treatment modality using diffusion and ultrafiltration. There are two types of dilution methods in OL-HDF: pre-dilution, which is commonly provided in Japan, and post-dilution, which is commonly provided in Europe. The optimal OL-HDF method for individual patients is not well studied. In this study, we compared the clinical symptoms, laboratory data, spent dialysate, and adverse events of pre- and post-dilution OL-HDF. We conducted a prospective study of 20 patients who underwent OL-HDF between January 1, 2019 and October 30, 2019. Their clinical symptoms and dialysis efficacy were evaluated. All patients underwent OL-HDF every 3months in the following sequence: first pre-dilution, post-dilution, and second pre-dilution. We evaluated 18 patients for the clinical study and 6 for the spent dialysate study. No significant differences in spent dialysates regarding small and large solutes, blood pressure, recovery time, and clinical symptoms were observed between the pre- and post-dilution methods. However, the serum α1-microglobulin level in post-dilution OL-HDF was lower than that in pre-dilution OL-HDF (first pre-dilution: 124.8 ± 14.3mg/L; post-dilution: 116.6 ± 13.9mg/L; second pre-dilution: 125.8 ± 13.0mg/L; first pre-dilution vs. post-dilution, post-dilution vs. second pre-dilution, and first pre-dilution vs. second pre-dilution: p = 0.001, p < 0.001, and p = 1.000, respectively). The most common adverse event was an increase in transmembrane pressure in the post-dilution period. Compared to pre-dilution, the post-dilution method decreased the α1-microglobulin level; however, there were no significant differences in clinical symptoms or laboratory data.

Systematic Comparison of Uremic Toxin Removal Using Different Hemodialysis Modes: A Single-Center Crossover Prospective Observational Study

Many hypotheses could explain the mortality decrease observed using hemodiafiltration, such as reduction of intradialytic hypotension and more efficient toxin removal. We led a systematic analysis of representative uremic toxin removal with hemodialysis (HD), online postdilution hemodiafiltration (postHDF) and online predilution hemodiafiltration (preHDF), in a single-center crossover and prospective observational study. The primary outcome was the reduction ratio of uremic toxins of the three categories defined by the Eutox group. Twenty-six patients were treated by those three techniques of extra renal epuration. Mean Kt/Vurea was not different between the treatment methods. Mean reduction ratio of beta2microglobulin was significantly higher for both HDF treatments than for HD (p < 0.001). Myoglobin, kappa, and lambda free light chain reduction ratio was significantly different between the modes: 37.75 ± 11.95%, 45.31 ± 11% and 61.22 ± 10.56%/57.21 ± 12.5%, 63.53 ± 7.93%, and 68.40 ± 11.79%/29.12 ± 8.44%, 34.73 ± 9.01%, and 45.55 ± 12.31% HD, preHDF, and postHDF, respectively (p < 0.001). Mean protein-bound solutes reduction ratio was not different between the different treatments except for PCS with a higher reduction ratio during HDF treatments. Mean albumin loss was always less than 2 g. HDF improved removal of middle molecules but had no effect on indoles concentration without any difference between synthetic dialysis membranes.

High-volume pre-dilution on-line hemodiafiltration is the adequate blood purification method from the viewpoint of amino acid nutrition

BackgroundWe compared amino acid leakage among high-volume pre-dilution on-line hemodiafiltration (Pre O-HDF), hemodialysis (HD), and post-dilution on-line hemodiafiltration (Post O-HDF).Subjects and methodsThe subjects were 9 patients. For HD, the total dialysate flow rate was established as 500 mL/min. For high-volume Pre O-HDF, it was established as 600 mL/min, under a replacement fluid volume of 90 L. For Post O-HDF, it was established as 600 mL/min, under a replacement fluid volume of 10 L. In both procedures, the duration of treatment was 4 h, and the blood flow volume was 200 mL/min. We compared the leakages of total amino acid, non-essential amino acid, and essential amino acid, clear spaces (CSs), β2-microglobulin (β2-MG) reduction rate, Kt/V for urea, and albumin leakage among the three procedures.ResultsAmino acid leakages after high-volume Pre O-HDF were significantly lower than HD and Post O-HDF. The CSs after high-volume Pre O-HDF were significantly lower than Post O-HDF. The β2-MG reduction rate after high-volume Pre O-HDF was significantly lower than Post O-HDF. The Kt/V for urea was not significantly different. Albumin leakages were below the detection limit (< 1 g) in the three procedures.ConclusionUnder the treatment conditions we performed this time, high-volume Pre O-HDF reduces amino acid leakage in comparison with HD and Post O-HDF. High-volume Pre O-HDF is a therapeutic mode that suppresses amino acid leakage.

Effects of Japanese-style online hemodiafiltration on survival and cardiovascular events

BackgroundAll-cause mortality can be reduced in patients receiving European-style high-volume post-dilution online hemodiafiltration (post-OHDF) compared with hemodialysis (HD). Japanese-style high-volume pre-dilution online hemodiafiltration (pre-OHDF) can also decrease all-cause mortality. No studies have investigated survival in patients receiving Japanese-style post-OHDF, and directly compared survival between pre-OHDF and post-OHDF. This study sought to clarify these issues.MethodsWe conducted this retrospective observational study at multiple facilities of our medical corporation, which have similar quality of healthcare management, from July 1, 2017 to July 1, 2020. Japanese-style OHDF included pre-OHDF and post-OHDF. Pre-OHDF and post-OHDF were each divided into high-volume and low-volume subgroups. We compared 3-year all-cause mortality and cardiovascular events between OHDF and high-flux HD using propensity score matching. In addition, we examined the effects of different modalities through comparisons between high-volume and low-volume pre-OHDF and between pre-OHDF and post-OHDF.ResultsPost-OHDF was associated with significantly lower all-cause mortality (P = 0.004, log-rank test; hazard ratio [HR] 0.257, 95% confidence interval [CI] 0.094–0.701) and cardiovascular events during all 3 years (P < 0.05) compared with HD. High-volume post-OHDF was associated with lower all-cause mortality compared with hemodialysis (log-rank test P = 0.022) but low-volume post-OHDF was not. Pre-OHDF was also associated with lower all-cause mortality (P < 0.001, log-rank test; HR 0.316; 95% CI 0.212–0.472) compared with HD but was not associated with cardiovascular events. All-cause mortality did not significantly differ between post-OHDF and pre-OHDF.ConclusionsThese findings suggest that Japanese-style post-OHDF may improve all-cause mortality to a level similar to that of pre-OHDF and that post-OHDF, particularly high-volume post-OHDF may reduce cardiovascular events.

Supportive Effects of Online Hemodiafiltration Therapy on the Nutritional State and Lipid Profile in Very Elderly Dialysis Patients

Introduction: Online hemodiafiltration (HDF) therapy has been recognized as one of the potential dialysis modalities. However, the long-term effects of online HDF therapy on very elderly dialysis patients older than 75 years have yet to be fully elucidated. Methods: Seventy-four very elderly patients older than 75 years undergoing maintenance dialysis therapy were studied retrospectively. Twenty-four (mean ± SE, 81.5 ± 1.0 years) were treated by predilution online HDF, and fifty (81.2 ± 0.6 years) were treated by conventional hemodialysis (HD) for 3 years. Laboratory data related to the nutritional state and lipid profile were collected. Body composition was measured by a bioelectrical impedance method. Results: Dry weight and body mass index decreased in HD patients (2.9%, p = 0.003 and 3.1%, p = 0.001, respectively), while no significant changes were found in online HDF patients. Serum albumin levels reduced in both HD and online HDF groups (3.5%, p = 0.003 and 2.9%, p = 0.026, respectively). The geriatric nutritional risk index decreased in HD patients (3.0%, p < 0.001), while no significant change was shown in online HDF patients. Body composition analysis demonstrated a significant decrease in intracellular water and increases in extracellular water and edema ratio in both groups. Fat mass and %fat showed significant decreases in HD patients (8.1%, p = 0.003 and 7.3%, p = 0.003, respectively), but no significant changes in online HDF patients. Among laboratory data, serum high-density lipoprotein cholesterol levels did not change in HD patients. However, the levels elevated significantly (10.6%, p = 0.03) in online HDF patients. Discussion/Conclusion: These results indicated that the time-dependent deterioration of the nutritional state in very elderly dialysis patients was inevitable; however, such deterioration was not prominent in online HDF patients. Moreover, the lipid profile showed unique changes in online HDF patients. In order to treat very elderly dialysis patients, online HDF should preferentially be taken into consideration because the maintenance of general condition seems to be a practical goal against the natural time-dependent deterioration.

The Effect of Predilution Online Hemodiafiltration on Body Composition, Nutritional Status, and Mortality

The Effect of Predilution Online Hemodiafiltration on Body Composition, Nutritional Status, and Mortality

Hemodiafiltration Improves Low Levels of Health-Related Quality Of Life (Qol) and Nutritional Conditions of Hemodialysis Patients.

We compared the effects on the nutritional condition and health-related quality of life (HR-QoL) of the treatment of patients with on-line hemodiafiltration (OL-HDF) and conventional hemodialysis (CHD) using a superflux dialyzer. In total, 47 maintenance (M) HD patients were treated by CHD with a high-flux dialyzer for the first 4 months (1st CHD) and were then switched to predilution OL-HDF for the next 4 months (OL-HDF), after which CHD was resumed for the last 4 months (2nd CHD). We assessed the clinical parameters, fat mass value, muscle mass value, and HR-QoL. In patients with low serum albumin levels, these levels significantly (p < 0.05) increased in the OL-HDF period. Moreover, the fat mass values significantly (p < 0.05) increased in patients with decreased fat mass values in the OL-HDF period. Although there was no significant difference in the patients with higher scores of physical functioning, role physical, vitality, and social functioning, patients with lower scores in the 1st CHD period had significantly increased (p < 0.05) in the OL-HDF period. In this crossover study, we revealed that OL-HDF treatment significantly improved the nutritional conditions and HR-QoL scores compared with the improvement observed after CHD with a superflux dialyzer, especially for maintenance hemodialysis patients with malnutrition and a low QoL.

Comparison of the effects of pre-dilution and post-dilution online hemodiafiltration on the levels of inflammatory markers, lymphocytes, and platelets.

Online hemodiafiltration (OL-HDF) is a blood purification therapy based on diffusion and ultrafiltration and is classified into two types according to the mode of addition of the substitution fluid: pre-dilution OL-HDF (pre-HDF) and post-dilution OL-HDF (post-HDF); we previously reported that pre-HDF is more biocompatible. However, we used lower blood and substitution flow rates in that study and may not have accurately simulated the treatment conditions used in Europe. In this study, we compared the biocompatibilities of the treatment conditions of pre-HDF, commonly used in Japan, and post-HDF, commonly used in Europe, to determine the most biocompatible treatment conditions. We compared the biocompatibilities of pre-HDF and post-HDF using high blood flow rates and high substitution fluid volumes, and also compared the results with those of our previous study. We enrolled six stable patients undergoing maintenance dialysis at our clinic for this study. After the patients underwent hemodialysis (HD), post-HDF, and pre-HDF treatment, the biocompatibilities (based on the serum levels of high-sensitivity C-reactive protein, interleukin-6, pentraxin-3, β-thromboglobulin, and soluble P-selectin, and the results of the lymphocyte blastogenesis test using phytohemagglutinin and concanavalin A as mitogens) and removal performances (removal performance for urea, creatinine, β2-microglubulin [MG], and α1-MG, and albumin leakage) were determined. There were no significant differences in the biocompatibility parameters evaluated among the three treatment modes. Post-HDF was associated with significantly higher removal rates of β2-MG than HD. Post-HDF was associated with significantly higher removal rate of α1-MG, and also significantly higher albumin leakage, than HD and pre-HDF.

MO477SERUM C-REACTIVE PROTEIN AND PROCALCITONIN LEVELS IN HEMODIALYSIS AND INTRADIALYTIC ALTERATIONS

Abstract Introduction C-reactive protein (CRP) and procalcitonin (PCT) are widely used as markers of inflammation and infection in general population and in chronic hemodialysis (HD) as well. However, in dialysis (D) patients, serum CRP and PCT levels may be elevated even in the absence of inflammatory or infectious disease and diagnostic process is a challenge in such cases. We studied HD patients' laboratory profile concerning CRP and PCT. Subjects and Methods We studied 25 stable HD patients, M/F=22/3, aged 68(44-89) years, dialyzed thrice weekly for 55(6-274) months with a dialysate flow rate of 700 ml/min, with a residual daily diuresis less than 200 ml, Kt/V values of 1,44±0,3 and no signs of infection. Patients were classified in two groups. Group A included 10 patients on pre-dilution online hemodiafiltration (HDF). Group B consisted of 15 patients on conventional HD with low-flux polysulfone membrane. Twenty healthy subjects formed a control group C. Serum CRP and PCT levels were measured in duplicate in A and B groups before and at the end of mid-week dialysis sessions and also in C group. Results Pre-D serum CRP values in the total of patients were higher than those in healthy controls (10,89±19,29 vs 2,54±1,28 mg/L-p=0,004). Compared with group C, pre-D CRP values were higher only in B group (15,98±24,54 mg/L-p=0,001) but not in A group (4,09±3,33 mg/L-p=NS). There was a significant difference in pre-D serum CRP values between A and B groups (p=0,028). At the end of D session serum CRP values showed a tendency to increase in both groups A (5,16±4,81 mg/L) and B (17,00±27,00 mg/L) but differences were not significant. Pre-D serum PCT values in the total of patients were higher than those in healthy controls (0,82±0,9 vs 0,29±0,55 ng/ml-p&amp;lt;0,001). Compared with group C, pre-D PCT values were higher in both A group (0,52±0,15 ng/ml-p&amp;lt;0,001) and B group (1,01±1,13 ng/ml-p=0,006). There was no significant difference in pre-D serum PCT values between A and B groups (p=0,261). At the end of D session serum PCT values decreased in A group (0,32±0,11 ng/ml-p&amp;lt;0,001) and increased in B group (1,12±1,21 ng/ml-p=0,014). Conclusions In patients on both conventional low-flux HD and online HDF pre-D serum CRP and PCT levels were higher than those in healthy subjects. Dialysis modality and membrane flux did not affect post-D serum CRP values, but post-PCT values decreased in online HDF. PCT usefulness might be limited in dialysis with high-flux membranes. Cut-off values have to be established for both markers to eliminate confusion in diagnosis of inflammatory and infectious diseases in hemodialyzed patients.

P1100IMPACT OF THE RELATIONSHIP BETWEEN LOW MOLECULAR WEIGHT PROTEINS REMOVAL EFFICIENCIES AND THE VOLUME OF ALBUMIN LEAKAGE IN HEMODIAFILTRATION THERAPY

Abstract Background and Aims The purpose of hemodiafiltration (HDF) is to remove small- to large molecular weight solutes in order to prevent and treat complications and to improve the prognosis of dialysis patients. Especially, larger low molecular weight proteins (LMWPs) must be removed efficiently. β2-microglobulin (MG) (molecular weight [MW], 11.8 kDa: Stokes radius, 15.6A), is considered as an important marker of dialysis efficiency. However, MW of β2-MG is too small as a marker in HDF. Conversely, α1-MG (MW, 33 kDa: Stokes radius, 28.4A) is the most appropriate marker for evaluation of solute removal efficiency of HDF because of the following reasons: (1) optical molecular size; (2) not very low physiological blood concentration; (3) stable production rate; (4) removal by convection; and (5) accumulation in ESRD. Efficient removal of α1-MG without losing albumin (Alb) (MW,66 kDa: Stokes radius, 35.5A) is impossible even by HDF. In this study, we investigated the relationship between LMWP removal efficiencies and the volume of Alb leakage by analyzing the results of patients undergoing HDF. And we also evaluated the trend of the serum levels of patients who had received high-efficiency HDF for more than three years Method Eighty-seven patients who had received HDF in 2018–2019 were included. The results of HDF (a total of 435 sessions) were analyzed (blood flow rate, 261.5±28.5 mL/min; replacement fluid volume, 48.7 L/s pre-dilution on-line HDF and 14.2 L/s post-dilution on-line HDF). The removal efficiencies of β2-MG, prolactin (PRL), and α1-MG, and the volume of Alb leakage were examined. In addition, the relationship between the removal efficiency of each solute and the volume of Alb leakage was investigated. Changes in serum Alb level were analyzed in 13 patients who continued to receive high-efficiency HDF (the removal rate of α1-MG was 30% or more) for more than three years. Results Analysis of the results (mean ± SD) obtained from a total of 435 sessions (87 patients) showed that the removal rates of β2-MG, PRL, and α1-MG were 80.7 ± 4.5%, 75.8±9.4 and 33.8 ± 9.4%, respectively, and the Alb leakage was 3.9 ± 1.8 g/s. The equations of the approximate curve between Alb leakage and β2-MG, PRL, and α1-MG removal rates were expressed as follows: ï½™= 1.4197ln(x) + 78.972 (R2 = 0.0426), y = 9.7185ln(x) + 64.134 (R2 =0.4632), and ï½™™= 11.225ln(x) + 20.282 (R2 = 0.6191), respectively. These results indicate that the dynamics between Alb leakage and α1-MG removal are very similar. That is, although the molecular weight of Alb is twice as that of α1-MG, the difference in their Stokes radius is 20%; therefore, separate removal of Alb and α1-MG is impossible. The mean serum Alb level in 13 patients who received high-efficiency HDF for 3 years or longer was 3.59 ± 0.23 g/dL in January 2017 and 3.69 ± 0.28 g/dL in December 2019, revealing no changes. Conclusion The efficient removal of larger LMWPs leads to the leakage of Alb. However, an Alb leakage of 3 to 6 g/s has little influence on the serum Alb level of patients. Thus, α1-MG is the most appropriate marker of the solute removal efficiency of HDF.

Comparison between citrate and acetate dialysate in chronic online hemodiafiltration: A short-term prospective study in pediatric settings

BackgroundThe use of citrate in chronic hemodialysis to acidify dialysis solutions, in replacement of acetate, began in the 2000's. The purpose of the following study is to determine whether this change represents a better alternative regarding short-term tolerance, efficiency and biocompatibility of chronic renal replacement therapy (RRT) in pediatric patients. MethodsA monocentric prospective observational study was conducted in the pediatric dialysis department of Nancy (France) between December 1st, 2014 and January 25, 2015 on a cohort of pediatric patients under predilution on-line hemodiafiltration (olHDF). Sessions were analysed during two study periods of 14 days: a first period during which dialysis solutions were acidified using acetate and a second during which solutes were acidified using citrate. These periods were separated by a washout period of 28 days on citrate solution. Each patient served as his own control. ResultsDialysis clinical tolerance seems better under citrate regimen, with no statistical significance. No benefit was brought out regarding the prevention of coagulation accidents in the extracorporeal circuit under citrate regimen. The efficiency of olHDF sessions was similar between periods, both in terms of uremic toxins clearance and medium-molecular-weight molecules (MMWM) removal. The evolution of several biological parameters seemed favourable over the citrate period: increase in pre-dialysis serum bicarbonate, stability of plasma hemoglobin and decrease in erythropoietin resistance index (ERI). However, differences in the variation of these parameters between the two periods were not significant. No severe and/or symptomatic hypocalcemia occurred. ConclusionThe use of citrate instead of acetate in dialysis and substitution solutions appears in the short term as a safe alternative for chronic online hemodiafiltration in children.

Therapeutic effect of high-efficiency online hemodiafiltration for recurrent restless legs syndrome in dialysis patients

Two dialysis patients developed recurrent restless legs syndrome. The clinical courses and the association between the α1-microglobulin removal rate and the therapeutic effects of hemodiafiltration were analyzed. Case 1: a middle-aged woman was switched from predilution online hemodiafiltration to hemodialysis, following which the α1-microglobulin removal rate decreased from 39.1 to 29.9%. A month later, the severe restless legs syndrome occurred. The treatment was then switched to high-efficiency hemodiafiltration and 2 weeks later, these symptoms were resolved. The α1-microglobulin removal rate increased to 41.9%. Her symptoms recurred 5 years later with severity; thus, the hemodiafiltration treatment conditions were changed. Under revised conditions, the α1-microglobulin removal rate was 42.6%, and her symptoms were alleviated. Continuation of high-efficiency hemodiafiltration led to the resolution of the syndrome at 1 month after recurrence. Case 2: a middle-aged man on hemodialysis developed the restless legs syndrome in the second year of treatment. The α1-microglobulin removal rate was 23.8%. After switching to a month-long high-efficiency hemodiafiltration with a removal rate of ≥ 40%, his symptoms were resolved. However, the syndrome recurred after a year with severity. The symptoms were alleviated using various measures. The hemodiafilters were changed, and hemodiafiltration with an α1-microglobulin removal rate of ≥ 40% was continued; 2 months later, his symptoms resolved. High-efficiency online hemodiafiltration is an effective therapeutic strategy for restless legs syndrome in dialysis patients. We found, for the first time, that target removal efficiency is an α1-microglobulin removal rate of 40% or higher.

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.

Predilution online hemodiafiltration is associated with improved survival compared with hemodialysis

On-line hemodiafiltration is an increasingly common alternative to chronic hemodialysis in some countries, based on the results of randomized controlled trials of post-dilution on-line hemodiafiltration. There are now more than 60,000 patients treated with on-line hemodialfiltration in Japan, over 95% of whom use predilution on-line hemodiafiltration; however, large-scale data on clinical outcomes with this modality are lacking. We created a propensity-matched cohort of 5,000 pairs of patients treated with conventional hemodialysis or predilution on-line hemodiafiltration, using the Japanese Society for Dialysis Therapy Renal Data Registry database from December 31, 2012 to December 31, 2013. One-year all-cause and cardiovascular mortality were compared between the groups. Predilution on-line hemodiafiltration was associated with improved overall survival compared to hemodialysis (hazard ratio for all cause-mortality 0.83, 95% confidence interval 0.705-0.986), with a trend towards improved cardiovascular survival. Among patients treated with predilution on-line hemodiafiltration, those treated with high substitution volumes (≥40.0 L per session) had improved all-cause and cardiovascular survival compared to those treated with low substitution volumes (<40.0 L per session) or those on hemodialysis. The optimal substitution volume associated with improved overall survival was estimated to be 50.5 L [95% confidence interval 39.0-63.5 L]. This observational study suggests that predilution on-line hemodiafiltration, especially with high substitution volumes, may improve all-cause and cardiovascular survival, but randomized controlled trials are needed.

A case of severe carbamazepine overdose treated successfully with pre-dilution online hemodiafiltration

A case of severe carbamazepine overdose treated successfully with pre-dilution online hemodiafiltration