Dialyzer Reuse and Outcomes of High Flux Dialysis

Abstract

BackgroundThe bulk of randomized trial evidence for the expanding use of High Flux (HF) hemodialysis worldwide comes from two randomized controlled trials, one of which (HEMODIALYSIS, HEMO) allowed, while the other (Membrane Outcomes Permeability, MPO) excluded, the reuse of membranes. It is not known whether dialyzer reuse has a differential impact on outcomes with HF vs low flyx (LF) dialyzers.MethodsProportional Hazards Models and Joint Models for longitudinal measures and survival outcomes were used in HEMO to analyze the relationship between β2-microglobulin (β2M) concentration, flux, and reuse. Meta-analysis and regression techniques were used to synthesize the evidence for HF dialysis from HEMO and MPO.FindingsIn HEMO, minimally reused (< 6 times) HF dialyzers were associated with a hazard ratio (HR) of 0.67 (95% confidence interval, 95%CI: 0.48–0.92, p = 0.015), 0.64 (95%CI: 0.44 – 0.95, p = 0.03), 0.61 (95%CI: 0.41 – 0.90, p = 0.012), 0.53 (95%CI: 0.28 – 1.02, p = 0.057) relative to minimally reused LF ones for all cause, cardiovascular, cardiac and infectious mortality respectively. These relationships reversed for extensively reused membranes (p for interaction between reuse and flux < 0.001, p = 0.005) for death from all cause and cardiovascular causes, while similar trends were noted for cardiac and infectious mortality (p of interaction between reuse and flux of 0.10 and 0.08 respectively). Reduction of β2M explained only 1/3 of the effect of minimally reused HF dialyzers on all cause mortality, while non-β2M related factors explained the apparent attenuation of the benefit with more extensively reused dialyzers. Meta-regression of HEMO and MPO estimated an adjusted HR of 0.63 (95% CI: 0.51–0.78) for non-reused HF dialyzers compared with non-reused LF membranes.ConclusionsThis secondary analysis and synthesis of two large hemodialysis trials supports the widespread use of HF dialyzers in clinical hemodialysis over the last decade. A mechanistic understanding of the effects of HF dialysis and the reuse process on dialyzers may suggest novel biomarkers for uremic toxicity and may accelerate membrane technology innovations that will improve patient outcomes.

Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

“…These issues are believed to arise from the reprocessing procedure involving sanitizing agents [ 67 , 70 ]. However, two studies have indicated that single, minimal (>6 times), or multiple dialyzer reuse carries no impact on dialysis adequacy, body weight, and serum albumin level [ 71 , 72 ].…”

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

“…The issue of the reuse of dialysers has not been developed in this discussion, because the practice has been banned in Italy, as well as in most European countries, for over 20 years. Notwithstanding the increased risk of infection that is often reported, reuse is a highly complex issue, probably also because most of the measures of "biocompatibility" are indirect (like pre-dialysis beta2 microglobulin level) and, as it is common in the field of dialysis, it is very difficult to disentangle the effect on mortality from that of the overall patient care, of which reuse may be a reflection [94,95]. The low quality of the evidence in the available studies, acknowledged in the only systematic review we were able to retrieve, and the heterogeneity of the reuse modalities suggest that the time may be ripe for re-thinking this practice in the different context of ecological sustainability.…”

“…The low quality of the evidence in the available studies, acknowledged in the only systematic review we were able to retrieve, and the heterogeneity of the reuse modalities suggest that the time may be ripe for re-thinking this practice in the different context of ecological sustainability. In this regard, future studies should balance the advantages in reducing plastic waste with the need for using potentially toxic chemicals for membrane sterilization [ 94 – 97 ].…”

<p>Measuring serum beta2-microglobulin to predict long-term mortality in hemodialysis patients using low-flux dialyzer reuse</p>

“…Thus, removal of circulating β2-M during hemodialysis has been considered to be beneficial. Several methods to reduce plasma β2-M levels have been used in dialyzed patients, such as the use of high-flux membrane,7–9 hemodiafiltration 10–13. Role of β2-M in predicting outcome and mortality in both hemodialysis and peritoneal dialysis patients was published in few previous papers 14–16.…”