Is Expanded Hemodialysis an Option to Online Hemodiafiltration for Small- and Middle-Sized Molecules Clearance?

Reque, Javier; Alba, Alejandro Pérez; Panizo, Nayara; Sánchez-Canel, Juan J; Pascual, María José; Prades, Ramón Pons

doi:10.1159/000493910

Cited by 32 publications

(38 citation statements)

References 21 publications

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“…The reduction rate of β2-microglobulin was related to membrane composition, blood flow rates and substitution volume [18]. Thus, it is not surprising that the present study and other published studies [16,19] did not find a change in the levels of β2-microglobulin following conversion to the MCO HD from standard dialysis treatments.…”

Section: Discussionsupporting

confidence: 65%

A tRial Evaluating Mid Cut-Off Value Membrane Clearance of Albumin and Light Chains in HemoDialysis Patients: A Safety Device Study

et al. 2020

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Background: A new class of dialysis membrane, the mid cutoff (MCO) dialyzer, has been developed to improve the clearance of uremic toxins in hemodialysis (HD). The a tRial Evaluating Mid cutOff Value membrane clearance of Albumin and Light chains in HemoDialysis patients (REMOVAL-HD) study aimed to determine if regular use of MCO dialyzer was safe and specifically did not result in a significant loss of albumin. Methods: This investigator initiated, crossover, longitudinal , device study was conducted across 9 centers in Australia and New Zealand (n = 89). Participants had a 4-week wash-in with high-flux HD, followed by 24-week intervention with MCO HD and a subsequent 4-week wash-out with high-flux HD. The primary outcome was change in serum albumin between weeks 4 and 28. Secondary outcomes included trends in serum albumin, changes in kappa-and lambda-free light chains (FLC), 6-min walk test (6MWT), malnutrition inflammation score (MIS), restless legs score and quality of life. Results: Participants had a mean age of 66 ± 14 years, 62% were men, 45% were anuric, and 51% had diabetes. There was no reduction in serum albumin following treatment with MCO HD (mean reduction-0.7 g/L, 95% CI-1.5 to 0.1). A sustained, unexplained reduction in serum REMOVAL-HD Study 469

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Section: Discussionsupporting

confidence: 65%

A tRial Evaluating Mid Cut-Off Value Membrane Clearance of Albumin and Light Chains in HemoDialysis Patients: A Safety Device Study

et al. 2020

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“…Thus, the MCO dialyzer has a smaller surface area than conventional high-flux dialyzers, but it can obtain greater convection and shows the effective removal of middle molecules. Although the MCO dialyzer was not compared with HDF in our study, we speculate that use of the MCO dialyzer could improve QOL in patients treated with HDF because the MCO dialyzer has displayed better removal of larger middle molecules than HDF 35,37 . www.nature.com/scientificreports www.nature.com/scientificreports/ One of the major concerns of the MCO dialyzer is the risk of albumin loss through the more permeable membrane.…”

Section: Discussionmentioning

confidence: 92%

Randomized controlled trial of medium cut-off versus high-flux dialyzers on quality of life outcomes in maintenance hemodialysis patients

Lim

Park

Yook

et al. 2020

Sci Rep

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Medium cutoff (MCO) dialyzers help remove larger middle molecules associated with symptoms related to the accumulation of uremic retention solutes. We investigated the effect of an MCO dialyzer on the improvement of quality of life (QOL) in maintenance hemodialysis (HD) patients. Forty-nine HD patients with high-flux dialysis were randomly assigned to either an MCO (Theranova 400, Baxter) or a high-flux (FX CorDiax 80 or 60, Fresenius Medical Care) dialyzer and completed the study. QOL was assessed at baseline and after 12 weeks of treatment using the Kidney Disease Quality of Life Short Form-36, and pruritus was assessed using a questionnaire and visual analog scale. The reduction ratios of middle molecules were also evaluated. Laboratory markers, including serum albumin, did not differ between the two groups after 12 weeks. Removals of kappa and lambda free light chains were greater for MCO dialyzer than high-flux dialyzer. The MCO group had higher scores than the high-flux group in the domains of physical functioning and physical role (75.2 ± 20.8 vs. 59.8 ± 30.1, P = 0.042; 61.5 ± 37.6 vs. 39.0 ± 39.6, P = 0.047, respectively), and the MCO group had lower mean scores for morning pruritus distribution and the frequency of scratching during sleep (1.29 ± 0.46 vs. 1.64 ± 0.64, P = 0.034; 0.25 ± 0.53 vs. 1.00 ± 1.47, P = 0.023, respectively). MCO dialyzers may improve patientreported outcomes, particularly the physical components of QOL and uremic pruritus, in patients with high-flux dialyzers. Patients on maintenance dialysis suffer variable symptoms such as fatigue, generalized weakness, and pruritus. These subjective conditions are assumed to be related to middle molecules that are not cleared by conventional hemodialysis (HD) 1. Middle molecules have molecular weights (MWs) ranging between 500 and 60,000 daltons, and their size is a barrier to removal with dialyzers 2,3. The accumulation of middle molecules is associated with specific complications such as amyloidosis, inflammatory reactions, oxidative stress, and endothelial dysfunction 3-5. Consequently, middle molecules contribute to morbidity and mortality and poor quality of life (QOL) in end-stage renal disease (ESRD) patients 6,7. High-flux dialysis, which has benefits for middle molecule clearance, has not displayed a clear mortality advantage compared with low-flux dialysis; the survival benefits of high-flux dialysis were only observed in patients with hypoalbuminemia and diabetes 8,9. Another dialytic modality, hemodiafiltration (HDF) with increased convection, has a higher efficiency for reducing middle-sized solutes than high-flux dialysis 10,11. Large randomized trials comparing HDF and high-flux dialysis have shown conflicting patient outcome results 12-15 ; however, recent results have consistently shown that HDF with a high convection volume improves patient survival 16-18. Medium cutoff (MCO) dialyzers are characterized by a more even distribution of larger pore sizes and a higher number of pores. MCO dialyzers have a higher permeability and...

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“…In addition, MCO dialyzer has also been verified as an independent predictor that reduces ERI. HD using MCO dialyzer does not involve a higher cost, specific hardware, or unusual nursing skills as OL-HDF 44,45 ; therefore, it will be useful for HD patients with ESA resistance in dialysis centers that cannot perform OL-HDF.…”

Section: Discussionmentioning

confidence: 99%

Medium cut-off dialyzer improves erythropoiesis stimulating agent resistance in a hepcidin-independent manner in maintenance hemodialysis patients: results from a randomized controlled trial

Lim

Jeon

Yook

et al. 2020

Sci Rep

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The response to erythropoiesis stimulating agents (ESAs) is affected by inflammation linked to middle molecules in hemodialysis (HD) patients. We evaluated the effect of a medium cut-off (MCO) dialyzer on ESA resistance in maintenance HD patients. Forty-nine patients who underwent high-flux HD were randomly allocated to the MCO or high-flux group. The primary outcome was the changes of erythropoietin resistance index (ERI; U/kg/wk/g/dL) between baseline and 12 weeks. The MCO group showed significant decrease in the ESA dose, weight-adjusted ESA dose, and ERI compared to the high-flux group at 12 weeks (p < 0.05). The generalized estimating equation models revealed significant interactions between groups and time for the ESA dose, weight-adjusted ESA dose, and ERI (p < 0.05). Serum iron and transferrin saturation were higher in the MCO group at 12 weeks (p < 0.05). The MCO group showed a greater reduction in TNF-α and lower serum TNF-α level at 12 weeks compared to the high-flux group (p < 0.05), whereas no differences were found in the reduction ratio of hepcidin and serum levels of erythropoietin, erythroferrone, soluble transferrin receptor and hepcidin between groups. HD with MCO dialyzer improves ESA resistance over time compared to high-flux HD in maintenance HD patients. The MCO dialyzer provides superior removal of the inflammatory cytokine and thus improves iron metabolism in a hepcidin-independent manner.

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Is Expanded Hemodialysis an Option to Online Hemodiafiltration for Small- and Middle-Sized Molecules Clearance?

Cited by 32 publications

References 21 publications

A tRial Evaluating Mid Cut-Off Value Membrane Clearance of Albumin and Light Chains in HemoDialysis Patients: A Safety Device Study

A tRial Evaluating Mid Cut-Off Value Membrane Clearance of Albumin and Light Chains in HemoDialysis Patients: A Safety Device Study

Randomized controlled trial of medium cut-off versus high-flux dialyzers on quality of life outcomes in maintenance hemodialysis patients

Medium cut-off dialyzer improves erythropoiesis stimulating agent resistance in a hepcidin-independent manner in maintenance hemodialysis patients: results from a randomized controlled trial

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