Removal of water-soluble and protein-bound solutes with reversed mid-dilution versus post-dilution haemodiafiltration

Eloot, Sunny; Dhondt, Annemieke; Landschoot, Mieke Van; Waterloos, Marjan; Vanholder, Raymond

doi:10.1093/ndt/gfs060

Cited by 21 publications

(10 citation statements)

References 34 publications

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“…Nevertheless, both techniques were similarly effective in reducing the microinflammatory state in the patient. A recent study [21] supports our findings. They compared the total solute removal of mid-dilution and post-dilution HDF which was not different for both small water-soluble and protein-bound compounds.…”

Section: Discussionsupporting

confidence: 93%

Post-Dilution High Convective Transport Improves Microinflammation and Endothelial Dysfunction Independently of the Technique

Ariza

Merino²,

Carracedo³

et al. 2013

Blood Purif

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Background/Aims: We examined the effects of different online hemodiafiltration techniques on microinflammation and endothelial damage/repair. Methods: The study was designed as a prospective crossover study. Flow cytometry was used to measure CD14⁺CD16⁺ monocytes, apoptotic endothelial microparticles (EMPs), and endothelial progenitor cells (EPCs). Results: Patients treated with high-flux hemodialysis showed a marked chronic inflammatory state (HF-HD 11 ± 2) versus healthy subjects (HS 3.9 ± 2.3; p < 0.05). High convective transport, independent of the technique used, improves microinflammatory parameters (OL-HDF 7.3 ± 2.1 or MID 6.5 ± 3.4; p < 0.05) and the endothelial damage/repair balance compared to HF-HD (EPCs HF-HD 0.3 ± 0.2), with no differences found between the two modalities (EPCs OL-HDF 0.6 ± 0.1, MID 0.6 ± 0.2; p < 0.05). Conclusion: An increase in convective transport improves the microinflammatory state and the endothelial damage/repair of these patients independently of the technique used.

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Section: Discussionsupporting

confidence: 93%

Post-Dilution High Convective Transport Improves Microinflammation and Endothelial Dysfunction Independently of the Technique

Ariza

Merino²,

Carracedo³

et al. 2013

Blood Purif

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“…The RR and TRS values behaved similarly for different dialysis modalities and settings for urea, IS and IAA as mean RR and TRS values were significantly lower for conventional low-flux dialysis than for other dialysis settings for all solutes (p < 0.001), which is in good relation with results of the previous studies [51,52]. However, Trp RR values were not influenced by dialysis modality.…”

Section: Discussionsupporting

confidence: 83%

Serum Levels and Removal by Haemodialysis and Haemodiafiltration of Tryptophan-Derived Uremic Toxins in ESKD Patients

Paats

Adoberg

Arund

et al. 2020

IJMS

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Tryptophan is an essential dietary amino acid that originates uremic toxins that contribute to end-stage kidney disease (ESKD) patient outcomes. We evaluated serum levels and removal during haemodialysis and haemodiafiltration of tryptophan and tryptophan-derived uremic toxins, indoxyl sulfate (IS) and indole acetic acid (IAA), in ESKD patients in different dialysis treatment settings. This prospective multicentre study in four European dialysis centres enrolled 78 patients with ESKD. Blood and spent dialysate samples obtained during dialysis were analysed with high-performance liquid chromatography to assess uremic solutes, their reduction ratio (RR) and total removed solute (TRS). Mean free serum tryptophan and IS concentrations increased, and concentration of IAA decreased over pre-dialysis levels (67%, 49%, −0.8%, respectively) during the first hour of dialysis. While mean serum total urea, IS and IAA concentrations decreased during dialysis (−72%, −39%, −43%, respectively), serum tryptophan levels increased, resulting in negative RR (−8%) towards the end of the dialysis session (p < 0.001), despite remarkable Trp losses in dialysate. RR and TRS values based on serum (total, free) and dialysate solute concentrations were lower for conventional low-flux dialysis (p < 0.001). High-efficiency haemodiafiltration resulted in 80% higher Trp losses than conventional low-flux dialysis, despite similar neutral Trp RR values. In conclusion, serum Trp concentrations and RR behave differently from uremic solutes IS, IAA and urea and Trp RR did not reflect dialysis Trp losses. Conventional low-flux dialysis may not adequately clear Trp-related uremic toxins while high efficiency haemodiafiltration increased Trp losses.

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“…This novel analysis suggests that changes in β 2 M concentration explain one third of the estimated benefit of minimally reused HF dialyzers, while the remainder is accounted for by direct effects which are not related to β 2 M. Thus, in spite of the theoretical predominance of the “middle molecule” hypothesis on dialysis technology research[ 62 ], a closer examination of HEMO suggests that removal of these uremic solutes may have only a modest effect on outcomes. Although β 2 M is considered a marker for the entire spectrum of “middle” molecule toxins [ 63 , 64 ], other uremic retention solutes may demonstrate dialytic kinetics that differ from those of β 2 M [ 65 , 66 ]. It is conceivable that the direct flux effect, could be ascribed to an imprecise quantification of middle molecule exposure by the predialysis β 2 M concentration, the removal of other molecules or to non-clearance effects of dialyzers.…”

Section: Discussionmentioning

confidence: 99%

Dialyzer Reuse and Outcomes of High Flux Dialysis

et al. 2015

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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.

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Removal of water-soluble and protein-bound solutes with reversed mid-dilution versus post-dilution haemodiafiltration

Cited by 21 publications

References 34 publications

Post-Dilution High Convective Transport Improves Microinflammation and Endothelial Dysfunction Independently of the Technique

Post-Dilution High Convective Transport Improves Microinflammation and Endothelial Dysfunction Independently of the Technique

Serum Levels and Removal by Haemodialysis and Haemodiafiltration of Tryptophan-Derived Uremic Toxins in ESKD Patients

Dialyzer Reuse and Outcomes of High Flux Dialysis

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