On-line Hemofiltration in Chronic Renal Failure: Advantages and Limits (original) (raw)
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Kidney International, 2015
Online hemodiafiltration (OL-HDF), the most efficient renal replacement therapy, enables enhanced removal of small and large uremic toxins by combining diffusive and convective solute transport. Randomized controlled trials on prevalent chronic kidney disease (CKD) patients showed improved patient survival with high-volume OL-HDF, underlining the effect of convection volume (CV). This retrospective international study was conducted in a large cohort of incident CKD patients to determine the CV threshold and range associated with survival advantage. Data were extracted from a cohort of adult CKD patients treated by post-dilution OL-HDF over a 101-month period. In total, 2293 patients with a minimum of 2 years of follow-up were analyzed using advanced statistical tools, including cubic spline analyses for determination of the CV range over which a survival increase was observed. The relative survival rate of OL-HDF patients, adjusted for age, gender, comorbidities, vascular access, albumin, C-reactive protein, and dialysis dose, was found to increase at about 55 l/week of CV and to stay increased up to about 75 l/week. Similar analysis of pre-dialysis β2-microglobin (marker of middle-molecule uremic toxins) concentrations found a nearly linear decrease in marker concentration as CV increased from 40 to 75 l/week. Analysis of log C-reactive protein levels showed a decrease over the same CV range. Thus, a convection dose target based on convection volume should be considered and needs to be confirmed by prospective trials as a new determinant of dialysis adequacy.
The International Journal of Artificial Organs, 2005
Sequential dialysis techniques (i.e pure ultrafiltration followed by dialysis) have been used in the past, due to their capability to remove large volumes of fluids without inducing hemodynamic instability. The disadvantages of inadequate efficiency and lack of technology lead to the decline of such methods. Hemofiltration (HF) and hemodiafiltration (HDF) are recently being utilized in a greater proportion thanks to on-line fluid preparation systems. Each process (HF and HDF) has its own benefits in the removal of small, medium and high-molecular weight substances and in hemodynamic stability. Sequential convective therapies (SCT) such as hemofiltration-hemodiafiltration in sequence (HF-HDF) may combine the benefits and eliminate the disadvantages of each method and should be studied in order to explore their potential application in modern dialysis. Furthermore they can be easily applied nowadays, due to the development of new sophisticated dialysis machines. In order to evaluate t...
Hemodialysis International, 2020
Disclosure of grants or other funding: The HDFIT trial was a multi-center investigator-initiated study, whereby the site investigators and principal investigator were not being monetary funded for the conduct of study activities. This project was supported by: 1) the study investigators, 2) the proponent institution Pontifícia Universidade Católica do Paraná, 3) the outpatient dialysis centers, and 4) Fresenius Medical Care. The steering committee was comprised of nephrologists representing site institutions and supporting affiliates. Investigators were involved in the design of the protocol and performed medical oversight and the coordination of data collection during the trial. The principal investigator provided medical oversight of the conduct of the trial at all sites under the guidance of the steering committee and coordinated the trial management. The proponent institution Pontifícia Universidade Católica do Paraná supported the trial with infrastructure for study management through use of the university's ACRO, hosting of the REDCap electronic case report form on the university's server, and use of the university's central Ethics Review Board and Research Council that approved the protocol (central application# 54926916.7.1001.0020; approval# 1.538.784). The outpatient dialysis centers permitted clinical research at the clinics and supported the trial with their clinical staff who performed data collection and the conduct of study procedures under the oversight of the site investigators and local trial leadership. Fresenius Medical Care provided the sites with the infrastructure for the conduct of the trial including HDF machines, dialysis supplies for study participants, body composition monitor machines in clinics without them. Also, they provided some staff for site monitoring. Fresenius Medical Care provided a monetary award to PUCPR's ACRO (EPICENTER) that performed the central management, data acquisition, and monitoring. Fresenius Medical Care and the subsidiary company Renal Research Institute provided support from statistical experts to assist in the analysis of trial data under the oversight of the steering committee. Fresenius Medical Care has supported three investigator meetings, as well as three steering committee meetings. The leadership of Fresenius Medical Care reviewed and approved the protocol prior to commencement. The steering committee members who represent supporting institutions reviewed and approved the research design, protocol, addendums and changes to the protocol, analyses, and this publication of study data, as well as provided oversight of the trial conduct and safety.
Nephrology Dialysis Transplantation, 2001
Background. The potential superiority of various renal replacement treatment modalities consisting largely of convective mass transfer as opposed to primarily diffusive mass transfer, is still a matter of debate. The objective of the present study was to evaluate acute and long-term clinical effects of varying degrees of convection and diffusion in a group of 24 clinically stable patients with end-stage renal disease. Methods. The patients were prospectively assigned to three consecutive treatment schedules of 6 months each: phase I (HF1) (on-line predilution haemo®ltration)£ phase II (HD) (high-¯ux haemodialysis)£phase III (HF2; as phase I). We used the AK100u200 ULTRA monitor (Gambro), which prepares ultrapure dialysis uid for HD and sterile, pyrogen-free substitution solution for HF. The membrane (polyamide),¯uid composition, and treatment time were the same on HF and HD. The targeted equilibrated KtuV was 1.2 for both treatment modes, creating a similar urea clearance. Results. Fifteen patients, mean age 62.8"8.4 years, completed the study according to the above conditions. Urea kinetics, nutritional parameters, and dry weight were similar in the three periods. The frequency of intra-treatment episodes of hypotensionupatientumonth was signi®cantly lower on HF1 (1.24) and HF2 (1.27) than on HD (1.80) (P-0.04). It decreased progressively on HF1, then increased on HD, and decreased again during HF2. Patients had fewer muscular cramps on HF than on HD (P-0.03) and required signi®cantly less saline and plasma expander during HF than HD sessions. The prevalence of inter-treatment symptoms, including fatigue and hypotension, was lower on HF than on HD (score difference Ps0.04). Quality of life, determined by the Laupacis method in all three periods, showed a tendency towards improvement during the study, reaching the best values during HF2. Conclusions. HF has a progressive stabilizing haemodynamic effect, producing a more physiological cardiovascular pro®le than HD. This long-term effect, observed in stable patients treated under strictly identical conditions, is probably due to the mechanism of convection, and is different from the acute effect observed mainly in unstable patients.
Clinical Kidney Journal, 2017
Background. Available evidence suggests a reduced mortality risk for patients treated with high-volume postdilution hemodiafiltration (HDF) when compared with hemodialysis (HD) patients. As the magnitude of the convection volume depends on treatment-related factors rather than patient-related characteristics, we prospectively investigated whether a high convection volume (defined as !22 L/session) is feasible in the majority of patients (>75%). Methods. A multicenter study was performed in adult prevalent dialysis patients. Nonparticipating eligible patients formed the control group. Using a stepwise protocol, treatment time (up to 4 hours), blood flow rate (up to 400 mL/min) and filtration fraction (up to 33%) were optimized as much as possible. The convection volume was determined at the end of this optimization phase and at 4 and 8 weeks thereafter. Results. Baseline characteristics were comparable in participants (n ¼ 86) and controls (n ¼ 58). At the end of the optimization and 8 weeks thereafter, 71/86 (83%) and 66/83 (80%) of the patients achieved high-volume HDF (mean 25.5 6 3.6 and 26.0 6 3.4 L/session, respectively). While treatment time remained unaltered, mean blood flow rate increased by 27% and filtration fraction increased by 23%. Patients with <22 L/session had a higher percentage of central venous catheters (CVCs), a shorter treatment time and lower blood flow rate when compared with patients with !22 L/session.
Continuous Hemofiltration/Hemodiafiltration in Critical Care
Therapeutic Apheresis and Dialysis, 2002
Continuous hemofiltration and continuous hemodiafiltration (CHF/CHDF) were developed as continuous renal replacement therapy for patients with severe conditons and has come to be widely performed mainly in critical care, taking the place of intermittent hemodialysis. The membrane pore size of a hemofilter used for CHF/ CHDF allows passage of substances ranging from 30,000 to 50,000 Da, and the method for solute removal in CHF/ CHDF employs the principle of convection, which is advantageous for removing middle-to high-molecularweight substances. As apheresis therapy to remove pathogenic substances in blood, CHF/CHDF is therefore being investigated for its possible effect on various morbid conditions. It has recently been found that CHF/CHDF removes humoral mediators including cytokines, particu
Kidney international, 2015
Mortality remains high for hemodialysis patients. Online hemodiafiltration (OL-HDF) removes more middle-sized uremic toxins but outcomes of individual trials comparing OL-HDF with hemodialysis have been discrepant. Secondary analyses reported higher convective volumes, easier to achieve in larger patients, improved survival. Here we tested different methods to standardize OL-HDF convection volume on all-cause and cardiovascular mortality compared with hemodialysis. Pooled individual patient analysis of four prospective trials compared thirds of delivered convection volume with hemodialysis. Convection volumes were either not standardized or standardized to weight, body mass index, body surface area, and total body water. Data were analyzed by multivariable Cox proportional hazards modeling from 2793 patients. All-cause mortality was reduced when the convective dose was unstandardized or standardized to body surface area and total body water; hazard ratio (95% confidence intervals) o...