Divert to ULTRA: Differences in Infused Volumes and Clearance in Two On-Line Hemodiafiltration Treatments

Panichi, Vincenzo; Ferrari, Giacomo De; Saffioti, Stefano; Sidoti, Antonino; Biagioli, Marina; Bianchi, Stefano; Imperiali, Patrizio; Gabbrielli, Claudio; Conti, Paolo; Patrone, Pietro; Falqui, Valeria; Rombolà, Giuseppe; Mura, Carlo; Icardi, A.; Mulas, Donatella; Rosati, Alberto; Santori, F. S.; Mannarino, Antonio; Tomei, Valeria; Bertucci, Andrea; Steckiph, Denis; Palla, Roberto

doi:10.5301/ijao.5000106

Cited by 13 publications

(7 citation statements)

References 26 publications

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“…Systems exist helping to achieve high convection volumes in post dilution OL-HDF. These systems are very efficient as they allow maximum filtration rates and consequently high convection volumes [ 28 – 30 ]. They have an automatic adaptation of convection which avoids TMP alarms whereas the modification of the infusion rates was manual by the nursing staff in our unit.…”

Section: Discussionmentioning

confidence: 99%

Consequences of increasing convection onto patient care and protein removal in hemodialysis

et al. 2017

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IntroductionRecent randomised controlled trials suggest that on-line hemodiafiltration (OL-HDF) improves survival, provided that it reaches high convective volumes. However, there is scant information on the feasibility and the consequences of modifying convection volumes in clinics.MethodsTwelve stable dialysis patients were treated with high-flux 1.8 m2 polysulphone dialyzers and 4 levels of convection flows (QUF) based on GKD-UF monitoring of the system, for 1 week each. The consequences on dialysis delivery (transmembrane pressure (TMP), number of alarms, % of achieved prescribed convection) and efficacy (mass removal of low and high molecular weight compounds) were analysed.ResultsTMP increased exponentially with QUF (p<0.001 for N >56,000 monitoring values). Beyond 21 L/session, this resulted into frequent TMP alarms requiring nursing staff interventions (mean ± SEM: 10.3 ± 2.2 alarms per session, p<0.001 compared to lower convection volumes). Optimal convection volumes as assessed by GKD-UF-max were 20.6 ± 0.4 L/session, whilst 4 supplementary litres were obtained in the maximum situation (24.5 ± 0.6 L/session) but the proportion of sessions achieving the prescribed convection volume decreased from 94% to only 33% (p<0.001). Convection increased high molecular weight compound removal and shifted the membrane cut-off towards the higher molecular weight range.ConclusionsReaching high convection volumes as recommended by the recent RCTs (> 20L) is feasible by setting an HDF system at its optimal conditions based upon the GKD-UF monitoring. Prescribing higher convection volumes resulted in instability of the system, provoked alarms, was bothersome for the nursing staff and the patients, rarely achieved the prescribed convection volumes and increased removal of high molecular weight compounds, notably albumin.

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Section: Discussionmentioning

confidence: 99%

Consequences of increasing convection onto patient care and protein removal in hemodialysis

et al. 2017

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“…These machines can achieve fluid balance with a precision of 6100 ml irrespective of the convection volume. Achieving the desired convection volume can be facilitated by using automated ultrafiltration control systems (16,17), which ensure a maximal tolerable filtration fraction regardless of the blood flow and targeted convection volume (17,18).…”

Section: Technical Requirements For Hdf Hdf Machinesmentioning

confidence: 99%

Hemodiafiltration to Address Unmet Medical Needs ESKD Patients

Canaud

Vienken²,

Ash

et al. 2018

CJASN

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Hemodiafiltration combines diffusive and convective solute removal in a single therapy by ultrafiltering 20% or more of the blood volume processed using a high-flux hemodialyzer and maintaining fluid balance by infusing sterile nonpyrogenic replacement fluid directly into the patient's blood. In online hemodiafiltration, the large volumes of replacement fluid required are obtained by online filtration of standard dialysate through a series of bacteria- and endotoxin-retaining filters. Currently available systems for online hemodiafiltration are on the basis of conventional dialysis machines with added features to safely prepare and infuse replacement fluid and closely control fluid balance. Hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis, and recently completed randomized, controlled clinical trials suggest better patient survival with online hemodiafiltration compared with standard high-flux hemodialysis when a high convection volume is delivered. Hemodiafiltration is also associated with improvements in other clinical outcomes, such as a reduction in intradialytic hypotension, and it is now used routinely to treat >100,000 patients, mainly in Europe and Japan.

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“…The new generation of dialysis machines has improved the software in terms of increasing the total convective volume, thus optimizing infusion flows. The ultracontrol system in the Gambro machines or the Fresenius 5008 CorDiax automated replacement system are technological advances that attempt to maximize the convective volume administered automatically. In comparison with the initial manual prescription of HDF, automated substitution is a practical way of prescribing postdilution on‐line HDF.…”

Section: Association Between Survival and Convective Volumementioning

confidence: 76%

Hemodiafiltration versus conventional hemodialysis: Should “conventional” be redefined?

Maduell

2018

Seminars in Dialysis

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In the 1980s, conventional hemodialysis was considered as dialysis with acetate dialysate, dialysis machines without volumetric control, low blood flow and low-flux dialyzers; in the 1990s, the concept of conventional hemodialysis changed due to technological advances in dialysis machines, control of ultrafiltration and the widespread use of bicarbonate dialysate, which allowed an increase in blood flow and the use of synthetic high-flux dialyzers. To avoid backfiltration-induced adverse reactions, exogenous replacement fluid was promoted but its adoption was limited for technical and financial reasons. This scenario changed in 1995 with the development of on-line hemodiafiltration (HDF) techniques using the dialysis fluid itself as a replacement fluid. Dialysis machines were modified to perform on-line HDF, incorporating safety filters to ensure the quality of this replacement fluid (ultrapure dialysate). After more than two decades of clinical experience and technological development with high-volume HDF, the present article discusses whether HDF can currently be considered as the standard conventional treatment for chronic hemodialysis patients. A review of the evidence indicates that the time has come to consider HDF as the conventional hemodialysis treatment for the following reasons: first, technological development in water treatment and advances in dialysis machines, as well as the widespread use of synthetic high-flux dialyzers has made it a feasible proposition. Second, there is an absence of published literature showing any undesirable effects. Finally, scientific evidence is available showing the superiority of HDF over hemodialysis in overall and cardiovascular mortality in both prevalent and incident patients.

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Divert to ULTRA: Differences in Infused Volumes and Clearance in Two On-Line Hemodiafiltration Treatments

Cited by 13 publications

References 26 publications

Consequences of increasing convection onto patient care and protein removal in hemodialysis

Consequences of increasing convection onto patient care and protein removal in hemodialysis

Hemodiafiltration to Address Unmet Medical Needs ESKD Patients

Hemodiafiltration versus conventional hemodialysis: Should “conventional” be redefined?

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