Is hemodiafiltration the technical solution to chronic inflammation affecting hemodialysis patients?

Santoro, Antonio; Mancini, Elena

doi:10.1038/ki.2014.81

Cited by 14 publications

(16 citation statements)

References 13 publications

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“…A number of extracorporeal factors have been implicated into inflammatory activation in dialysis patients, including impurities in dialysis water, microbiological quality of the dialysate, and bioincompatible factors in the extracorporeal dialysis circuit [60,61]. …”

Section: Etiology Of Inflammation In Ckdmentioning

confidence: 99%

“…For ESRD patients, two main approaches to decrease inflammatory load related to the dialysis procedure were proposed: elimination of factors triggering inflammation and direct removal of inflammatory mediators [60]. Interventions that were tested include the use of biocompatible membranes, stringent purity standards for HD water, ultrapure dialysate, increased dialysis frequency, and hemodiafiltration.…”

Section: Correction Of Inflammation In Ckdmentioning

confidence: 99%

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Update on Inflammation in Chronic Kidney Disease

2015

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Background: Despite recent advances in chronic kidney disease (CKD) and end-stage renal disease (ESRD) management, morbidity and mortality in this population remain exceptionally high. Persistent, low-grade inflammation has been recognized as an important component of CKD, playing a unique role in its pathophysiology and being accountable in part for cardiovascular and all-cause mortality, as well as contributing to the development of protein-energy wasting. Summary: The variety of factors contribute to chronic inflammatory status in CKD, including increased production and decreased clearance of pro-inflammatory cytokines, oxidative stress and acidosis, chronic and recurrent infections, including those related to dialysis access, altered metabolism of adipose tissue, and intestinal dysbiosis. Inflammation directly correlates with the glomerular filtration rate (GFR) in CKD and culminates in dialysis patients, where extracorporeal factors, such as impurities in dialysis water, microbiological quality of the dialysate, and bioincompatible factors in the dialysis circuit play an additional role. Genetic and epigenetic influences contributing to inflammatory activation in CKD are currently being intensively investigated. A number of interventions have been proposed to target inflammation in CKD, including lifestyle modifications, pharmacological agents, and optimization of dialysis. Importantly, some of these therapies have been recently tested in randomized controlled trials. Key Messages: Chronic inflammation should be regarded as a common comorbid condition in CKD and especially in dialysis patients. A number of interventions have been proven to be safe and effective in well-designed clinical studies. This includes such inexpensive approaches as modification of physical activity and dietary supplementation. Further investigations are needed to evaluate the effects of these interventions on hard outcomes, as well as to better understand the role of inflammation in selected CKD populations (e.g., in children).

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Section: Etiology Of Inflammation In Ckdmentioning

confidence: 99%

Section: Correction Of Inflammation In Ckdmentioning

confidence: 99%

Update on Inflammation in Chronic Kidney Disease

2015

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“…Frequent infectious and thrombotic events provide additional inflammatory stimulations, particularly in dialysis patients, including catheter‐related bloodstream infections, access site infections and thrombosed intravenous fistulas and grafts . The microbiological quality of the dialysate and impurities in dialysis water may also contribute to inflammation . Overall, the acute effect of hemodialysis on cytokine levels is controversial, with inconsistent results regarding changes in IL‐1β, TNF‐ α, IL‐6, and interleukin‐18 .…”

Section: Etiology Of Inflammation In Ckd and Chronic Dialysismentioning

confidence: 99%

Does inflammation affect outcomes in dialysis patients?

Nowak

Chonchol

2018

Seminars in Dialysis

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Chronic, low-grade inflammation is a common comorbid condition in chronic kidney disease (CKD), and particularly in chronic dialysis patients. In this review, we consider the question of whether inflammation affects outcomes in dialysis patients. Levels of proinflammatory cytokines, as well as C-reactive protein, are elevated in chronic dialysis patients. Multiple factors likely contribute to chronic inflammatory activation in kidney disease patients including the uremic milieu, lifestyle and epigenetic influences, infectious and thrombotic events, the dialysis process, and dysbiosis. Increased inflammatory markers in both CKD and chronic dialysis patients are associated with adverse clinical outcomes including all-cause mortality, cardiovascular events, kidney disease progression, protein energy wasting and diminished motor function, cognitive impairment, as well as other adverse consequences including CKD-mineral and bone disorder, anemia, and insulin resistance. Strategies that have been shown to reduce chronic systemic inflammation in CKD and chronic dialysis patients include both pharmacological and nonpharmacological interventions. However, despite evidence that systemic inflammatory markers can be lowered in kidney disease patients treated with various strategies, evidence that this improves clinical outcomes is largely unavailable and represents an important future research direction. Overall, there is strong observational evidence that inflammation is high in chronic dialysis patients and that this is independently associated with numerous adverse clinical outcomes. Targeting inflammation represents a potentially novel and attractive strategy if it can indeed improve adverse outcomes common in this population.

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“…Many studies have demonstrated that hsCRP levels positively correlate to the severity of anemia and increased ESA dose in patients on HD treatment [17,18] . However, the effect of ol-HDF on either inflammation or ESA resistance has been conflicting [10,19] . The main finding from our prospective study is that 12 months after the switchover from hfHD to ol-HDF ( table 3 ), there was a significant and long-lasting reduction in pre-dialysis hsCRP, β 2 M concentrations and ESAdose, with stable Hb and Hct values.…”

Section: Discussionmentioning

confidence: 99%

“…Our study is in agreement with these observations because, as shown in table 3 , both variables decreased significantly at 6 and 12 months in Study group patients after the switch from hfHD to ol-HDF, while no change was seen in Controls over the same time period. Among the factors negatively influencing the inflammatory status of HD patients, age, vintage, comorbidities, poor nutrition, vascular access, membrane biocompatibility, and microbiological quality of the dialysate are the most quoted [19] . However, as shown in table 1 , Study group and Controls at baseline were well matched for age, sex, dialytic vintage, vascular access, and comorbidities, as well as for other parameters such as Hb, sProt, sAlb, PCRn, BW, IDWL, pre-dialysis SBP, and DBP.…”

Section: Discussionmentioning

confidence: 99%

Total Convection Affects Serum β2 Microglobulin and C-Reactive Protein but Not Erythropoietin Requirement following Post-Dilutional Hemodiafiltration

et al. 2015

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Background: Inflammation and increased erythropoiesis stimulating agents (ESA) requirement are frequently associated in patients on dialysis. On-line hemodiafiltration (ol-HDF), putting together high levels of diffusion, and convection could improve both conditions. However, it is still not known which depurative component plays a major role in determining this result. The aim of the study was to evaluate the role of convection and diffusion on long-term variations of serum β₂ microglobulin (Δβ₂M), high-sensitive C-reactive protein (ΔhsCRP) concentrations, and ESA requirement (ΔESA) in ol-HDF. Methods: Seventy-three patients prevalent on high flux HD (hfHD) were studied. Thirty-eight patients were switched from hfHD to post-dilutional ol-HDF (Study group); the other 35 patients were considered the Control group. At 6 and 12 months, the effects of ol-HDF and hfHD on ΔhsCRP, ΔB₂M, and ΔESA (U/kg/week) were evaluated. Other variables considered were body weight (BW), serum albumin (sAlb), hemoglobin (Hb), and equilibrated Kt/V (eKt/V). Iron therapy and ESA were administered intravenously according to the K/DOQI guidelines in order to maintain transferrin saturation between 20 and 40%, serum ferritin between 150 and 500 ng/ml and Hb between 11 and 12 g/dl. Qb, treatment time and Qd remained constant. Ol-HDF and hfHD were performed using membranes of size 1.9-2.1 sqm. Ultrapure dialysate and substitution fluid were employed in both HDF and HD treatments. Data are expressed as mean ± SD. Paired t test, Mann-Whitney U test, and simple and multiple regression analyses were employed for statistical evaluation. Results: Study group: total convective volume (TCV) was 22.1 ± 1.9 l/session. A significant reduction of hsCRP: from 6.8 ± 7.1 to 2.3 ± 2.4 mg/dl (p < 0.001), β₂M: from 36.5 ± 14.4 to 24.7 ± 8.6 mg/dl (p < 0.0001) and ESAdose: from 107 ± 67 to 65 ± 44 U/kg/week (p < 0.005) was observed. No significant variations of Hb, BW and sAlb were seen. A significant inverse correlation was found between TCV and Δβ₂M (r = -0.627; p < 0.0001), and TCV and ΔhsCRP (r = -0.514; p < 0.0001); no correlation between TCV and ΔESAdose was observed. No correlation was found between eKt/V and Δβ₂M, ΔhsCRP, and ΔESAdose. Multiple regression analysis with ΔESAdose as dependent variable showed ΔhsCRP as the only significantly associated independent factor (p < 0.01). Control group: no significant variations of hsCRP, β₂M, and ESAdose were observed over time. Conclusions: Ol-HDF induces a long-term significant reduction in pre-dialysis β₂M and hsCRP concentrations. The magnitude of reduction is directly correlated to the amount of TCV achieved but not on eKt/V. The observed reduction in ESAdose requirement is independent either on convection or diffusion, but is directly associated to the concomitant reduction of inflammation.

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Is hemodiafiltration the technical solution to chronic inflammation affecting hemodialysis patients?

Cited by 14 publications

References 13 publications

Update on Inflammation in Chronic Kidney Disease

Update on Inflammation in Chronic Kidney Disease

Does inflammation affect outcomes in dialysis patients?

Total Convection Affects Serum β2 Microglobulin and C-Reactive Protein but Not Erythropoietin Requirement following Post-Dilutional Hemodiafiltration

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