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

Abstract

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.

Expanded Hemodialysis and Its Effects on Hospitalizations and Medication Usage: A Cohort Study

“…Interestingly, this study population had relatively low levels of inflammation seen as measured by hsCRP, in comparison to other reports [24]. Furthermore, our findings coincide with a recent randomized clinical trial that showed that compared to HD performed with high-flux dialyzers, HDx was associated with a superior removal of inflammatory cytokines, improving iron metabolism in a manner independent of that related to hepcidin [25].…”

Expanded Haemodialysis as a Current Strategy to Remove Uremic Toxins

“…This was also demonstrated in this study for the coagulation factors analysed that have a molecular weight in the range of albumin. The relationship between MM uremic toxins removal and medication has also been investigated by Lim et al [48] that demonstrated in 49 patients how HDx reduces ESA resistance compared to HD. It has been hypothesized a link between a better TNF-α removal found with MCO and a possible consequent reduced ESA resistance, likely associated with a lower inflammatory state.…”

Assessment of the influence of expanded hemodialysis on the rate of removal of middle molecular weight uremic toxins

“…This results in the development of functional iron deficiency, resistance to the action of erythropoietin and the development of anemia. Extended hemodialysis reduces microinflammation, effectively removes hepcidin, reduces resistance to the action of erythropoietin and enables optimal control of anemia (achieving and maintaining the target value of hemoglobin in the blood of patients treated with regular dialysis) (34,35).…”