The Impact of Membrane Permeability and Dialysate Purity on Cardiovascular Outcomes

Abstract

The effects of high-flux dialysis and ultrapure dialysate on survival of hemodialysis patients are incompletely understood. We conducted a randomized controlled trial to investigate the effects of both membrane permeability and dialysate purity on cardiovascular outcomes. We randomly assigned 704 patients on three times per week hemodialysis to either high-or low-flux dialyzers and either ultrapure or standard dialysate using a two-by-two factorial design. The primary outcome was a composite of fatal and nonfatal cardiovascular events during a minimum 3 years follow-up. We did not detect statistically significant differences in the primary outcome between high-and low-flux (HR=0.73, 95% CI=0.49 to 1.08, P=0.12) and between ultrapure and standard dialysate (HR=0.90, 95% CI=0.61 to 1.32, P=0.60). Posthoc analyses suggested that cardiovascular event-free survival was significantly better in the high-flux group compared with the low-flux group for the subgroup with arteriovenous fistulas, which constituted 82% of the study population (adjusted HR=0.61, 95% CI=0.38 to 0.97, P=0.03). Furthermore, high-flux dialysis associated with a lower risk for cardiovascular events among diabetic subjects (adjusted HR=0.49, 95% CI=0.25 to 0.94, P=0.03), and ultrapure dialysate associated with a lower risk for cardiovascular events among subjects with more than 3 years of dialysis (adjusted HR=0.55, 95% CI=0.31 to 0.97, P=0.04). In conclusion, this trial did not detect a difference in cardiovascular event-free survival between flux and dialysate groups. Posthoc analyses suggest that high-flux hemodialysis may benefit patients with an arteriovenous fistula and patients with diabetes and that ultrapure dialysate may benefit patients with longer dialysis vintage.

Clinical Outcome of Twice-Weekly Hemodialysis Patients with Long-Term Dialysis Vintage

“…Secondly, recent advance in hemodialysis may enable twiceweekly HD to maintain for a long-term dialysis vintage. Most patients in the study used Fresenius high flux dialyzers and all the patients used ultrapure dialysate, such conditions would ensure an optimal solute clearance and benefit both the twice-weekly HD and thriceweekly HD patients [19][20][21]. Thus, our unique twice-weekly HD model characterized as a longer HD session time, a higher spKt/V around 2.0, and using high flux dialyzers and a personalized incremental dialysis approach.…”

Global challenges posed by the growth of end-stage renal disease

“…While survival remains much higher in Japan than in other countries, further improvement should always be sought, and public policy planners should be aware that stabilization in the prevalent population is, in reality, a sign that new efforts to improve dialysis survival must be supported. Perhaps technological advancements such as the use of ultrapure dialysis [17][18][19] might conceivably result in gains in prevalent patient survival. Additionally, the Japanese research community should continue to investigate whether increasing the use of β-adrenergic blockers, which may benefit some patients [20,21] and which are used in comparatively lower amounts in Japan than in some other countries [22], could provide longevity benefits, especially in patients with heart failure or left ventricular hypertrophy.…”

Effect of a More Permeable Dialysis Membrane on ESA Resistance in Hemodialysis Patients - A Pilot Investigation

“…A systematic review found a significant benefit of ultrapure dialysis fluid [28] and a recent controlled trial found a lower ESA dose usage in 85 patients randomized to ultrapure fluid [29] . In our study, all treatments were performed with dialysis machines having on-line ultrafiltration of dialysis fluid.…”