Treatment Policy rather than Patient Characteristics Determines Convection Volume in Online Post-Dilution Hemodiafiltration

Chapdelaine, Isabelle; Mostovaya, Ira M.; Blankestijn, Peter J.; Bots, Michiel L.; Dorpel, Marinus A. van den; Lévesque, Renée; Nubé, Menso J.; Wee, Piet M. ter; Grooteman, Muriël P.C.

doi:10.1159/000362108

Cited by 42 publications

(52 citation statements)

References 28 publications

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“…Although the CONTRAST study was designed to provide high-volume online hemodiafiltration treatments (8), there was a wide variation in the delivered convective volumes particularly between centers (11). It is well recognized that blood flow and sessional time are important in determining convective exchange (12), but we wished to determine whether there were additional patient or treatment-related factors that were important in achieving higher volume convective exchanges.…”

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confidence: 99%

Dialysis and Patient Factors Which Determine Convective Volume Exchange in Patients Treated by Postdilution Online Hemodiafiltration

Davenport

2016

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Recent reports suggest a survival advantage for dialysis patients treated by postdilutional online hemodiafiltration (OL-HDF) who achieve higher volume convective exchanges. As such, the factors associated with achieving higher convective volume exchange were determined. The convective exchange volumes during the midweek OL-HDF session in a cohort of 653 patients with corresponding bio-impedance measurements of volume status and sessional electronic records were audited. Mean patient age was 64.9 ± 14.9 years, 65.3% male, 47.7% diabetes, with 81.6% dialyzing using fistula access. Sessional substitution volume exchanged was 17.0 ± 3.5 L (83.8 ± 13.9 mL/min), with a filtration fraction of 23.3 ± 4.6%, sessional time of 3.8 ± 0.5 h, and blood flow 321 ± 28 mL/min. As expected, convection exchange volume achieved was associated with sessional time (β 3.24, P < 0.001), blood flow (β 0.03, P < 0.001), dialysate flow (β 0.03, P < 0.001), but also patient factors: postsessional intracellular water (ICW) (β 0.07, P = 0.002), and serum albumin (β 0.71, P = 0.011). In addition convective exchange was lower for diabetics (16.6 ± 3.0 vs. 17.3 ± 3.8 L, P < 0.01), and for patients with higher Davies co-morbidity grades (16.6 ± 2.8 vs. 17.0 ± 3.6 vs. 17.9 ± 4.0 L), P = 0.01 respectively. As expected the convective volume exchanged with OL-HDF was associated with sessional time and blood and dialysate flows. However, the convective volume exchange achieved was also associated with patient factors, including ICW, which is related to body cell mass and also co-morbidity. Although some center practices can be modified to increase convective exchange, patient factors are not so readily remediable. As such, highly comorbid patients may not be able to achieve the higher volume convective exchanges reported to be associated with improved patient survival.

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Dialysis and Patient Factors Which Determine Convective Volume Exchange in Patients Treated by Postdilution Online Hemodiafiltration

Davenport

2016

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“…As the duration of the dialysis session is an important determinant of the convection volume achieved, this finding is extremely relevant because it highlights the importance of the convection volume per se [22]. To the best of our knowledge, this is the first study that distinguishes the magnitude of the convection volume from treatment time in a survival analysis.…”

Section: Discussionmentioning

confidence: 99%

“…The results of these studies and a recent meta-analysis of these studies strongly suggest a survival benefit of ol-HDF over HD when high convection volumes (>21.95 l/session) are achieved [20]. Considering the convection volume, it was recently shown that its magnitude is for the main part determined by treatment-related factors, such as session time and blood flow rate, and only for a minor part by patient-related factors, including hematocrit and albumin [21,22]. …”

Section: Introductionmentioning

confidence: 99%

Treatment Time or Convection Volume in HDF: What Drives the Reduced Mortality Risk?

Zuijdewijn

Nubé²,

Wee³

et al. 2015

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Background/Aims: Treatment time is associated with survival in hemodialysis (HD) patients and with convection volume in hemodiafiltration (HDF) patients. High-volume HDF is associated with improved survival. Therefore, we investigated whether this survival benefit is explained by treatment time. Methods: Participants were subdivided into four groups: HD and tertiles of convection volume in HDF. Three Cox regression models were fitted to calculate hazard ratios (HRs) for mortality of HDF subgroups versus HD: (1) crude, (2) adjusted for confounders, (3) model 2 plus mean treatment time. As the only difference between the latter models is treatment time, any change in HRs is due to this variable. Results: 114/700 analyzed individuals were treated with high-volume HDF. HRs of high-volume HDF are 0.61, 0.62 and 0.64 in the three models, respectively (p values <0.05). Confidence intervals of models 2 and 3 overlap. Conclusion: The survival benefit of high-volume HDF over HD is independent of treatment time.

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“…Achieving adequate convective volumes may be difficult in patients with limited Q b (patients with catheters or malfunctioning vascular access). However, prescription of Q b is more a matter of treatment policy in each dialysis unit than of the characteristics of the patients themselves [26]. …”

Section: Main Limiting Factors In Achieving High Convective Volume or Qimentioning

confidence: 99%

Is There an ‘Optimal Dose' of Hemodiafiltration?

Maduell

2015

Blood Purif

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Background: Retrospective randomized clinical studies have shown that online hemodiafiltration (OL-HDF) is associated with a lower risk reduction of mortality than standard hemodialysis. Summary: In all of these large randomized studies, the convective volume seemed to be an important issue, but the optimal OL-HDF dose has not yet been defined. This article, to make a EUDIAL working group position, reviews the association between survival and convective volume, the minimum recommended replacement volume, the importance of the infusion flow rate, and the main limiting factors in achieving a high convective volume. Finally, the article discusses whether the convective dose should be normalized to body size. Key Messages: At present, there is sufficient scientific evidence to indicate that OL-HDF treatment reduces mortality risk and that it should be the first-line option in hemodialysis patients. It seems reasonable to recommend that patients should receive the highest possible convective dose and that the largest possible blood flow should be used to obtain the highest possible infusion flow rate. Based on the results of secondary analyses of the main clinical trials, the current recommendation of the optimal dose of OL-HDF, in the postdilutional mode and on a thrice-weekly treatment schedule, would be a convective volume higher than 23 liters/session. There is insufficient scientific evidence to recommend that the convective dose should be normalized to body size.

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Treatment Policy rather than Patient Characteristics Determines Convection Volume in Online Post-Dilution Hemodiafiltration

Cited by 42 publications

References 28 publications

Dialysis and Patient Factors Which Determine Convective Volume Exchange in Patients Treated by Postdilution Online Hemodiafiltration

Dialysis and Patient Factors Which Determine Convective Volume Exchange in Patients Treated by Postdilution Online Hemodiafiltration

Treatment Time or Convection Volume in HDF: What Drives the Reduced Mortality Risk?

Is There an ‘Optimal Dose' of Hemodiafiltration?

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