Protein-bound solute removal during extended multipass versus standard hemodialysis

Sunny Eloot, Wim Van Biesen, Mette Axelsen, Griet Glorieux, Robert Smith Pedersen, James Goya Heaf, Sunny Eloot, Wim Van Biesen, Mette Axelsen, Griet Glorieux, Robert Smith Pedersen, James Goya Heaf

Abstract

Background: Multipass hemodialysis (MPHD) is a recently described dialysis modality, involving the use of small volumes of dialysate which are repetitively recycled. Dialysis regimes of 8 hours for six days a week using this device result in an increased removal of small water soluble solutes and middle molecules compared to standard hemodialysis (SHD). Since protein-bound solutes (PBS) exert important pathophysiological effects, we investigated whether MPHD results in improved removal of PBS as well.

Methods: A cross-over study (Clinical Trial NCT01267760) was performed in nine stable HD patients. At midweek a single dialysis session was performed with either 4 hours SHD using a dialysate flow of 500 mL/min or 8 hours MPHD with a dialysate volume of 50% of estimated body water volume. Blood and dialysate samples were taken every hour to determine concentrations of p-cresylglucuronide (PCG), hippuric acid (HA), indole acetic acid (IAA), indoxyl sulfate (IS), and p-cresylsulfate (PCS). Dialyser extraction ratio, reduction ratio, and solute removal were calculated for these solutes.

Results: Already at 60 min after dialysis start, the extraction ratio in the hemodialyser was a factor 1.4-4 lower with MPHD versus SHD, resulting in significantly smaller reduction ratios and lower solute removal within a single session. Even when extrapolating our findings to 3 times 4 h SHD and 6 times 8 h MPHD per week, the latter modality was at best similar in terms of total solute removal for most protein-bound solutes, and worse for the highly protein-bound solutes IS and PCS. When efficiency was calculated as solute removal/litre of dialysate used, MPHD was found superior to SHD.

Conclusion: When high water consumption is a concern, a treatment regimen of 6 times/week 8 h MPHD might be an alternative for 3 times/week 4 h SHD, but at the expense of a lower total solute removal of highly protein-bound solutes.

Figures

Figure 1
Figure 1
Serum concentrations at different time points during standard hemodialysis SHD (squares - full line) and multipass hemodialysis MPHD (diamonds - dotted line) for p-cresylglucuronide (PCG -panel A), hippuric acid (HA - panel B), indole acetic acid (IAA - panel C), indoxyl sulfate (IS - panel D), and p-cresylsulfate (PCS - panel E). *P < 0.05 MPHD versus SHD. †P = 0.053 MPHD versus SHD.
Figure 2
Figure 2
Cumulative total solute removal (TSR) at different time points during standard hemodialysis SHD (squares - full line) and multipass hemodialysis MPHD (diamonds - dotted line) for p-cresylglucuronide (PCG - panel A), hippuric acid (HA - panel B), indole acetic acid (IAA - panel C), and indoxyl sulfate (IS - panel D), p-cresylsulfate (PCS - panel E). *P < 0.05 MPHD versus SHD.

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