Performance of hemodialysis with novel medium cut-off dialyzers

Alexander H Kirsch, Raphael Lyko, Lars-Göran Nilsson, Werner Beck, Michael Amdahl, Petra Lechner, Andreas Schneider, Christoph Wanner, Alexander R Rosenkranz, Detlef H Krieter, Alexander H Kirsch, Raphael Lyko, Lars-Göran Nilsson, Werner Beck, Michael Amdahl, Petra Lechner, Andreas Schneider, Christoph Wanner, Alexander R Rosenkranz, Detlef H Krieter

Abstract

Background: Compared to high-flux dialysis membranes, novel medium cut-off (MCO) membranes show greater permeability for larger middle molecules.

Methods: In two prospective, open-label, controlled, randomized, crossover pilot studies, 39 prevalent hemodialysis (HD) patients were studied in four dialysis treatments as follows: study 1, three MCO prototype dialyzers (AA, BB and CC with increasing permeability) and one high-flux dialyzer in HD; and study 2, two MCO prototype dialyzers (AA and BB) in HD and high-flux dialyzers in HD and hemodiafiltration (HDF). Primary outcome was lambda free light chain (λFLC) overall clearance. Secondary outcomes included overall clearances and pre-to-post-reduction ratios of middle and small molecules, and safety of MCO HD treatments.

Results: MCO HD provided greater λFLC overall clearance [least square mean (standard error)] as follows: study 1: MCO AA 8.5 (0.54), MCO BB 11.3 (0.51), MCO CC 15.0 (0.53) versus high-flux HD 3.6 (0.51) mL/min; study 2: MCO AA 10.0 (0.58), MCO BB 12.5 (0.57) versus high-flux HD 4.4 (0.57) and HDF 6.2 (0.58) mL/min. Differences between MCO and high-flux dialyzers were consistently significant in mixed model analysis (each P < 0.001). Reduction ratios of λFLC were greater for MCO. Clearances of α1-microglobulin, complement factor D, kappa FLC (κFLC) and myoglobin were generally greater with MCO than with high-flux HD and similar to or greater than clearances with HDF. Albumin loss was moderate with MCO, but greater than with high-flux HD and HDF.

Conclusions: MCO HD removes a wide range of middle molecules more effectively than high-flux HD and even exceeds the performance of high-volume HDF for large solutes, particularly λFLC.

Keywords: beta2-microglobulin; dialysis; hemodiafiltration; hemodialysis; uremic toxins.

© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA.

Figures

FIGURE 1
FIGURE 1
Free immunoglobulin light chain removal during hemodialysis with medium cut-off dialyzers and high-flux dialyzers in study 1. (A) Overall clearance. (B) Reduction ratio. Data are least square mean ± standard error. FLC, free light chain; MCO, medium cut-off dialyzer. *P < 0.001, compared to high-flux dialyzer.
FIGURE 2
FIGURE 2
Free immunoglobulin light chain removal during hemodialysis with medium cut-off dialyzers and high-flux dialyzers and hemodiafiltration in study 2. (A) Overall clearance. (B) Reduction ratio. Data are least square mean ± standard error. FLC, free light chain; HD, hemodialysis; HDF, hemodiafiltration; MCO, medium cut-off dialyzer. *P < 0.001, compared to high-flux HD; **P < 0.001, compared to HDF; ***P = 0.01, compared to HDF.

References

    1. Duranton F, Cohen G, De Smet R et al. . Normal and pathologic concentrations of uremic toxins. J Am Soc Nephrol 2012; 23: 1258–1270
    1. Vanholder R, De Smet R, Glorieux G et al. . Review on uremic toxins: classification, concentration, and interindividual variability. Kidney Int 2003; 63: 1934–1943
    1. Vanholder RC, Eloot S, Glorieux GL. Future avenues to decrease uremic toxin concentration. Am J Kidney Dis 2016; 67: 664–676
    1. Cohen G, Haag-Weber M, Mai B et al. . Effect of immunoglobulin light chains from hemodialysis and continuous ambulatory peritoneal dialysis patients on polymorphonuclear leukocyte functions. J Am Soc Nephrol 1995; 6: 1592–1599
    1. Cohen G, Rudnicki M, Horl WH. Uremic toxins modulate the spontaneous apoptotic cell death and essential functions of neutrophils. Kidney Int Suppl 2001; 78: S48–S52
    1. Vanholder R, Schepers E, Pletinck A et al. . The uremic toxicity of indoxyl sulfate and p-cresyl sulfate: a systematic review. J Am Soc Nephrol 2014; 25: 1897–1907
    1. Desjardins L, Liabeuf S, Lenglet A et al. . Association between free light chain levels, and disease progression and mortality in chronic kidney disease. Toxins 2013; 5: 2058–2073
    1. Lisowska-Myjak B. Uremic toxins and their effects on multiple organ systems. Nephron Clin Pract 2014; 128: 303–311
    1. Assi LK, McIntyre N, Fraser S et al. . The association between polyclonal combined serum free light chain concentration and mortality in individuals with early chronic kidney disease. PLoS ONE 2015; 10: e0129980.
    1. Haynes R, Hutchison CA, Emberson J et al. . Serum free light chains and the risk of ESRD and death in CKD. Clin J Am Soc Nephrol 2011; 6: 2829–2837
    1. Hutchison CA, Burmeister A, Harding SJ et al. . Serum polyclonal immunoglobulin free light chain levels predict mortality in people with chronic kidney disease. Mayo Clin Proc 2014; 89: 615–622
    1. DiRaimondo CR, Pollak VE. Beta 2-microglobulin kinetics in maintenance hemodialysis: a comparison of conventional and high-flux dialyzers and the effects of dialyzer reuse. Am J Kidney Dis 1989; 13: 390–395
    1. Locatelli F, Mastrangelo F, Redaelli B et al. . Effects of different membranes and dialysis technologies on patient treatment tolerance and nutritional parameters. The Italian Cooperative Dialysis Study Group. Kidney Int 1996; 50: 1293–1302
    1. Ward RA, Schmidt B, Hullin J et al. . A comparison of on-line hemodiafiltration and high-flux hemodialysis: a prospective clinical study. J Am Soc Nephrol 2000; 11: 2344–2350
    1. Boschetti-de-Fierro A, Voigt M, Storr M et al. . MCO membranes: enhanced selectivity in high-flux class. Sci Rep 2015; 5: 18448.
    1. Locatelli F, Martin-Malo A, Hannedouche T et al. . Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol 2009; 20: 645–654
    1. Krane V, Krieter DH, Olschewski M et al. . Dialyzer membrane characteristics and outcome of patients with type 2 diabetes on maintenance hemodialysis. Am J Kidney Dis 2007; 49: 267–275
    1. Chauveau P, Nguyen H, Combe C et al. . Dialyzer membrane permeability and survival in hemodialysis patients. Am J Kidney Dis 2005; 45: 565–571
    1. Nistor I, Palmer SC, Craig JC et al. . Convective versus diffusive dialysis therapies for chronic kidney failure: an updated systematic review of randomized controlled trials. Am J Kidney Dis 2014; 63: 954–967
    1. Grooteman MPC, van den Dorpel MA, Bots ML et al. . Effect of online hemodiafiltration on all-cause mortality and cardiovascular outcomes. J Am Soc Nephrol 2012; 23: 1087–1096
    1. Maduell F, Moreso F, Pons M et al. . High-efficiency postdilution online hemodiafiltration reduces all-cause mortality in hemodialysis patients. J Am Soc Nephrol 2013; 24: 487–497
    1. Ok E, Asci G, Toz H et al. . Mortality and cardiovascular events in online haemodiafiltration (OL-HDF) compared with high-flux dialysis: results from the Turkish OL-HDF Study. Nephrol Dial Transplant 2013; 28: 192–202
    1. Bock AH, Paul B. Efficient removal of beta2 microglobulin and leptin by online hemodiafiltration: comparison of three state of the art dialyzers. In: Kidney Week 2013, Atlanta, GA, 2013. Abstract SA-PO404, p. 718A. American Society of Nephrology, Washington, DC, USA
    1. Basile C, Libutti P, Di Turo AL et al. . Removal of uraemic retention solutes in standard bicarbonate haemodialysis and long-hour slow-flow bicarbonate haemodialysis. Nephrol Dial Transplant 2011; 26: 1296–1303
    1. Yeh KC, Kwan KC. A comparison of numerical integrating algorithms by trapezoidal, Lagrange, and spline approximation. J Pharmacokinet Biopharm 1978; 6: 79–98
    1. Schneditz D, Putz-Bankuti C, Ribitsch W et al. . Correction of plasma concentrations for effects of hemoconcentration or hemodilution. ASAIO J 2012; 58: 160–162
    1. Bergström J, Wehle B. No change in corrected beta 2-microglobulin concentration after cuprophane haemodialysis. Lancet 1987; 1: 628–629
    1. Tattersall JE, Ward RA, EUDIAL group. Online haemodiafiltration: definition, dose quantification and safety revisited. Nephrol Dial Transplant 2013; 28: 542–550
    1. Golper TA. Is hemodiafiltration ready for broader use? Kidney Int 2015; 88: 940–942
    1. Cohen G, Hörl WH. Free immunoglobulin light chains as a risk factor in renal and extrarenal complications. Semin Dial 2009; 22: 369–372
    1. Anandram S, Assi LK, Lovatt T et al. . Elevated, combined serum free light chain levels and increased mortality: a 5-year follow-up, UK study. J Clin Pathol 2012; 65: 1036–1042
    1. Dispenzieri A, Katzmann JA, Kyle RA et al. . Use of nonclonal serum immunoglobulin free light chains to predict overall survival in the general population. Mayo Clin Proc 2012; 87: 517–523
    1. Lamy T, Henri P, Lobbedez T et al. . Comparison between on-line high-efficiency hemodiafiltration and conventional high-flux hemodialysis for polyclonal free light chain removal. Blood Purif 2014; 37: 93–98
    1. Bourguignon C, Chenine L, Bargnoux AS et al. . Hemodiafiltration improves free light chain removal and normalizes κ/λ ratio in hemodialysis patients. J Nephrol 2016; 29: 251–257
    1. Fabbrini P, Sirtori S, Casiraghi E et al. . Polymethylmethacrylate membrane and serum free light chain removal: enhancing adsorption properties. Blood Purif 2013; 35(Suppl 2): 52–58
    1. Oshihara W, Nagao H, Megano H et al. . Trial use of a polymethylmethacrylate membrane for the removal of free immunoglobulin light chains in dialysis patients. NDT Plus 2010; 3: i3–i7
    1. Canaud B, Barbieri C, Marcelli D et al. . Optimal convection volume for improving patient outcomes in an international incident dialysis cohort treated with online hemodiafiltration. Kidney Int 2015; 88: 1108–1116
    1. Krieter DH, Canaud B. High permeability of dialysis membranes: what is the limit of albumin loss? Nephrol Dial Transplant 2003; 18: 651–654.
    1. Kaplan AA, Halley SE, Lapkin RA et al. . Dialysate protein losses with bleach processed polysulphone dialyzers. Kidney Int 1995; 47: 573–578
    1. Samtleben W, Dengler C, Reinhardt B et al. . Comparison of the new polyethersulfone high-flux membrane DIAPES HF800 with conventional high-flux membranes during on-line haemodiafiltration. Nephrol Dial Transplant 2003; 18: 2382–2386
    1. Meert N, Eloot S, Schepers E et al. . Comparison of removal capacity of two consecutive generations of high-flux dialysers during different treatment modalities. Nephrol Dial Transplant 2011; 26: 2624–2630
    1. Ward RA. Protein-leaking membranes for hemodialysis: a new class of membranes in search of an application? J Am Soc Nephrol 2005; 16: 2421–2430
    1. Caravaca F, Arrobas M, Dominguez C. Serum albumin and other serum protein fractions in stable patients on peritoneal dialysis. Perit Dial Int 2000; 20: 703–707
    1. Fiedler R, Neugebauer F, Ulrich C et al. . Randomized controlled pilot study of 2 weeks' treatment with high cutoff membrane for hemodialysis patients with elevated C-reactive protein. Artif Org 2012; 36: 886–893
    1. Daugirdas JT. Physiologic principles and urea kinetic modeling. In: Daugirdas JT, Blake PG, Ing TS (eds). Handbook of Dialysis. Philadelphia, PA: Lippincott Williams & Wilkins, 2007, pp. 25–58.
    1. Maduell F, Arias-Guillen M, Fontseré N et al. . Elimination of large uremic toxins by a dialyzer specifically designed for high-volume convective therapies. Blood Purif 2014; 37: 125–130
    1. Schindler R, Ertl T, Beck W et al. . Reduced cytokine induction and removal of complement products with synthetic hemodialysis membranes. Blood Purif 2006; 24: 203–211
    1. Hulko M, Gekeler A, Koch I et al. . Dialysis membrane pore size does not determine LPS retention. Nephrol Dial Transplant 2015; 30(Suppl 3): iii244.

Source: PubMed

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