¿Es la Hemodialfiltración On-line de alto volumen el mejor tratamiento en pacientes con enfermedad renal crónica estadio V? / Is High-Volume On-line Hemodiafiltration the best treatment for patients with Chronic Kidney Disease Stage V?

INTRODUCCIÓN: La hemodiafiltración en línea de alto volumen (HVHDF) es una técnica eficaz que permite la remoción de toxinas urémicas de mayor PM debido al transporte convectivo. Esta modalidad permite mayor estabilidad hemodinámica, disminución de los parámetros inflamatorios y reducción de la mortalidad cardiovascular y por todas las causas comparada con la hemodiálisis (HD). Estos beneficios se producen cuando los volúmenes de sustitución (VS) son mayores a 21 L/sesión de allí la denominación de hemodiafiltración de alto volumen. OBJETIVOS: Evaluar la eficacia de la HVHDF en comparación con HD y determinar si el cambio de modalidad se asocia a mayor estabilidad hemodinámica, mejoría en los resultados de laboratorio, en la cantidad de hospitalizaciones y en la calidad de vida. MATERIAL Y MÉTODOS: Estudio retrospectivo, observacional, en único centro que incluyó 53 pacientes, que completaron 6 meses de HVHDF luego de haber realizado al menos 6 meses de HD. Se analizaron datos demográficos, episodios de hipotensión, número y días de internación tanto en HD como en HVHDF. Se compararon: Hemoglobina (Hb), fósforo (P), parathormona intacta (PTHi), albúmina (alb), proteína C reactiva (PCR), KTV, y dosis de eritropoyetina durante el último mes de HD y sexto mes de HVHDF. Se analizó la encuesta sobre calidad de vida Kidney Disease Quality of Life-36 (KDQOL-36) al inicio y a los 6 meses de HVHDF. RESULTADOS: LA edad media fue de 60,6 años, el 67.9 % eran hombres. La FAV fue el acceso vascular en el 69.8% de los pacientes, mientras que 38 pacientes (71,1%) cumplían con volumen de sustitución > 21 litros/sesión. El 39,6 % presentó algún episodio de hipotensión en HD y 30.2 % lo hizo en HVHDF (p<0.001). El número de episodios de hipotensión fue significativamente mayor en hemodiálisis que en HVHDFL, 40 (18-68) vs 11 (3-33) (p< 0.001). El 32% de pacientes en HD requirió internación y sólo el 11% en HVHDF. Hubo mejoría significativa en la Hb: 10.7 a 11.3 (p<0.01), KTV: 1.4 a 1.5 (p<0.03) y menor requerimiento de EPO (p< 0,02) al 6° mes de HVHDF. En la encuesta de calidad de vida, KDQOL-36, se observó mejoría en el módulo, síntomas problemas, siendo estadísticamente significativo, adicionándose mejoría en short form 12 (SF) físico y mental sólo en los pacientes con volúmenes de sustitución > 21l/sesión. CONCLUSIÓN: En nuestra cohorte el cambio de HD a HVHDF se asoció a una disminución en el número de episodios de hipotensión, reflejando una mayor estabilidad hemodinámica, menor número de internaciones, una mejoría en la hemoglobina, KTV y disminución de dosis semanal de eritropoyetina

INTRODUCTION: High-volume online hemodiafiltration (HV-OL-HDF) is an effective technique to remove uremic toxins with higher molecular weight through convective transport. In correlation with hemodialysis (HD), through this method, greater hemodynamic stability, lower inflammatory parameters and a smaller risk of death due to cardiovascular or any other factors are achieved. These benefits are obtained when substitution volume (SV) is higher than 21L/session; that is the reason why the technique is called high-volume hemodiafiltration (HVHDF). OBJECTIVES: To assess the effectiveness of HVHDF as compared to HD and to determine if changing the type of therapy results in greater hemodynamic stability, better lab test results, a lower number of hospital admissions and a superior quality of life. METHODS: This retrospective observational study was conducted in only one center and included 53 patients who underwent HVHDF during 6 months after having hemodialysis (HD) for at least 6 months. We analyzed demographic variables, number of hypotension events, number of hospital admissions, and length of stay for each type of treatment. The following were compared: hemoglobin (Hb), phosphate (P), intact parathormone (iPTH), albumin (ALB), C-reactive protein (CRP), Kt/V and erythropoietin dose during the last month of HD and the sixth month of HVHDF. The Kidney Disease Quality of Life-36 (KDQOL-36™) questionnaire was completed at the beginning and after 6 months of HVHDF. RESULTS: The average age was 60.6 years old and 67.9% of the participants were men. The vascular access was created using an arteriovenous fistula in 69.8% of patients and 38 of them (71.1%) had substitution volume of > 21L/session. Some patients (39.6 %) experienced a hypotension event during HD and others (30.2%) during HVHDF (p<0.001). The number of hypotension events was significantly higher in patients treated with HD than in patients treated with HV-OL-HDF: 40 (18-68) vs. 11 (3-33) (p< 0.001). The percentage of patients admitted to hospital was the following: 32% for HD and 11% for HVHDF. A considerable improvement was observed in Hb (10.7 to 11.3 [p<0.01]) and Kt/V (1.4 to 1.5 [p<0.03]; a lower dose of EPO was needed after 6 months of HVHDF (p< 0.02). Only patients with substitution volume of > 21L/session showed statistically significant improvement in the symptoms/problems section of KDQOL-36 and in the Short Form-12 (SF-12) Physical and Mental Health Summary. CONCLUSION: When changing from HD to HVHDF, our study group had a lower number of hypotension events; greater hemodynamic stability; a smaller number of hospital admissions; better Hb levels and Kt/V, and they needed a lower dose of erythropoietin

Hemodiafiltración de alto volumen en pacientes en hemodiálisis crónica: importancia de la depuración de b2 microglobulina en el control de calidad del procedimiento / High volume hemodiafiltration in chronic hemodialysis patients: value of b2 microglobulin clearance in the quality control of the procedure

Introducción: La hemodiafiltración on line de alto volumen (HVHDF), ha demostrado mejorar los aclaramientos de medianas moléculas en los pacientes dializados a través de altos volúmenes de convección. El objetivo de este trabajo es valorar la eficacia de esta técnica en la depuración de la β2 microglobulina , comparando su concentración basal en pacientes hemodializados crónicos, con la del final del período analizado. Asimismo, se realizó al KDQOL-SF para valorar la calidad de vida de los pacientes participantes del estudio. Métodos: estudio de cohorte longitudinal de pacientes prevalentes en hemodiálisis de alto flujo - high flux- que pasaron a hemodiafiltración en línea de alto volumen. Se midió, entre otros, el clearance de β2 microglobulina y sus concentraciones a través del tiempo. Se utilizó paquete estadístico Stata 11. Resultados: El período de seguimiento total fue de 84 meses (promedio 23.4 ± 19 meses por paciente). Se realizaron 8978 tratamientos. Los niveles basales al ingreso a HVHDF de β2 fueron de 36,05 mg/l ± 10, y al final del período estudiado, fueron de 31,2 ±10 (p = 0,03). El clearance promedio de β2 fue de 71 ± 16 ml/min. Los niveles de β2 al inicio del estudio se asociaron con la antigûedad en diálisis de los pacientes (r 0,4 - p <0.02). Cinco años de permanencia en hemodiálisis convencional aumentan 11,2 mg/l los niveles de β2 micro globulina, y para obtener niveles por debajo de 30 mg/l en el 50% de nuestros pacientes, se requieren 5 años de High Volume HDF. Conclusión: Los valores de β2 microglobulina basal de los pacientes insuficientes renales crónicos en diálisis, tienen correlación con su antigûedad en hemodiálisis. Los niveles de β2 microglobulina séricas en estos pacientes, disminuyen lentamente y de forma progresiva con significación clínica, cuando la técnica indicada es la hemodiafiltración de alto volumen.

Background: On line high volume hemodiafiltration (HVHDF) has shown to improve the clearance of medium molecules in dialyzed patients through high volumes of convection. The objective of this work is to evaluate the effectiveness of this technique in β2 microglobulin depuration, comparing its basal concentration, in chronic hemodialyzed patients, with the final concentration of the analyzed period. Further more, the KDQOL-SF was performed in order to evaluate the quality of life of the patients who participated in the study. Methods: Longitudinal cohort study of prevalent patients in highflux hemodialysis who were changed to on line high volume hemodiafiltration. Among other, β2 microglobulin clearance and its concentrations changes over time were measured as indicators of efficiency and adequacy of treatment. A statistical package Stata 11 was used. Results: Total follow up period was of 84 months (average 23,4 ± 19 months per patient). 8978 treatments were performed. Basal levels of β2 were; 36.05 mg/l ± 10, when admitted and 31.2 ± 10 (p=0.03), at the end of the study. Clearance mean of β2 was of 71 ± 16ml/min. The levels of β2 at the beginning of the study were associated with elapsed time from the first dialysis of the patients (r 0.4 - p< 0,02). Five years of conventional hemodialysis increase 11.2 mg/l the levels of β2 seric microglobulin and to obtain levels below 30 mg/l in 50% of our patients, 5 years of High Volume HDF is required. Conclusion: Values of β2 basal microglobulin in patients with chronic renal failure undergoing dialysis, are related to the time spent under hemodialysis treatment. In these patients, levels of seric β2 microglobulin, decrease slowly and progressively and reach clinical significance when the technique is high volume hemodiafiltration.

The effect of on-line hemodiafiltration on heart rate variability in end-stage renal disease

BACKGROUND: The autonomic nervous system plays a central role in the maintenance of hemodynamic stability. Cardiac autonomic dysfunction may result in serious complications, such as sudden cardiac death. Heart rate variability (HRV) is sigificantly reduced in patients undergoing chronic hemodialysis (HD). The aim of this study was to evaluate the effect of on-line hemodiafiltration (OL-HDF) on the autonomic nervous system in chronic HD patients. METHODS: Forty chronic HD patients were prospectively studied. The participants were divided into conventional HD and OL-HDF groups. They received regular high-flux HD or OL-HDF for 4-hour sessions, three times a week. Time-and frequency-domain measures of the 24-hour HRV were analyzed during the interdialytic period prior to postdilution OL-HDF and every 6 months for 24 months. The 7-year survival was also evaluated. RESULTS: Among the 40 participants, 15 patients in the HD group and 11 patients in the OL-HDF group completed the study. There was no difference in the baseline characteristics. After 24 months of treatment, beta2-microglobulin concentration decreased (from 33.4 +/- 15.2 mg/dL to 28.4 +/- 6.2 mg/dL, P = 0.02) in the OL-HDF group, while there was no change in the HD group In the HRV analysis, the frequency-domain HRV parameters increased significantly compared with baseline in the OL-HDF group [natural logarithmic high frequency (lnHF), 3.15 +/- 3.36 ms2 vs. 4.42 +/- 3.81 ms2; ln low frequency (LF), 3.56 +/- 3.17 ms2 vs. 4.78 +/- 3.99 ms2; ln very low frequency (VLF), 4.90 +/- 4.62 ms2 vs. 6.38 +/- 5.54 ms2; LF/HF ratio, 1.4 +/- 0.4 vs. 2.5 +/- 0.1]. The survival rate was similar between the groups. CONCLUSION: This study shows that OL-HDF improved autonomic nervous system dysfunction in chronic HD patients.

The evaluation of on-line hemodiafiltration in acute cerebrovascular disease patients complicated with hyperosmolar nonketotic diabetic coma / 中华急诊医学杂志

Objective To access evaluate the efficacy and safety of on-line hemodiafiltration for treating a-cute cerebrovascular disease (ACVD) patients complicated with hyperosmolar nonketotie diabetic coma (HNDC).Method Totally 11 patients of ACVD complicated with HNDC were observed for this prospective control study.All of them underwent on-line hemodiafiltrafion for 90 minutes using Fressnius 4008S Hemodialysis Machine withONLILNEplus TM and F60 one hour after final diagnosis was made. The bicarbonate ultrafiltrate rate was set at 500ml/min and blood flow at 150 ～ 180 ml/min; and the substitute fluid were infused with post-dilution at 50 ～ 60ml/min. The symptom of brain edema and cardiac insufficiency during the same course of treatment was observed.Blood were taken from the patients to detect serum kalium, serum glucose, serum natrium, BUN and plasma os-motic pressure at one hour before treatment and six hours after treatment, respectively. The change of in conscious-ness and adverse effects were evaluated at 24 hours after treatment. Results All patients were treated successful-ly. The blood glucose, serum natrium, serum kalium, BUN and plasma osmotic pressure were decreased after on-line hemodiafiltration. Among the 11 patients, consciousness was improved obviously in 8 patients, 3 patientsdied, accounting for 73% of successful effectiveness. Conclusions The on-line hemodiafiltration was effectiveand safe for treating ACVD patients complicated with HNDC.

Effects of filter reuse on solute clearance and safety in on-line hemodiafiltration / 中华肾脏病杂志

Objective To investigate the effects of filter reuse on solute clearances, safety and oxidative stress parameters in on-line hemodiafiltration(HDF) . Methods 8 stable maintained uremic patients were treated by post-dilution on-line HDF with first-use or reuse F60 polysulfone filter, respectively. Both blood-side and dialysate-side solute clearances at 20 minute of HDF or during the whole session were measured. Whole blood interleukin-1?(IL-1?) production was monitored before HDF, after HDF, and at 20 minutes of HDF at both venous and arterial lines. Plasma before and after treatment and dialysate were collected for measuring total ascorbic acid, dehydroascorbic acid and total vitamin E. Restults No difference of small molecular substance clearances was observed in blood and dialysate side, while filter reuse group had a significantly higher dialysate side clearance and a significantly lower absorption clearance for ?2-microglobulin. In contrast with stable vitamin E concentration during dialysis, total ascorbic acid level decreased after treatment, with reuse group further inducing a reduced ration of dehydroascorbic acid to total ascorbic acid. No significant changes were found in whole blood IL-1? production within and between each group, so did intra-dialysis symptoms and temperature curves. Reuse filter also caused more albumin loss through high-flux membrane than that of first-use filter. Conclusions Although reuse filter can maintain both small and large molecular weight substance clearance, it increases albumin loss through high-flux membrane. Reuse filter does not stimulate white blood cell to produce more cytokine than the first-use filter, but it increases oxidative stress, and may harm uremic patients in a long run.