Most high‐flux dialyzers can be used in both hemodialysis (HD) and online hemodiafiltration (OL‐HDF). However, some of these dialyzers have higher permeability and should not be prescribed for OL‐HDF ...to avoid high albumin losses. The aim of this study was to compare the safety and efficacy of a currently used dialyzer in HD and OL‐HDF with those of several other high permeability dialyzers which should only be used in HD. A prospective, single‐center study was carried out in 21 patients. Each patient underwent 5 dialysis sessions with routine dialysis parameters: 2 sessions with Helixone (HD and postdilution OL‐HDF) and 1 session each with steam sterilized polyphenylene, polymethylmethacrylate (PMMA), and medium cut‐off (MCO) dialyzers in HD treatment. The removal ratios (RR) of urea, creatinine, ß2‐microglobulin, myoglobin, prolactin, α1‐microglobulin, α1‐acid glycoprotein, and albumin were compared intraindividually. A proportional part of the dialysate was collected to quantify the loss of various solutes, including albumin. Urea and creatinine RRs with the Helixone‐HDF and MCO dialyzers were higher than with the other 3 dialyzers in HD. The β2‐microglobulin, myoglobin and prolactin RRs with Helixone‐HDF treatment were significantly higher than those obtained with all 4 dialyzers in HD treatment. The β2‐microglobulin value obtained with the MCO dialyzer was also higher than that obtained with the other 3 dialyzers in HD treatment. The myoglobin RR with MCO was higher than those obtained with Helixone and PMMA in HD treatment. The prolactin RR with Helixone‐HD was significantly lower than those obtained in the other 4 study sessions. The α1‐microglobulin and α1‐ acid glycoprotein RRs with Helixone‐HDF were significantly higher than those obtained with Helixone and PMMA in HD treatment. The albumin loss varied from 0.54 g with Helixone‐HD to 3.3 g with polyphenylene. The global removal score values ((UreaRR + β2‐microglobulinRR + myoglobinRR + prolactinRR + α1‐microglobulinRR + α1‐acid glycoproteinRR – albuminRR)/6) were 43.7% with Helixone‐HD, 47.7% with PMMA, 54% with polyphenylene, 54.8% with MCO and 59.6% with Helixone‐HDF, with significant differences. In conclusion, this study confirms the superiority of OL‐HDF over HD with the high‐flux dialyzers that allow both treatments. Although new dialyzers with high permeability can only be used in HD, they are in an intermediate position and some are very close to OL‐HDF.
Blood flow (Qb) is one of the dialysis parameters most strongly influencing the performance of dialysis modalities. However, few studies have compared different dialysis modalities in patients with ...low Qb. We conducted a prospective, single‐center study in 21 patients. Each patient underwent four dialysis sessions with routine dialysis parameters: high‐flux hemodialysis (HD), predilution hemodiafiltration (pre‐HDF), expanded HD (HDx), and postdilution HDF (post‐HDF). The removal ratios (RR) of urea, creatinine, ß2‐microglobulin, myoglobin, prolactin, α1‐microglobulin, free kappa and lambda immunoglobulin light chains (ķFLC and λFLC), α1‐acid glycoprotein, and albumin were compared intraindividually. A proportional part of the dialysate was collected to quantify albumin loss. There were no differences in urea and creatinine RRs. The β2‐microglobulin RR was higher in pre‐HDF and post‐HDF. Myoglobin and prolactin RRs were higher with HDx and post‐HDF. The α1‐microglobulin and α1‐acid glycoprotein RRs were significantly higher with post‐HDF than with other treatments, and RRs obtained with HDx were higher than obtained with HD and pre‐HDF. Free ķFLC and λFLC RRs showed the following results in ascending order: HD, pre‐HDF, HDx, and post‐HDF, most of them with statistical significance. Albumin loss varied from 0.45 g with HD to 3.5 g with post‐HDF. The global removal score values were 41.0 ± 4.8% with HD, 44.0 ± 5.2% with pre‐HDF, 49.5 ± 4.6% with HDx, and 54.8 ± 5.3% with post‐HDF, with significant differences between all treatment modalities. In conclusion, this study confirms the superiority of post‐HDF over high‐flux HD, pre‐HDF, and HDx in patients with low Qb. HDx was the closest alternative to post‐HDF and was clearly superior to HD and pre‐HDF. Finally, pre‐HDF was also superior to HD. With this Qb, there was a higher risk of underdialysis, both diffusive and convective, especially in patients with a session duration of less than 5 h.
The aim of the study was to compare expanded hemodialysis (HDx) with hemodiafiltration (HDF) at different infusion flows to identify the main determinants, namely blood flow (Qb), replacement volume, ...infusion flow (Qi), ultrafiltration flow (Quf), filtration fraction (FF), and the point at which the effectiveness of HDF equals or exceeds that of HDx. We conducted a prospective, single‐center study in 12 patients. Each patient underwent 12 dialysis sessions: six sessions with Qb 350 and six with Qb 400 mL/min; with each Qb, one session was with HDx and five sessions were with FX80 (one in HD, and four with Qi 50, 75, 90/100 mL/min or autosubstitution in postdilution HDF). The reduction ratios (RR) of urea, creatinine, ß2‐microglobulin, myoglobin, prolactin, α1‐microglobulin, α1‐acid glycoprotein, and albumin were compared intraindividually and the global removal score (GRS) was calculated. The mean replacement volume with Qb 350 mL/min was 13.77 ± 0.92 L with Qi 50 mL/min, 20.75 ± 1.17 L with Qi 75, 23.83 ± 1.92 L with Qi 90, and 27.51 ± 2.77 L with autosubstitution. Similar results were obtained with Qb 400 mL/min, and the results were only slightly higher with Qi 100 mL/min or in autosubstitution. The GRS was positively correlated with replacement volume with Qb 350 (R2 = 0.583) and with Qb 400 (R2 = 0.584); with Quf with Qb 350 (R2 = 0.556) and with Qb 400 (R2 = 0.604); and also with FF with Qb 350 (R2 = 0.556) and with Qb 400 mL/min (R2 = 0.603). The minimum convective volume in HDF from which it is possible to overcome the efficacy of HDx was 19.2 L with Qb 350 and 17.6 L with Qb 400 mL/min. The cut‐off point of Quf at which HDF exceeded the effectiveness of HDx was 80.6 mL/min with Qb 350 and 74.1 mL/min with Qb 400 mL/min. The cut‐off point at which FF in HDF exceeded the effectiveness of the HDx was 23.0% with Qb 350 and 18.6% with Qb 400 mL/min. In conclusion, this study confirms the superiority of postdilution HDF over HDx when replacement volume, convective volume, Quf, or FF exceeds certain values. Increasing the Qb in postdilution HDF manages to increase the convective dose and more easily overcome the HDx.
The immunomodulatory effects of extracorporeal photopheresis (ECP) have been used for the treatment of T‐cell mediated disorders, such as rejection in organ transplantation. Currently, it is an ...established therapy for heart and lung rejection, but not for kidney transplantation (KT), where experience is limited. In addition, some data suggest that ECP could generate an immune response against infections, thus being an alternative for the treatment of rejection in case of active or high‐risk of infection. In the present study, we analyze four cases of use of ECP as concomitant therapy in patients with KT and high risk of opportunistic infections due to the high burden of immunosuppression throughout their renal diseases. Two patients had concomitant viral infection (cytomegalovirus and BK virus, respectively) and three patients were on treatment for graft rejection. In the two patients with active viral infection, the infection was successfully controlled during ECP treatment. In all cases, ECP has been shown to be a safe procedure, without complications.
The dialysis‐based definition of Delayed Graft Function (dDGF) is not necessarily objective as it depends on the individual physician’s decision. The functional definition of DGF (fDGF, the failure ...of serum creatinine to decrease by at least 10% daily on 3 consecutive days during the first week post‐transplant), may be more sensitive to reflect recovery after the ischemia‐reperfusion injury. We retrospectively analyzed both definitions in 253 deceased donor kidney transplant recipients for predicting death‐censored graft failure as primary outcome, using eGFR < 25 ml/min/1.73 m2 as a surrogate end‐point for graft failure. Secondary outcome was a composite outcome that included graft failure as above and also patient’s death. Median follow‐up was 3.22 2.38–4.21 years. Seventy‐nine patients developed dDGF (31.2%) and 127 developed fDGF (50.2%). Sixty‐three patients fulfilled criteria for both definitions (24.9%). At multivariable analysis, the two definitions were significantly associated with the primary HR (95%CI) 2.07 (1.09–3.94), P = 0.026 for fDGF and HR (95%CI) 2.41 (1.33–4.37), P = 0.004 for dDGF and the secondary composite outcome HR (95%CI) 1.58 (1.01–2.51), P = 0.047 for fDGF and HR (95%CI) 1.67 (1.05–2.66), P = 0.028 for dDGF. Patients who met criteria for both definitions had the worst prognosis, with a three‐year estimates (95%CI) of survival from the primary and secondary outcomes of 2.31 (2.02–2.59) and 2.20 (1.91–2.49) years for fDGF+/dDGF+, in comparison with the other groups (P < 0.01 for trend). fDGF provides supplementary information about graft outcomes on top of the dDGF definition in a modern series of kidney transplantation.
Introduction
Early graft loss is a devastating kidney transplant complication associated with high mortality and an increased risk of sensitization to antigens from the failed graft. Moreover, if ...rapid re‐transplantation were to occur, given that the human leukocyte antigen antibodies identification may not be reliable until several weeks after transplantation, the recipient's immunological status would be uncertain. Hence, there could be an increased immunological risk. To date, there is no information on whether a rapid re‐transplantation after early graft loss, without a new reliable anti‐HLA determination, is safe.
Methods
We retrospectively analysed the number of rejections and the graft survival of re‐transplanted patients with early graft loss (defined as graft failure before 30 days from transplant) from our centre between June 2003 and November 2019. The studied population was divided into rapid re‐transplantation (performed within 30 days of early graft loss) and late re‐transplantation (performed beyond those 30 days).
Results
Forty‐seven patients were re‐transplanted after early graft loss. There were nine rapid re‐transplantation cases with an 89% five‐year graft survival and one antibody‐mediated rejection episode. Furthermore, we identified 38 cases of late re‐transplantation with a 69% five‐year graft survival, 4 T cell‐mediated, and 11 antibody‐mediated rejections.
Conclusions
Rapid re‐transplantation appears to be safe and does not entail increased rejection risk, nor does it impact long‐term graft survival when compared to late re‐transplantation.
SUMMARY AT A GLANCE
This observational study provides information on the benefit and feasibility of early retransplantation, within 30 days of early graft loss (defined as graft failure within 30 days of kidney transplant).
Introduction
Nonantigen‐specific immunoadsorption (IA) has proven to be effective in acute antibody‐mediated rejection (aAMR). However, there is a lack of solid studies evaluating the safety and ...efficacy of IA with antihuman Ig‐columns in aAMR. For chronic‐active AMR (cAMR), no studies have evaluated the efficacy of nonantingen‐specific IA with antihuman Ig‐columns. The purpose of this study was to evaluate the role of nonantigen‐specific IA with antihuman Ig‐columns in the treatment of both aAMR and cAMR in kidney transplantation.
Material and Methods
In retrospective and observational study, kidney graft and recipient survival rates were assessed after treatment of aAMR and cAMR with nonantigen‐specific IA with Ig‐Flex columns (Therasorb) between January 2012 and May 2018. Protocols included nonantigen‐specific IA, rituximab, intravenous immunoglobulin, and rescue plasma exchange, if necessary.
Results
The study included 14 patients with AMR (acute in 9, chronic active in 5). For aAMR, mean follow‐up was 13 ± 6 months, and patient and graft survival were, respectively, of 100% and 83%, with a mean increase in estimated glomerular filtration rate (eGFR) of 7.98 ± 12.96, 10.18 ± 16.71, and 11.43 ± 13.85 mL/min/1.72 m2 (P > .05) at 3, 12 months after treatment, and at the end of follow‐up, respectively. For cAMR, mean follow‐up was 14 ± 8 months, and patient and graft survival were, respectively, of 100% and 60%, with an average increase in eGFR of 4.30 ± 7.86, 5.64 ± 10.47, and 14.5 ± 7.86 mL/min/m2 (P > .05) at 3, 12 months after IA treatment, and at the end of the follow‐up, respectively, although 40% did not respond and required chronic hemodialysis.
Conclusion
Nonantigen‐specific IA with Ig‐Flex columns was safe and effective for aAMR treatment in kidney transplantation. In cAMR, IA with Ig‐Flex columns was associated with a satisfactory kidney graft survival, suggesting that IA could potentially offer some benefits supporting its indication in cAMR.
A novel class of membranes, medium cut-off (MCO) membranes, has recently been designed to achieve interesting removal capacities for middle and large middle molecules in hemodialysis (HD) treatments. ...The few studies published to date have reported contradictory results regarding middle-sized molecules when comparing MCO dialyzers versus dialyzers used in online hemodiafiltration (OL-HDF).
A prospective, single-center study was carried out in 22 patients. Each patient underwent 9 dialysis sessions with routine dialysis parameters, one with an MCO dialyzer in HD and the other 8 with different dialyzers in OL-HDF. The removal ratio (RR) of urea, creatinine, β2-microglobulin, myoglobin, prolactin, α1-microglobulin, α1-acid glycoprotein, and albumin was intraindividually compared. Albumin loss in dialysate was measured. We propose a global removal score (ureaRR + β2-microglobulinRR + myoglobinRR + prolactinRR + α1-microglobulinRR + α1-acid glycoproteinRR/6 - albuminRR) as a new tool for measuring dialyzer effectiveness.
No significant differences in the RRs of small and middle molecular range molecules were observed between the MCO vs. OL-HDF dialyzers (range 60-80%). Lower RRs were found for α1-microglobulin and α1-acid glycoprotein without significant differences. The albumin RR was < 11% and dialysate albumin loss was < 3.5 g in all situations without significant differences. The global removal score was 54.9 ± 4.8% with the MCO dialyzer without significant differences.
Removal of a wide range of molecular weights, calculated with the proposed global removal score, was almost equal with the MCO dialyzer in HD treatment compared with 8 high-flux dialyzers in high-volume OL-HDF without relevant changes in albumin loss. The global removal score could be a new tool to evaluate the effectiveness of dialyzers and/or different treatment modalities.
In an overwhelming demand scenario, such as the SARS-CoV-2 pandemic, pressure over health systems may outburst their predicted capacity to deal with such extreme situations. Therefore, in order to ...successfully face a health emergency, scientific evidence and validated models are needed to provide real-time information that could be applied by any health center, especially for high-risk populations, such as transplant recipients. We have developed a hybrid prediction model whose accuracy relative to several alternative configurations has been validated through a battery of clustering techniques. Using hospital admission data from a cohort of hospitalized transplant patients, our hybrid Data Envelopment Analysis (DEA)—Artificial Neural Network (ANN) model extrapolates the progression towards severe COVID-19 disease with an accuracy of 96.3%, outperforming any competing model, such as logistic regression (65.5%) and random forest (44.8%). In this regard, DEA-ANN allows us to categorize the evolution of patients through the values of the analyses performed at hospital admission. Our prediction model may help guiding COVID-19 management through the identification of key predictors that permit a sustainable management of resources in a patient-centered model.
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