In patients with ESRD, the effects of online hemodiafiltration on all-cause mortality and cardiovascular events are unclear. In this prospective study, we randomly assigned 714 chronic hemodialysis ...patients to online postdilution hemodiafiltration (n=358) or to continue low-flux hemodialysis (n=356). The primary outcome measure was all-cause mortality. The main secondary endpoint was a composite of major cardiovascular events, including death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, therapeutic coronary intervention, therapeutic carotid intervention, vascular intervention, or amputation. After a mean 3.0 years of follow-up (range, 0.4-6.6 years), we did not detect a significant difference between treatment groups with regard to all-cause mortality (121 versus 127 deaths per 1000 person-years in the online hemodiafiltration and low-flux hemodialysis groups, respectively; hazard ratio, 0.95; 95% confidence interval, 0.75-1.20). The incidences of cardiovascular events were 127 and 116 per 1000 person-years, respectively (hazard ratio, 1.07; 95% confidence interval, 0.83-1.39). Receiving high-volume hemodiafiltration during the trial associated with lower all-cause mortality, a finding that persisted after adjusting for potential confounders and dialysis facility. In conclusion, this trial did not detect a beneficial effect of hemodiafiltration on all-cause mortality and cardiovascular events compared with low-flux hemodialysis. On-treatment analysis suggests the possibility of a survival benefit among patients who receive high-volume hemodiafiltration, although this subgroup finding requires confirmation.
Background Hyperphosphatemia is an independent risk factor for all-cause and cardiovascular mortality in hemodialysis (HD) patients. Phosphate control often is unsuccessful using conventional ...dialysis therapies. Study Design Short-term analysis of a secondary outcome of an ongoing randomized controlled trial. Setting & Participants 493 (84%) consecutive patients from 589 patients included in the Convective Transport Study (CONTRAST) by January 2009 from 26 centers in 3 countries. Intervention Online hemodiafiltration (HDF) versus continuation of low-flux HD. Outcomes Differences in change from baseline to 6 months in phosphate levels and proportion of patients reaching phosphate treatment targets (phosphate ≤ 5.5 mg/dL). Measurements Phosphate, use of phosphate-binding agents, and proportion of patients achieving treatment targets at baseline, 3 months, and 6 months. Results Phosphate levels decreased from 5.18 ± 0.10 (SE) mg/dL at baseline to 4.87 ± 0.10 mg/dL at 6 months in HDF patients ( P < 0.001) and were stable in HD patients (5.10 ± 0.10 mg/dL at baseline and 5.03 ± 0.10 mg/dL after 6 months; P = 0.5). The difference in change in phosphate levels between HD and HDF patients (B = −0.24; 95% CI, −0.52 to 0.03; P = 0.08) increased after adjustment for phosphate-binder use (B = −0.36; 95% CI, −0.65 to −0.06; P = 0.02). The proportion of patients reaching phosphate treatment targets increased from 64% to 74% in HDF patients and was stable in HD patients (66% and 66%); the difference between groups reached statistical significance ( P = 0.04). Nutritional parameters and residual renal function were similar in both treatment groups. Limitations Only predialysis serum phosphate levels were measured; phosphate clearance could therefore not be calculated. Conclusion HDF may help improve phosphate control. Whether this contributes to improved clinical outcome remains to be established.
There is increasing awareness that residual renal function (RRF) has beneficial effects in hemodialysis (HD) patients. The aim of this study was to investigate the role of RRF, expressed as GFR, in ...phosphate and anemia management in chronic HD patients.
Baseline data of 552 consecutive patients from the Convective Transport Study (CONTRAST) were analyzed. Patients with a urinary output≥100 ml/24 h (n=295) were categorized in tertiles on the basis of degree of GFR and compared with anuric patients (i.e., urinary output<100 ml/24 h, n=274). Relations between GFR and serum phosphate and erythropoiesis-stimulating agent (ESA) index (weekly ESA dose per kg body weight divided by hematocrit) were analyzed with multivariable regression models.
Phosphate levels were between 3.5 and 5.5 mg/dl in 68% of patients in the upper tertile (GFR>4.13 ml/min per 1.73 m2), as compared with 46% in anuric patients despite lower prescription of phosphate-binding agents. Mean hemoglobin levels were 11.9±1.2 g/dl with no differences between the GFR categories. The ESA index was 31% lower in patients in the upper tertile as compared with anuric patients. After adjustments for patient characteristics, patients in the upper tertile had significantly lower serum phosphate levels and ESA index as compared with anuric patients.
This study suggests a strong relation between RRF and improved phosphate and anemia control in HD patients. Efforts to preserve RRF in HD patients could improve outcomes and should be encouraged.
Sub-analyses of three large trials showed that hemodiafiltration (HDF) patients who achieved the highest convection volumes had the lowest mortality risk. The aims of this study were (1) to identify ...determinants of convection volume and (2) to assess whether differences exist between patients achieving high and low volumes.
HDF patients from the CONvective TRAnsport STudy (CONTRAST) with a complete dataset at 6 months (314 out of a total of 358) were included in this post hoc analysis. Determinants of convection volume were identified by regression analysis.
Treatment time, blood flow rate, dialysis vintage, serum albumin and hematocrit were independently related. Neither vascular access nor dialyzer characteristics showed any relation with convection volume. Except for some variation in body size, patient characteristics did not differ across tertiles of convection volume.
Treatment time and blood flow rate are major determinants of convection volume. Hence, its magnitude depends on center policy rather than individualized patient prescription.
Online hemodiafiltration (HDF) has been increasingly used for improved clearance of middle molecular weight toxins. The impact of this mode of clearance is unknown in critically ill patients. We ...aimed to determine whether the use of HDF in acute kidney injury (AKI) is associated with lower mortality and improved kidney recovery up to 90 days after initiation of therapy.
Single-center retrospective cohort study using data from 2017 to 2020 of adults with AKI who initiated intermittent renal replacement therapy (IRRT) in the intensive care unit (ICU), using either hemodialysis (HD) or HDF depending on the maintenance status of the water system without regards for patient characteristics. We assessed association with patient-events and session-events using time-dependent Cox models and general estimating equations models, respectively.
We included 182 adults with AKI for whom 848 IRRT sessions were performed in the ICU. The 90-day mortality rate was 43 of 182 (24.6%). There was no significant association with the use of HDF and mortality (adjusted hazard ratio aHR: 0.85 (0.43; 1.67) P = 0.64), kidney recovery (aHR: 1.18 (0.76; 1.84) P = 0.47), or intradialytic hypotension (adjusted odds ratio aOR: 0.91 confidence interval CI: 0.64–1.28 P = 0.58). HDF treatment was associated with a lower rate of subsequent vasopressor use (aOR: 0.60 CI: 0.36–0.99 P = 0.047) and a greater reduction of the neutrophil-to-lymphocyte ratio (NLR) following the first session (−15.0% vs. +5.1%, P = 0.047) but was also associated with increased risk of filter thrombosis during treatment (aOR: 2.42 CI: 1.67–3.50 P < 0.001).
The use of HDF in the setting of AKI was not associated with a differential risk of mortality or kidney recovery.
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Effect of Hemodiafiltration on Quality of Life over Time Mazairac, Albert H A; de Wit, G Ardine; Grooteman, Muriel P C ...
Clinical journal of the American Society of Nephrology,
01/2013, Letnik:
8, Številka:
1
Journal Article
Recenzirano
Odprti dostop
It is unclear if hemodiafiltration leads to a better quality of life compared with hemodialysis. It was, therefore, the aim of this study to assess the effect of hemodiafiltration on quality of life ...compared with hemodialysis in patients with ESRD.
This study analyzed the data of 714 patients with a median follow-up of 2 years from the Convective Transport Study. The patients were enrolled between June of 2004 and December of 2009. The Convective Transport Study is a randomized controlled trial on the effect of online hemodiafiltration versus low-flux hemodialysis on all-cause mortality. Quality of life was assessed with the Kidney Disease Quality of Life-Short Form. This questionnaire provides data for a physical and mental composite score and describes kidney disease-specific quality of life in 12 domains. The domains have scales from 0 to 100.
There were no significant differences in changes in health-related quality of life over time between patients treated with hemodialysis (n=358) or hemodiafiltration (n=356). The quality of life domain patient satisfaction declined over time in both dialysis modalities (hemodialysis: -2.5/yr, -3.4 to -1.5, P<0.001; hemodiafiltration: -1.4/yr, -2.4 to -0.5, P=0.004).
Compared with hemodialysis, hemodiafiltration had no significant effect on quality of life over time.
Resistance to erythropoiesis stimulating agents (ESA) is common in patients undergoing chronic hemodialysis (HD) treatment. ESA responsiveness might be improved by enhanced clearance of uremic toxins ...of middle molecular weight, as can be obtained by hemodiafiltration (HDF). In this analysis of the randomized controlled CONvective TRAnsport STudy (CONTRAST; NCT00205556), the effect of online HDF on ESA resistance and iron parameters was studied. This was a pre-specified secondary endpoint of the main trial. A 12 months' analysis of 714 patients randomized to either treatment with online post-dilution HDF or continuation of low-flux HD was performed. Both groups were treated with ultrapure dialysis fluids. ESA resistance, measured every three months, was expressed as the ESA index (weight adjusted weekly ESA dose in daily defined doses DDD/hematocrit). The mean ESA index during 12 months was not different between patients treated with HDF or HD (mean difference HDF versus HD over time 0.029 DDD/kg/Hct/week -0.024 to 0.081; P = 0.29). Mean transferrin saturation ratio and ferritin levels during the study tended to be lower in patients treated with HDF (-2.52% -4.72 to -0.31; P = 0.02 and -49 ng/mL -103 to 4; P = 0.06 respectively), although there was a trend for those patients to receive slightly more iron supplementation (7.1 mg/week -0.4 to 14.5; P = 0.06). In conclusion, compared to low-flux HD with ultrapure dialysis fluid, treatment with online HDF did not result in a decrease in ESA resistance.
ClinicalTrials.gov NCT00205556.
Background and objectives: Removal of β
2
-microglobulin (β2M) can be increased by adding convective transport to hemodialysis (HD). The aim of this study was to investigate the change in β2M levels ...after 6-mo treatment with hemodiafiltration (HDF) and to evaluate the role of residual kidney function (RKF) and the amount of convective volume with this change.
Design, setting, participants, & measurements: Predialysis serum β2M levels were evaluated in 230 patients with and 176 patients without RKF from the CONvective TRAnsport STudy (CONTRAST) at baseline and 6 mo after randomization for online HDF or low-flux HD. In HDF patients, potential determinants of change in β2M were analyzed using multivariable linear regression models.
Results: Mean serum β2M levels decreased from 29.5 ± 0.8 (±SEM) at baseline to 24.3 ± 0.6 mg/L after 6 mo in HDF patients and increased from 31.9 ± 0.9 to 34.4 ± 1.0 mg/L in HD patients, with the difference of change between treatment groups being statistically significant (regression coefficient −7.7 mg/L, 95% confidence interval −9.5 to −5.6,
P
< 0.001). This difference was more pronounced in patients without RKF as compared with patients with RKF. In HDF patients, β2M levels remained unchanged in patients with GFR >4.2 ml/min/1.73 m
2
. The β2M decrease was not related to convective volume.
Conclusions: This study demonstrated effective lowering of β2M levels by HDF, especially in patients without RKF. The role of the amount of convective volume on β2M decrease appears limited, possibly because of resistance to β2M transfer between body compartments.
Background
BK polyomavirus virus (BKPyV) screening and immunosuppression reduction effectively prevent graft loss due to BKPyV‐associated nephropathy (BKPVAN) during the first year after ...transplantation. The aim of our study was to evaluate the impact of this infection during longer follow‐up periods.
Methods
We reviewed the outcome of our screening and immunosuppression reduction protocol in 305 patients who received a kidney transplant between March 2008 and January 2013. Quantitative BKPyV DNA surveillance in plasma was performed at 1, 2, 3, 6, 9, and 12 months after transplantation. Patients with significant viremia and/or biopsy‐proven BKPVAN were treated with immunosuppression reduction and leflunomide.
Results
During the first post‐transplant year, 24 patients (7.9%) developed significant viremia at a median time of 95 days, and 18 patients had BKPVAN; 23 of the 24 (7.5%) were treated according to our protocol (group BKV+); 225 patients (73.8%) did not develop any BK viremia (group BKV−). Allograft function was similar in both groups at 1 month post transplantation (P=.87), but significantly worse at 1 year in the BKV+ group (P=.002). Thereafter, kidney function stabilized in the BKV+ group and no differences in patient and graft survival were seen between the groups after a median follow‐up of 4 years.
Conclusions
We confirm the early occurrence of BKPyV replication after transplantation and the short‐term decline in renal function. However, early detection of BKPyV replication, prompt diagnosis, and reduction in immunosuppression may offer long‐term benefits for graft function.
Background. Large convective volumes are recommended for online haemodiafiltration (HDF) to maximize solute removal. There has been little systematic evaluation of factors that determine convective ...volumes in routine clinical practice. Methods. In the present study, potential patient- and treatment-related determinants of convective volume were analysed in 235 consecutive patients on post-dilution HDF using multivariable linear regression models. All patients (age 64 ± 14 years; 61% male) participated in the ongoing CONvective TRAnsport STudy (CONTRAST). Additionally, differences in convective volumes between dialysers were evaluated. Results. The mean convective volume was 19.4 ± 4.0 L (±SD) per treatment, with a large variation between the participating centres (centre means ranging from 13.4 ± 0.9 L to 24.5 ± 0.12 L, ± SE). The mean filtration fraction of the blood flow was 25.9 ± 3.6. In the multivariable analysis, factors that were significantly related to convective volume were haematocrit inversely, regression coefficient (B) = −1.4 ± 0.4 L per 10%, serum albumin (positively, B = 1.0 ± 0.4 L per 10 g/L), blood flow rate (positively, B = 0.4 ± 0.04 L per 10 mL/min) and treatment time (positively, B = 5.1 ± 0.4 L/h). In addition, significant differences between dialysers were observed, likely explained by different operational conditions. Conclusions. Apart from increasing the treatment time and blood flow rate, convective volumes could be optimized by increasing the filtration fraction in each individual, provided that transmembrane pressures are well within safe limits. The precise role of dialyser characteristics on maximal achievable convective volumes in clinical practice is a topic for further research.
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