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The combination of hemodialysis-hemoperfusion (HDHP) has been proved to be superior to hemodialysis (HD) in eliminating uremic toxins. There are two methods of combination of HD and HP: the HP regime is utilized during the first two-hour an early HP conducted HDHP (EHDHP) or the last two-hour late HP conducted HDHP (LHDHP) of 4 h regular HD session. The present study was to compare these two methods in uremic toxins removal. Twenty adult chronic HD patients were enrolled in this self-control method study. The patients were randomized to receive one session of EHDHP or LHDHP. Two weeks later, the dialysis modalities were switched. The reduction ratio (RR) of targeted uremic toxins for each session was assessed. Both EHDHP and LHDHP showed a significant removal of small water-soluble solutes, middle-sized toxins and cytokines as well (p < 0.05). There were no significant differences between two methods in RR of small water-soluble solutes, like urea and creatinine. For middle-sized molecules and cytokines, such as PTH, β(2)-M, IL-1, IL-6, and TNF-α, the RR was markedly increased in LHDHP than that in EHDHP (p < 0.05). LHDHP showed no more intradialytic events than EHDHP. The combination of HD and HP in the last two hours in one hemodialysis session had more effect on eliminating middle-sized toxins and cytokines.

Objective: To investigate whether the combination of maintenance hemodialysis (MHD) with hemoperfusion (HP) could improve the clearance rate of middle and large molecule uremic toxins so as to improve the quality of life of MHD patients and reduce their mortality rate., Methods: This study was a prospective, randomized, controlled clinical trial. 100 MHD patients were selected and then randomly divided into two groups after four weeks of run-in period. Group 1 received HD alone 2 times a week and the combined treatment of HD with HP (HD+HP) once a week, whereas Group 2 was given HD alone 3 times a week. This study was followed up for a mean of 2 years. The primary outcome was the death of patients. Secondary end points included normal clinical data, leptin, high sensitive C-reactive protein (hsCRP), interleukin-6 (IL-6), ß(2) microglobulin (ß(2)-MG), immunoreactive parathyroid hormone (iPTH), tumor necrosis factor-α (TNF-α) and the index of dimensions of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 Chinese Edition )., Results: At the end of the two-year observation, the serum concentration of leptin, hsCRP, iPTH, IL-6, ß(2)-MG and TNF-α, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), cardiothoracic ratio, left ventricular mass index (LVMI), the EPO doses and the types of antihypertensive drugs used were lower with Group 1 than with Group 2 (p<0.05); Group 1 had higher hemoglobin (Hb), ejection fraction (EF), and body mass index (BMI) (p<0.05). No statistical difference between the two groups was observed in terms of serum albumin, serum iron (SI), total iron binding capacity (TIBC), cardiac output (CO), Kt/V, early/atrial mitral inflow velocities (E/A) (p>0.05). Besides, the SF-36 indicated that the total score of overall dimentions of Group 1 was higher than Group 2 (p<0.05) and the quality of life of Group 1 was evidently better than Group 2. The Kaplan-Meier Survival Curves for the 2-year observation period showed that patients in Group 1 had obvious survival advantage while Log-rank test results showed p<0.05. No serious adverse incidents occurred during the HD+HP treatment., Conclusions: HD+HP was superior to HD in regularly eliminating middle and large molecule uremic toxins accumulated in the body. These findings suggest a potential role for HD+HP in the treatment to improve the quality of life and survival rate of MHD patients.

The capacity of charcoal to absorb endogenous and exogenous toxins is well established. It removes substances of higher molecular weight than standard dialysis membranes. The regular use of charcoal hemoperfusion as an adjunct to hemodialysis in chronic uremia is a real prospect capable of improving the patient's clinical and laboratory condition and/or reducing the weekly time of treatment. In line with our previous experience, 5 consenting informed patients on regular dialysis treatment from 9 to 35 months (residual creatinine clearance 0-1.8 ml/min, mean diuresis 350 ml) were treated without interruption for 5-8 months according to a schedule including two combined hemodialysis/hemoperfusion procedures instead of the previous three hemodialysis sessions. Patients were on adequate dialysis and their clinical, metabolic and laboratory conditions were stable. In the hemodialysis/hemoperfusion procedure a cartridge containing 150 g of methacrylate-coated activated charcoal with high biocompatibility was inserted in the dialysis circuit in series with a flat plate or hollow fiber dialyzer. Clinical, laboratory and metabolic conditions remained unchanged in all patients despite the one third reduction in dialysis hours per week. The tolerance of treatment was good: platelets, white cells and fibrinogen were unaffected. The marked reduction in weekly time of treatment led to a more satisfactory personal and social rehabilitation, enabling more patients to be treated with the same facilities.

An effect of haemoperfusion on plasma oxidizing capacity and erythrocyte sensitivity to oxidation was investigated in patients with the chronic uremia. It was found that plasma oxidizing capacity measured with NTB reduction is more pronounced in patients with the chronic uremia than in normal subjects. Oxidizing capacity of plasma is increased at the beginning of haemoperfusion. This effect is clearly seen during single pass of blood through the column with activated carbon. Erythrocyte sensitivity to oxidation following their suspension in the normal saline with phosphate buffer and measured with ascorbic-cyanate test does not differ significantly in patients with the chronic uremia and healthy subjects and does not change markedly during haemoperfusion.

The present status of hemoperfusion using the principle of artificial cells is described in detail using coated charcoal hemoperfusion as an example. The laboratory and clinical results show that in 1981 increasing numbers of new commercial models are approaching the efficiency and blood compatibility of the ACAC laboratory system. The results of hemoperfusion for uremia, acute intoxication and hepatic coma are analyzed. Other approaches are briefly discussed.

A multicentric study was carried out to investigate the safety and effectiveness of long-term treatment of chronic uremic patients by a regular combination of hemodialysis and charcoal hemoperfusion. 39 RDT patients from five dialysis centers were treated for up to 12 months. The combined treatment proved to be safe, well tolerated and effective in improving certain dialysis-resistant uremic signs, mainly severe peripheral neuropathy, asthenia, anorexia, nausea, lack of well-being and relapsing pericarditis. There was also a marked decrease, after several weeks of combined treatment, in plasma values of urea, uric acid and creatinine.

In evaluating biocompatibility, haematological changes induced by ACCM in vivo and in vitro were studied. Twenty minutes after the start of haemoperfusion a significant fall in white blood cell number was found. After 60 minutes the leucopenia still occurred. In a previous work we suggested that complement activation is at least one of the possible mechanisms responsible for these phenomena. Moreover, our data showed a significant decrease in platelet number after 60 minutes of haemoperfusion. During the in vitro study, we found, using citrated blood, a significant correlation between aggregation response to ADP and collagen, either at different ACCM doses or at various periods of incubation. Our results suggest that the fall in platelets is due to platelet aggregation. The haemocoagulation study may have clinical importance in high-risk patients when haemoperfusion is required.