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Introduction: Bisphenol A (BPA) is an ubiquitous environmental toxin that is also found in dialyzers. Online hemodiafiltration (OL-HDF) more efficiently clears high molecular weight molecules, and this may improve BPA clearance. However, the BPA contents of dialysis membranes may be a source of BPA loading during OL-HDF. Methods A prospective study assessed plasma BPA levels in OL-HDF patients using BPA-free (polynephron) or BPA-containing (polysulfone) dialyzers in a crossover design with two arms, after a run-in OL-HDF period of at least 6 months with the same membrane: 31 patients on polynephron at baseline were switched to polysulfone membranes for 3 months (polynephron-to-polysulfone) and 29 patients on polysulfone were switched to polynephron for 3 months (polysulfone-to-polynephron). Results After a run-in OL-HDF period of at least 6 months with the same membrane, baseline predialysis BPA was lower in patients on polynephron (8.79±7.97 ng/ml) than in those on polysulfone (23.42±20.38 ng/mL, p < 0.01), but still higher than in healthy controls ( < 2 ng/mL). After 3 months of polynephron-to-polysulfone switch, BPA was unchanged (8.98±7.88 to 11.14±15.98 ng/mL, ns) while it decreased on the polysulfone-to-polynephron group (23.42±20.38 to 11.41±12.38 ng/mL, p < 0.01). Conclusion OL-HDF for 3 months with BPA-free dialyzer membranes was associated to a significant decrease in predialysis BPA levels when compared to baseline BPA levels while on a BPA-containing membrane, The Renal, Vascular and Diabetes Laboratory is funded by Ministerio de Economia, Industria y competitividad: FIS ISCIII FEDER funds PI16/01298, PI15/00298, PI16/02057, PI16/01900, SCIII-RETIC REDinREN RD12/0021 RD16/0009, CYTED IBERERC and Sociedad Madrileña de Nefrologia, Programa Intensificación Actividad Investigadora (ISCIII) to AO. This work was supported by a grant from Nipro corporation, and Fundacioón Renal Íñigo Álvarez de Toledo (FRIAT)

Background With its convective component, hemodiafiltration (HDF) provides better middle molecule clearance compared with hemodialysis (HD) and is postulated to improve survival. A previous analysis of Dialysis Outcomes and Practice Patterns Study (DOPPS) data in 1998-2001 found lower mortality rates for high replacement fluid volume HDF versus HD. Randomized controlled trials have not shown uniform survival advantage for HDF; in secondary (non-randomized) analyses, better outcomes were observed in patients receiving the highest convection volumes. Methods In a 'real-world' setting, we analyzed patients on dialysis >90 days from seven European countries in DOPPS Phases 4 and 5 (2009-15). Adjusted Cox regression was used to study HDF (versus HD) and mortality, overall and by replacement fluid volume. Results Among 8567 eligible patients, 2012 (23%) were on HDF, ranging from 42% in Sweden to 12% in Germany. Median follow-up was 1.5 years during which 1988 patients died. The adjusted mortality hazard ratio (95% confidence interval) was 1.14 (1.00-1.29) for any HDF versus HD and 1.08 (0.92-1.28) for HDF >20 L replacement fluid volume versus HD. Similar results were found for cardiovascular and infection-related mortality. In an additional analysis aiming to avoid treatment-by-indication bias, we did not observe lower mortality rates in facilities using more HDF (versus HD). Conclusions Our results do not support the notion that HDF provides superior patient survival. Further trials designed to test the effect of high-volume HDF (versus lower volume HDF versus HD) on clinical outcomes are needed to adequately inform clinical practices.

Purpose: Patients’ perception of health-related quality of life (HRQOL) is a consistent and powerful predictor of the outcome of end-stage renal disease (ESRD) patients under dialysis. This study aims to identify factors that could affect the HRQOL of ESRD patients under online hemodiafiltration (OL-HDF). Methods: We evaluated 322 ESRD patients under OL-HDF (59.63 % males; 64.9 ± 14.3 years old) from five dialysis units in the north of Portugal. Socio-demographic data, comorbidities, hematological data, iron status, dialysis adequacy, nutritional and inflammatory markers were collected from patients records. Patient’s reported HRQOL score was assessed by using the Kidney Disease Quality of Life-Short Form (KDQOL-SF). Results: ESRD patients showed a mean (±SD) of 53.17 % (±15.31 %) in SF-36 total score, 50.17 % (±9.51 %) in the SF-36 mental component summary (MCS) and 49.75 % (±9.44 %) in the SF-36 physical component summary (PCS). Red cell distribution width (RDW), feminine gender and diabetes were found as significant predictors of SF-36 total score of HRQOL, which accounts for 12 % of the total explained variance. Patient satisfaction, RDW, body mass index and gender were identified as predictors for the PCS, which accounts for 22 % of total explained variance. Furthermore, patient satisfaction and dry weight were found as predictors for MCS. These predictors accounted for 28 % of the total explained variance. Conclusions: Our results showed that the coexistence of diabetes, gender and erythropoietic disturbances are predictors of HRQOL in patients under OL-HDF and suggest that more attention should be given to woman patients, to the improvement of anemia and to diabetic patients, who are more prone to perceive a worst HRQOL.

Background Online hemodiafiltration (oHDF) is increasingly used in children; we treated 28 children since 2009, adapting this technique to pediatric patients. Methods In this service evaluation audit, we assessed plasma electrolytes to evaluate the evolution of total (tCa) and ionized (iCa) during a session, as well as dialysate calcium (dCa) concentrations. Results Using a 1.25 mmol Ca/L-dialysate, both tCa and iCa decreased during the session, with iCa falling below 1.1 mmol/L in 4/5 patients. In contrast, using a 1.5 mmol Ca/L-dialysate, iCa remained normal in all patients. Major discrepancies were observed between the expected and the measured dCa: 1.25 vs. 1.01 (0.83–1.04), and 1.5 vs. 1.47 (0.85–1.75) mmol/L, respectively (results presented as median [range]). These differences were explained by the modality of reconstituting dialysate: increasing bicarbonates and/or decreasing sodium requested in the dialysate decreases calcium extraction from the acid preparation. Proof of concept was given when requesting in an “ex-vivo” setting modifications in the requested sodium and bicarbonate in dialysate directly on the Fresenius machine. Conclusion Nephrologists should be aware that “high bicarbonate and/or low sodium” requirements in oHDF decrease calcium in the dialysate.

P-wave dispersion (PWD) (difference between the maximum and minimum P-wave duration), has been proposed as a useful predictor of paroxysmal atrial fibrillation (AF). The consequences of hemodialysis (HD) on PWD and P-wave duration have not been unequivocally documented and understood, and may be complex. We aimed in this work to demonstrate the effects of online hemodiafiltration (OL-HDF) on the risk of developing AF through assessment of PWD. Thirty-three pediatric patients (14 males and 19 females with mean age of 11.66 ± 2.93 years) on conventional HD for at least 6 months underwent echocardiography, 12-lead electrocardiogram and PWD calculation. Then they were switched to OL-HDF for another 6 months and same parameters were reassessed. Thirty sex- and aged-matched healthy children, served as controls. PWD significantly decreased upon switching to OL-HDF (P

Background: By combining diffisive and convective with a large volume in the same exchange method, Online Haemodiafiltration provide the highest clearances of both small and large solutes in the end stage renal disease patients who treated by maintenance hemodialysis. Objective: To investigate the serum levels of Ure, creatinin, phosphorus, Beta2-microglobulin and Homocystein before and after one session of Online Hemodiafiltration and one session of conventional Hemodialysis in the same patient. Method: Cross – sectional study. Results: 34 patients were treated by combining one session Online Hemodiafiltration and two sessions intermittent Hemodialysis/week. The urea reduction rate: 76.61 ± 7.37% Online Hemodiafiltration compare with 69.90 ± 7.55% conventional hemodialysis; the creatinin reduction rate: 67.76 ± 6.05% Online Hemodiafiltration compare with 61.40 ± 7.82% conventional hemodialysis; the phospho reduction rate: 52.37 ± 14.47% Online Hemodiafiltration compare with 42.81 ± 21.39% conventional hemodialysis; the Beta 2-microglobulin reduction rate: 72.42 ± 7.60% Online Hemodifiltration compare with 56.91 ± 12.76% conventional hemodialysis; the Homocysteine reduction rate: 43.23 ± 15.46% Online Hemodiafiltration compare with 33.68 ± 14.72% conventional hemodialysis. A differrent in two methods was significally and the solute reduction rate was higher with Online Hemodiafiltration, p < 0.01. Conclusion: Online Haemodiafiltration provide the highest clearances of both small and large solutes and helping to improve patient’s survival and quality of life.

Objective: To investigate the effect of in different type hemopurification techniques on adipokine and flammatory factor in diabetic nephropathy with maintenance hemodialysis (MHD). Methods: A total of 81 diabetic nephropathy patients were randomly divided into on hemodialysis group (HD, n=27), hemodialysis with hemoperfusion group (HD+HP, n=27), online hemodiafiltration group (OL-HDF, n=27). Levels of adiponectin, resistin, interleukin-6 (IL-6), and tumor necrosis factor (TNF-α) were tested and compared before and after treatment. Results: Indicators of HD group have no statistical significance before and after treatment. HD+HP and OL-HDF group adiponectin level increased significantly, resistin, IL-6 and TNF-α level decreased significantly before and after treatment; OL-HDF group resistin, IL-6 and TNF-α level decreased more significantly than HD+HP group after treatment. Conclusion: HD+HP and OL-HDF treatments have reliable curative effect on diabetic nephropathy patients, which can regulate adiponectin, resistin, IL-6 and TNF-α level. Effect of OL-HDF treatment eliminates resistin, IL-6 and TNF-α more markedly than HD+HP treatment.

On-line hemodiafiltration is an increasingly common alternative to chronic hemodialysis in some countries, based on the results of randomized controlled trials of post-dilution on-line hemodiafiltration. There are now more than 60,000 patients treated with on-line hemodialfiltration in Japan, over 95% of whom use predilution on-line hemodiafiltration; however, large-scale data on clinical outcomes with this modality are lacking. We created a propensity-matched cohort of 5,000 pairs of patients treated with conventional hemodialysis or predilution on-line hemodiafiltration, using the Japanese Society for Dialysis Therapy Renal Data Registry database from December 31, 2012 to December 31, 2013. One-year all-cause and cardiovascular mortality were compared between the groups. Predilution on-line hemodiafiltration was associated with improved overall survival compared to hemodialysis (hazard ratio for all cause-mortality 0.83, 95% confidence interval 0.705-0.986), with a trend towards improved cardiovascular survival. Among patients treated with predilution on-line hemodiafiltration, those treated with high substitution volumes (≥40.0 L per session) had improved all-cause and cardiovascular survival compared to those treated with low substitution volumes (40.0 L per session) or those on hemodialysis. The optimal substitution volume associated with improved overall survival was estimated to be 50.5 L [95% confidence interval 39.0-63.5 L]. This observational study suggests that predilution on-line hemodiafiltration, especially with high substitution volumes, may improve all-cause and cardiovascular survival, but randomized controlled trials are needed.

Purification of high molecular uremic toxins by conventional hemodialysis is limited. It remains associated with a high morbidity and excessively high mortality. Online hemodiafiltration using a high permeability hemodiafilter, an ultrapure dialysate, and which tends to maximize substitution volumes, provides a high efficiency and low bio-incompatibility renal supplementation. Regular use of online hemodiafiltration is associated with reduced morbidity (reduction of intradialytic hypotension episodes, improved blood pressure control, reduced inflammatory profile, better anemia correction and prevention of β2-microglobulin-associated amyloidosis). Recently, several cohort studies have shown that hemodiafiltration with high substitution volume was associated with a significant reduction in mortality. Randomized studies have been conducted in Europe to confirm these facts. The high safety of online hemodiafiltration has been confirmed in clinical practice by prospective studies. Online hemodiafiltration has reached its full maturity phase and is expected to represent the new standard of renal replacement therapy.

Purification of high molecular uremic toxins by conventional hemodialysis is limited. It remains associated with a high morbidity and excessively high mortality. Online hemodiafiltration using a high permeability hemodiafilter, an ultrapure dialysate, and which tends to maximize substitution volumes, provides a high efficiency and low bio-incompatibility renal supplementation. Regular use of online hemodiafiltration is associated with reduced morbidity (reduction of intradialytic hypotension episodes, improved blood pressure control, reduced inflammatory profile, better anemia correction and prevention of β

Online hemodiafiltration (OL-HDF) has now demonstrated some benefits in reducing mortality. It seems that rising convective volumes improve the outcomes, but the risks of it, such as albumin leakage, are not well defined yet. The aim of the present study was to evaluate the albumin leakage using two different filters with 20 and 30 L of post-dilution OL-HDF. In this cross-sectional study, 20 prevalent patients receiving post-dilution OL-HDL were included. We analyzed two dialyzers: FX1000, FMC and Polyflux 210H, Gambro. During four consecutive dialysis sessions, monitors were programmed using control-volume to obtain 20 or 30 L with both dialyzers. We collected albumin samples of the effluent at 5, 15, 30, 45 and 60 min and performed area under the curve (AUC) determinations for evaluating the losses. Mean patient age was 60 ± 9 years, and 70% were men. Albumin leakage was significant higher with Polyflux 210H when compared to FX 1000 FMC. A convective volume of 30 L produced greater albumin leakage than 20 L with both filters, though only with the FX 1000 FMC was it significant (minimum albumin leakage during first hour with FX 1000 FMC 20 L: 79.2 [0.0–175.7] mg; 30 liters: 403.3 [63.5–960.7] mg; with PF 210 Gambro 20 L: 869.1 [420.0–3214.7] mg; 30 L: 1841.7 [443.8–3417.5] mg). During OL-HDF, convective transport causes albumin leakage at least during the first hour. The albumin concentration in the effluent differs according to the type of filter used and the convective volume.

Resume Introduction L’hemodiafiltration (HDF) est encore peu utilisee en pediatrie en raison des exigences techniques, de son cout et des adaptations rendues necessaires par les differences de poids et de taille des enfants. Depuis 2009, nous utilisons l’HDF online (oHDF) et avons observe des concentrations plasmatiques basses d’hormone parathyroidienne (PTH) malgre une gestion des anomalies minerales et osseuses suivant les recommandations internationales. Methodes Les dossiers de 6 enfants suivis en oHDF dans notre centre ont ete repris retrospectivement, avec une evaluation prospective de leurs principaux parametres phosphocalciques sur un mode avant/apres session. Resultats Nous avons observe des concentrations basses de PTH ( Conclusion Il semble que l’oHDF en pediatrie puisse induire des modifications phosphocalciques specifiques, que des essais cliniques en cross-over hemodialyse conventionnelle/oHDF pourraient permettre de mieux comprendre. En attendant, l’utilisation en premiere intention des bains a 1,25 mmol/L de calcium, de meme qu’un suivi regulier de la PTH semblent necessaires.

There are no studies evaluating the impact of dialyzer reprocessing on solute removal in short-daily online hemodiafiltration (OL-HDF). Our aim was to evaluate the impact of dialyzer reuse on solute removal in daily OL-HDF and compare with that in high-flux short-daily hemodialysis (SDH). Fourteen patients undergoing a SDH program were included. Pre-dialysis and post-dialysis blood samples and effluent dialysate were collected in the 1st, 7th, and 13th dialyzer uses in SDH sessions and in daily OL-HDF sessions. Directly quantified small solute (urea, phosphorus, creatinine, and uric acid) total mass removal (TM(DQ)) and clearance (K(DQ)) were similar when the 1st, 7th, and 13th dialyzer SDH uses were compared with the 1st, 7th, and 13th daily OL-HDF uses. TMDQ and K(DQ) of small solutes were similar among analyzed dialyzer uses in SDH sessions and in daily OL-HDF sessions. β2-Microglobulin TM(DQ) and K(DQ) were statistically higher in daily OL-HDF dialyzer uses than in the respective SDH uses. There was no difference in β2-microglobulin TM(DQ) and K(DQ) among dialyzer uses in daily OL-HDF sessions or in SDH sessions. In daily OL-HDF, albumin loss was significantly different among dialyzer uses (P < 0.001), being lower in the 7th and 13th dialyzer uses than in the first use. Dialyzer reprocessing did not impair solute extraction in daily OL-HDF. β2-Microglobulin removal was greater in daily OL-HDF than in SDH sessions, without significant differences in other solutes extraction. There was a significant reduction in intradialytic albumin loss with dialyzer reprocessing in daily OL-HDF sessions.

A 63-year-old male patient first experienced recurrent hypotensive episode during the dialysis session just after switching the mode from hemodialysis to online hemodiafiltration (OL-HDF) with infusion in pre-dilution of the bicarbonate dialysate containing 9.2 mEq/L of acetate. Peripheral eosinophil count and serum IgE were both elevated to 16,440/μL and 2000 IU/L. The reactions promptly dissolved with substitution of acetate-free solution. This case illustrated that pre-dilution OL-HDF can induce an occult hypersensitivity to acetate in the standard bicarbonate dialysate.

Purpose The aim of this work is to evaluate the patient-reported health-related quality of life (HRQOL), according to the type and location of vascular access used for dialysis procedure. Methods In this transversal study, 322 end-stage renal disease (ESRD) patients under online hemodiafiltration (OL-HDF, 59.63% males; 64.9±14.3 years) were enrolled. Arteriovenous fistula (AVF) was used by 252 patients (78.3%), whereas 70 patients (21.7%) had a central venous catheter (CVC). Besides AVF location, data on comorbidities, hematological data, iron status, dialysis adequacy, nutritional and inflammatory markers were collected. Moreover, the patients’ reported HRQOL score, using the Kidney Disease Quality of Life-Short Form, was evaluated. Results ESRD patients using CVC as vascular access presented a decrease in four SF-36 domain scores, namely physical functioning, emotional well-being, role-emotional and energy/fatigue when compared with those using AVF as vascular access. Additionally, these patients also showed significant differences in ESRD target areas, namely decline in cognitive function and quality of social interaction domains. When comparing the variables according to the localization of the AVF, significant differences were found in three SF-36 domain scores, namely physical functioning, pain and general health. Moreover, we also found significant differences in ESRD target areas, namely symptoms/problem list, effects of kidney disease and quality of social interaction domains. Conclusions Our results showed that ESRD patients under OL-HDF using AVF as vascular access had higher HRQOL scores in several domains when compared with those using CVC. Additionally, we also found that dialysis patients using AVF in the left forearm presented with higher HRQOL scores.

Introduction Patients in end stage renal disease on hemodialysis are in higher risk of bleeding related to the anticoagulation used during a session, so only the lowest effective dose of anticoagulation must be used. The aim of this study was to evaluate the efficacy of predilution in hemodiafiltration with reduced dose of anticoagulation compared to hemodialysis in preventing coagulation of circuits. Patients and methods This study was conducted in stable hemodialysis patients without high bleeding risk. All patients were treated by two different treatments: (A) conventional hemodialysis, (B) predilution hemodiafiltration with the half dose of anticoagulation used during treatment (A). Other confounding parameters were kept constant during the study. The primary endpoint was the incidence of major thrombotic events judged on a subjective visual score. Results Twenty-one patients were included (105 sessions for each treatment). Major incidents are occurring more frequently in predilution hemodiafiltration with reduced dose of anticoagulation (P=0.03). The premature discontinuation of sessions was more frequent in predilution hemodiafiltration, this difference was not significant (P=0.07). Duration of sessions was significantly shorter in predilution hemodiafiltration (P=0.03). The higher frequency of thrombotic events in predilution hemodiafiltration has no effect on net ultrafiltration volume achieved in both treatments. Conclusion Predilution hemodiafiltration with a lower dose of anticoagulation did not prevent major clotting of extracorporeal circuit manner at least equivalent to a reference method.

Online hemodiafiltration (OL-HDF) as a renal replacement therapy is gaining momentum due to the perceived added benefit from enhanced clearance of potential‐ ly harmful middle molecules. Favorable effect of OL-HDF on all-cause mortality and cardiovascular mortality and morbidity has been suggested by some clinical trials. Health-related quality of life (HRQOL) is an important component of hemodialysis patients’ care. HRQOL is of interest to both health care providers and patients. Improved quality of life in hemodialysis patients has been associated with improved outcome in terms of reduced rate of hospitalization and mortality. Data on HRQOL in end-stage renal disease (ESRD) patients under OL-HDF is scarce and of marginal quality. In this review, we will try to summarize the available evidence on this subject.

Care of patients with end-stage renal disease (ESRD) is essential but also resource intense. We review several studies on online hemodiafiltration (OL-HDF), which concluded that high-volume OL-HDF is associated with better outcome compared to conventional hemodialysis. The cost-effectiveness of OL-HDF was shown in many studies. For example, in the Canadian setting of the Convective Transport Study (CONTRAST), the high-efficiency OL-HDF was shown to be cost-effective compared with low-flux hemodialysis (LF-HD) for patients with ESRD. In our study (Al Saran et al.), it was shown that the cost of hemodialysis was quite less in Saudi Arabia than in other industrialized countries while maintaining a high standard of care. In our retrospective analysis of the cost of OL-HDF in the same center, it was only 3% higher than the conventional HD, which indicates that it is cost-effective considering the improved hospitalization rate, the mortality rates, and the likely better quality of life associated with it. The trend of increased practice of OL-HDF may encourage the practice of home OL-HDF as well. It has been shown that home HD is more costeffective than in-center HD and we presume that the same results will be applied to home OL-HDF as well.

Objetivo: Comparar la biocompatibilidad entre la hemodiafiltración en línea (HDF) y la hemodiafiltración con reinfusión endógena (HFR). Material y método: Estudio comparativo observacional en una población de 15 pacientes en hemodiálisis crónica elegidos al azar entre los pacientes de nuestra unidad. Se compararon cambios en el perfil hematológico, nivel de PCR y constantes vitales, pre y post hemodiálisis, tras someterse a ambas técnicas de hemodiafiltración. Se comparó las diferencias entre los parámetros estudiados pre y post hemodiálisis en cada técnica. Resultados: Los niveles de plaquetas descendieron más en la HDF (HDF -1,33 vs HFR -19,73 x10³/mm³, p=0,005). El nivel de leucocitos disminuyó en la HDF y aumentó en la HFR (HDF -0,46 vs HFR +0,8 x10³/mm³; p=0,006). Respecto a la fórmula leucocitaria hubo resultados dispares: segmentados HDF -1,7 vs HFR +5,4%, pAim: To compare biocompatibility between online hemodiafiltration (HDF) and hemodiafiltration with endogenous reinfusion. Methods: Observational comparative study in a population of 15 chronic hemodialysis patients randomly selected among the patients in our unit. We compared changes in hematological profile, CRP level and vital signs, pre and post hemodialysis, after undergoing both hemodiafiltration techniques. Comparing the differences between the parameters studied before and after each hemodialysis technique. Results: Platelet levels decreased more in the HDF (HDF -1,33 vs HFR -19,73 x10³/mm³, p=0,005). Leukocyte levels decreased in the HDF and increased with HFR (HDF -0,46 vs HFR +0,8 x10³/mm³; p=0,006). Regarding the leukocyte formula had mixed results: segmented HDF -1,7 vs HFR +5,4%, p

Background: Phosphate is an important factor in explaining the high progress of vascular calcification among dialysis patients. Today, phosphate concentration is measured in plasma on a regular basis. The aim of this study was to find out if it is possible to estimate total removed phosphate (TRp) in spent dialysate utilizing UV absorbance during hemodiafiltration. Methods: Eleven patients were monitored online with UV absorbance at 297 nm, three times during one week each (n = 33). Dialysate samples were taken at different times during treatment and from a collection tank to chemically determine phosphate concentrations. Two mathematical models (UVIND and UVGROUP) were tested to estimate TRp with supervision by UV absorbance and compared with TRp measured in the tank (reference). Results: High correlation between UV absorbance and phosphate concentration for each single patient and lower for the whole group together was found. TRp was (mean ± SD) 30.7 ± 7.3 mmol for the reference and 30.8 ± 8.2 and 29.1 ± 5.2 mmol for UVIND and UVGROUP, respectively (p > 0.05). Conclusion: This study demonstrates a novel possibility to estimate TRp based on linear relationship between online monitoring of UV absorbance and concentration of phosphate in spent dialysate.

Background: Anticoagulation of the blood circuit with heparin is essential for hemodialysis, but exposes patients to several risks (bleeding, thrombocytopenia, etc.). The use of citric acid-based dialysate (CitA-D) allows the reduction of heparin in conventional hemodialysis. We evaluated the feasibility of using CitA-D in postdilution online hemodiafiltration (OL-HDF) and of removing heparin. Methods: We prospectively compared chlorhydric acid-based dialysate with CitA-D in 10 patients treated by OL-HDF. First, we reduced heparin by half the dose and then we totally removed anticoagulation. Results: For all 120 sessions using heparin-free CitA-D, only one clotting episode related to an arteriovenous fistula stenosis was observed. No adverse clinical effect was observed. (Kt/V)sp, predialytic serum bicarbonate, calcium, phosphate, parathroid hormone, and β2-microglobulin remained the same in all cases. Conclusion: Our data suggest that the use of CitA-D in OL-HDF is safe and allows heparin removal in most patients.

Cost reduction and quality improvement seem to be conflicting issues. However, online hemodiafiltration (oHDF) with new automatic functions offers a cost-efficient therapy compared to hemodialysis (HD). Seven dialysis centers conducted a randomized clinical trial with cross-over design: high-flux HD vs. postdilutional oHDF with functions coupling both dialysate and substitution flow rates to blood flow rates. During the 6 weeks of the study, all treatment parameters remained unchanged for HD and oHDF, apart from dialysate and substitution flow rate. Treatment data were recorded during each treatment, and predialytic and postdialytic concentrations of urea were recorded at the end of each study phase. The analysis involved 956 treatments of 54 patients. The mean dialysate consumption was 123.2 ± 6.4 l for HD and 113.4 ± 14.9 l for oHDF (p

Background: Measurement of ionic dialysance has been shown to accurately determine urea dialyzer clearance and vascular access flow rate (Qa) in diffusive hemodialysis. Recently, online clearance monitoring (OCM) in an online hemodiafiltration (OL-HDF) machine could accurately measure urea dialyzer clearance. In the present study, OCM was utilized to assess the Qa in OL-HDF. Methods: In 32 stable end-stage renal disease patients undergoing predilution OL-HDF, the values of Qa measured by the OCM technique (QaOCMT) in a Fresenius 4008H HDF machine were compared with those determined by the standard ultrasound dilution technique (QaUDT). Results: The values of QaUDT and QaOCMT measured at the beginning of the HDF session were 800.5 ± 910.3 and 794.6 ± 895.4 ml/min (nonsignificant). There was a significant correlation between the two techniques (r = 0.95, p < 0.01). A Bland-Altman plot demonstrated a good agreement. Conclusion: The vascular access flow determined by OCM, which is integrated mostly in the current HDF machine, is highly accurate, easy to perform, and economical and can be used for vascular access surveillance in OL-HDF.

Background: Guidelines recommend regular measurements of the delivered hemodialysis dose Kt/V. Nowadays, automatic non-invasive online measurements are available as alternatives to the conventional method with blood sampling, laboratory analysis, and calculation. Methods:In a prospective clinical trial, three different methods determining dialysis dose were simultaneously applied: Kt/VDau (conventional method with Daugirdas’ formula), Kt/VOCM [online clearance measurement (OCM) with urea distribution volume V based on anthropometric estimate], and Kt/VBCM [OCM measurement with V measured by bioimpedance analysis (Body Composition Monitor)]. Results:1,076 hemodialysis patients were analyzed. The dialysis dose was measured as Kt/VDau = 1.74 ± 0.45, Kt/VOCM = 1.47 ± 0.34, and Kt/VBCM = 1.65 ± 0.42. The difference between Kt/VOCM and Kt/VBCM was due to the difference between anthropometric estimated VWatson and measured VBCM. Compared to Kt/VDau, Kt/VOCM was 15% lower and Kt/VBCM 5% lower. Kt/VDau was incidentally prone to falsely high values due to operative errors, whereas in these cases OCM-based measurements Kt/VOCM and Kt/VBCM delivered realistic values. Conclusions:The automated OCM Kt/VOCM with anthropometric estimation of urea distribution volume was the easiest method to use, but Kt/VBCM with measured urea distribution volume was closer to the conventional method.

Although protein-bound uremic compounds have been related to outcome in observational studies, few current dialysis strategies provide more removal of those compounds than standard hemodialysis. We evaluated the evolution of protein-bound uremic solutes after a switch from high-flux hemodialysis to postdilution hemodiafiltration (n = 13). We compared predialysis solute concentration at 4, 5, and 9 weeks versus baseline for several protein-bound compounds and water-soluble solutes, as well as for beta(2)-microglobulin. After 9 weeks of postdilution hemodiafiltration, a significant decrease versus baseline could be detected for total concentration of protein-bound solutes: p-cresylsulfate (3.98 +/- 1.51-3.17 +/- 1.77 mg/dL, -20%, P < 0.01) and 3-carboxyl-4-methyl-5-propyl-2-furanpropionic acid (0.72 +/- 0.52-0.64 +/- 0.46 mg/dL, -11%, P < 0.01). For the other protein-bound solutes, hippuric acid, indoleacetic acid, and indoxylsulfate, no change in total concentration could be detected. The concentration of the middle molecule, beta(2)-microglobulin, decreased as well after 9 weeks of postdilution hemodiafiltration (24.7 +/- 9.3-18.1 +/- 6.7 mg/L, -27%, P < 0.01). For water-soluble compounds, no significant change of concentration was found. Postdilution hemodiafiltration in comparison to high-flux hemodialysis provided significant reduction of predialysis concentration of protein-bound compounds, especially those with the highest protein binding, and of beta(2)-microglobulin, by -11 to -27% in 9 weeks.

Background and objectives: Theoretical advantages exist of online hemodiafiltration (HDF) over high-flux hemodialysis (HD), but outcome data are scarce. Our objective was to compare outcomes between these modalities. Design, setting, participants, & measurements: We studied 858 incident patients in our incremental high-flux HD and online HDF program during an 18-yr period. We compared outcomes, including survival, in those who were treated predominantly with HDF (>50% sessions) and those with high-flux HD. Survival comparisons used a Cox model taking into account the time-varying proportion of time spent on HDF. All data were prospectively collected. Results: A total of 152,043 sessions were delivered as HDF and 291,222 as high-flux HD. A total of 232 (27%) patients were treated predominantly with HDF and 626 (73%) with high-flux HD. Total Kt/V, serum albumin, erythropoietin resistance index, and BP were similar in both groups up to 5 yr after HD initiation. Intradialytic hypotension was less frequent in the predominant HDF group. Predominant HDF treatment was associated with a reduced risk for death after correction for confounding variables. In a second Cox model, proportion of time spent on HDF predicted survival, such that patients who were treated solely by HDF would have a hazard for death of 0.66 compared with those who solely used high-flux HD. Conclusions: We found no benefits of HDF over high-flux HD with respect to anemia management, nutrition, mineral metabolism, and BP control. The mortality benefit associated with HDF requires confirmation in large randomized, controlled trials. These data may contribute to their design.

Hemodiafiltration (HDF) includes a variety of technologies and preparation of ultrapure dialysis fluid has made it possible to perform online HDF and its extensive alternatives. According to current statistics, 5.8% of ESRD patients are treated with HDF in Japan. The majority of these HDF treatments are performed using the central dialysis fluid delivery system (CDDS), this is because most Japanese clinicians and researchers consider that with CDDS it is easier to prepare substitution fluid; moreover, CDDS has economical advantages against single-patient dialysis machine (SPDM)-based counterparts. The water quality at each patient station (dialysis console) is regularly validated by bacterial culture (colony-forming units) and by measuring endotoxin concentration (ET). Since ET measurement takes much less time than bacterial culture, ET is often used as an indicator to verify the water quality for online use. Dialysis fluid with ET below the detection level (usually

The measurement of ionic dialysance by conductivity variation is an established method in diffusive hemodialysis. To extend the validity of this method for use in highly convective therapies, such as online hemodiafiltration, we derived a new model for the measurement of ionic dialysance. This method was validated in a study involving 12 patients on pre- and postdilution online hemodiafiltration under various conditions. Clinically, there was a very good agreement between the dialysance determined by conductivity variation and blood side urea clearance. Neither the dilution modes nor the flow rate of the substitution fluid was found to significantly influence this agreement. Our results show that ionic dialysance can be easily and precisely measured by conductivity variation, and this provides an excellent surrogate for urea clearance even in highly convective therapies.

Hemodiafiltration (HDF) is an extracorporeal renal-replacement technique using a highly permeable membrane, in which diffusion and convection are conveniently combined to enhance solute removal in a wide spectrum of molecular weights. In this modality, ultrafiltration exceeds the desired fluid loss in the patient, and replacement fluid must be administered to achieve the target fluid balance. Over the years, various HDF variants have emerged, including acetate-free biofiltration, high-volume HDF, internal HDF, paired-filtration dialysis, middilution HDF, double high-flux HDF, push-pull HDF, and online HDF. Recent technology has allowed online production of large volumes of microbiologically ultrapure fluid for reinfusion, greatly simplifying the practice of HDF. Several advantages of HDF over purely diffusive hemodialysis techniques have been described in the literature, including a greater clearance of urea, phosphate, beta(2)-microglobulin and other larger solutes, reduction in dialysis hypotension, and improved anemia management. Although randomized controlled trials have failed to show a survival benefit of HDF, recent data from large observational studies suggest a positive effect of HDF on survival. This article provides a brief review of the history of HDF, the various HDF techniques, and summary of their clinical effects.

Anaemia secondary to chronic kidney disease is a complex syndrome. Adequate dialysis can contribute to its correction by removing small, and possibly medium/large toxins that inhibit erythropoiesis. Accordingly, a positive relationship between anaemia improvement and dialysis dose has already been observed in the 1980s. Dialysate contamination and low-compatible treatments may also increase cytokine production and consequently inhibit erythropoiesis. Convective treatments and, particularly, on-line haemodiafiltration, could theoretically improve anaemia correction by two mechanisms: higher removal of medium and large solutes (possibly containing bone marrow inhibitors) and reduced microbiological and pyrogenic contamination of the dialysate. Unfortunately, available results are conflicting, mainly because of differences in treatment modalities or membranes, and lack of control groups. Patient selection and higher achieved dialysis dose with online hemodiafiltration may also have complicated interpretation. Increasing treatment time (nocturnal dialysis) and/or frequency (daily dialysis) may diminish rebound from the extravascular space of middle- large molecules and thus possibly improve anaemia. Again, available studies are conflicting.

Observing the development of HDF patient numbers on a global scale between 2004 and 2010, the number of HDF patients increased by around 13 % per year. Online HDF was by far the predominant mode of HDF therapy, being applied to around 90 % of HDF patients in 2010. In this situation, NIKKISO has developed the “DBB-07” Dialysis System, which is focused on online-therapies. In this chapter the DBB-07 features will be explained.

The interest in convection as a transport principle in haemodialysis grew in the 1970s. In 1980 Gambro launched the world’s first complete system for auto-controlled haemofiltration, AK-10 HFM 10-1, an important breakthrough in improving clearance of middle sized molecules. Bags with pharmacy-prepared infusion fluid were used and fluid balance was achieved by weighing devices. An experimentally modified HFM-10 system was found to safely deliver on-line prepared fluid for convective treatments.

The Surdial-X, manufactured by Nipro, is a dialysis machine that can be equipped with one, two, or three pumps. In its HDF configuration, the machine permits double needle online HDF, in pre and post dilution, as well as single needle online HDF in pre and post dilution. All therapies can be carried out with different ultrafiltration, bicarbonate and sodium profiles. A 15 inch touch screen display allows straightforward operations, properly assisting users with full-text guidance. The Surdial-X comes standard with two innovative techniques: Clean Treatment Start (CTS) and Dialysate Infusion Function (DIF). This last one permits the use of the typical online functions even without using the HDF circuit, extending their benefits also to regular HD treatments.

B.Braun provides renal care with all modalities of dialysis for >23,000 patients in 24 countries. The hemodialysis system Dialog + was introduced to the market in 2003. It is available in different configurations, e.g. single-pump, double-pump and HDF-online. All machines are suitable for hospital and in-center dialysis.

Hemodiafiltration has been identified by Fresenius Medical Care (FMC) as a vital need to improve care and outcome of chronic kidney disease patients. By enhancing the removal of middle molecular uremic toxins and improving hemodynamic and global tolerance of dialysis sessions, HDF was recognized as an efficient dialysis modality and a mean to improve patient treatment perception and reduce disease burden. By providing fluid substitution online, HDF appeared the only economically and technically long-term viable solution. Online HDF therapy has been a major R&D focus for FMC over the last decades leading to the development of several online HDF machines with different features.