High convection volume in online post-dilution haemodiafiltration: relevance, safety and costs

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Abstract

Increasing evidence suggests that treatment with online post-dilution haemodiafiltration (HDF) improves clinical outcome in patients with end-stage kidney disease, if compared with haemodialysis (HD). Although the primary analyses of three large randomized controlled trials (RCTs) showed inconclusive results, post hoc analyses of these and previous observational studies comparing online post-dilution HDF with HD showed that the risk of overall and cardiovascular mortality is lowest in patients who are treated with high-volume HDF. As such, the magnitude of the convection volume seems crucial and can be considered as the ‘dose’ of HDF. In this narrative review, the relevance of high convection volume in online post-dilution HDF is discussed. In addition, we briefly touch upon some safety and cost issues.

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Most cited references 42

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Clinical epidemiology of cardiovascular disease in chronic renal disease.

RN Foley, PS Parfrey, MJ Sarnak (1998)

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Immune cell dysfunction and inflammation in end-stage renal disease.

Michiel Betjes (2013)

Uraemia causes inflammation and reduces immune system function as evidenced by an increased risk of viral-associated cancers, increased susceptibility to infections and decreased vaccination responses in patients with end-stage renal disease (ESRD). The substantially increased risk of atherosclerosis in these patients is also probably related to uraemia-associated inflammation. Uraemia is associated with a reduction in the number and function of lymphoid cells, whereas numbers of myeloid cells in uraemic patients are normal or increased with increased production of inflammatory cytokines and reactive oxygen species. Similar to healthy elderly individuals, patients with ESRD have increased numbers of specific proinflammatory subsets of T cells and monocytes, suggesting the presence of premature immunological ageing in these patients. These cells might contribute to inflammation and destabilization of atherosclerotic plaques, and have, therefore, been identified as novel nonclassical cardiovascular risk factors. The cellular composition of the immune system does not normalize after successful kidney transplantation despite a rapid reduction in inflammation and oxidative stress. This finding suggests that premature ageing of the immune system in patients with ESRD might be related to a permanent skewing of the haematopoetic stem cell population towards myeloid-generating subsets, similar to that seen in healthy elderly individuals.

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The intestinal microbiota, a leaky gut, and abnormal immunity in kidney disease.

Hans-Joachim Anders, Kirstin Andersen, Bärbel Stecher (2013)

Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are associated with systemic inflammation and acquired immunodeficiency, which promote cardiovascular disease, body wasting, and infections as leading causes of death. This phenomenon persists despite dialysis-related triggers of immune deregulation having been largely eliminated. Here we propose a potential immunoregulatory role of the intestinal microbiota in CKD/ESRD. We discuss how the metabolic alterations of uremia favor pathogen overgrowth (dysbiosis) in the gut and an increased translocation of living bacteria and bacterial components. This process has the potential to activate innate immunity and systemic inflammation. Persistent innate immune activation involves the induction of immunoregulatory mediators that suppress innate and adaptive immunity, similar to the concept of 'endotoxin tolerance' or 'immune paralysis' in advanced sepsis or chronic infections. Renal science has largely neglected the gut as a source of triggers for CKD/ESRD-related immune derangements and complications and lags behind on the evolving microbiota research. Interdisciplinary research activities at all levels are needed to unravel the pathogenic role of the intestinal microbiota in kidney disease and to evaluate if therapeutic interventions that manipulate the microbiota, such as pre- or probiotics, have a therapeutic potential to correct CKD/ESRD-related immune deregulation and to prevent the associated complications.

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Author and article information

Journal

Journal ID (nlm-ta): Clin Kidney J

Journal ID (iso-abbrev): Clin Kidney J

Journal ID (publisher-id): ckj

Journal ID (hwp): ndtplus

Title: Clinical Kidney Journal

Publisher: Oxford University Press

ISSN (Print): 2048-8505

ISSN (Electronic): 2048-8513

Publication date (Print): August 2015

Publication date (Electronic): 10 June 2015

Publication date PMC-release: 10 June 2015

Volume: 8

Issue: 4

Pages: 368-373

Affiliations

[1 ]Department of Nephrology, University Medical Center Utrecht , Utrecht, The Netherlands

[2 ]Department of Nephrology, VU University Medical Center , Amsterdam, The Netherlands

[3 ]Institute for Cardiovascular Research VU University Medical Center (ICaR-VU), VU University Medical Center , Amsterdam, The Netherlands

[4 ]Department of Medicine, Miulli General Hospital , Acquaviva delle Fonti, Italy

[5 ]UCL Centre for Nephrology, Royal Free Hospital , London, UK

[6 ]Division of Nephrology, Department of Medicine, University of Würzburg , Würzburg, Germany

Author notes

Correspondence to: Peter J. Blankestijn; E-mail: p.j.blankestijn@ 123456umcutrecht.nl

Article

Publisher ID: sfv040

DOI: 10.1093/ckj/sfv040

PMC ID: 4515895

PubMed ID: 26251701

SO-VID: f325c143-dea4-46e4-80df-a820660d9cb7

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 24 October 2014

Date revision received : 30 April 2015

Date accepted : 4 May 2015

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High convection volume in online post-dilution haemodiafiltration: relevance, safety and costs

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UCL: UN SDG 03 Good Health and Well-Being

Most cited references 42

Clinical epidemiology of cardiovascular disease in chronic renal disease.

Immune cell dysfunction and inflammation in end-stage renal disease.

The intestinal microbiota, a leaky gut, and abnormal immunity in kidney disease.

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