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    "textoCompleto" => "INTRODUCTION <br></br><br></br>On-line hemodiafiltration &#40;OL-HDF&#41; is a dialysis procedure that adds to diffusive transport characteristic of standard hemodialysis &#40;HD&#41; a significant amount of convective transport&#46; Convective transport allows for an increased clearance of medium and large-sized molecules&#44; difficult to remove by diffusion&#46; 1 Retention of these uremic molecules has traditionally been associated to various chronic complications in patients on hemodialysis&#46; Several studies have shown decreases in these complication when procedures with greater convective transport are used&#46;2-6 The disparity in the clinical results of HDF procedures reported in the literature may be accounted for by the different convective component&#46; Hemodiafiltrations of 6-8 L of ultrafiltrate per session are often compared to <br></br>HDs greater than 20 L&#46; It was recently reported that the relative mortality risk could be decreased in patients treated with HDF with a high convective transport&#44; as compared to either low or high-flux HD&#46;7&#44;8 <br></br><br></br>On-line postdilutional HDF &#40;OL-P-HDF&#41; is the most efficient renal clearance procedure in clinical practice&#44; being <br></br>more efficient&#44; the higher the infusion rate is&#46; In this regard&#44; agreement begins to exist about the need for achieving at least 20 L of ultrafiltration &#40;UF&#41;9 and B2-M clearance rates higher than 70&#37;&#46;4&#44;10 However&#44; postdilutional infusion is limited by the progressive plasma hemoconcentration in the dialyzer&#46;11 <br></br><br></br>When a filtration coefficient of 25&#37; of real Qb is exceeded in the OL-P-HDF procedure&#44; a hemoconcentration will be induced in the dialyzer that will interfere with diffusion&#44; with a subsequent decrease in clearance of small molecules and a trend to coagulability in capillaries&#44; which may further decrease clearance&#46;12 Coagulation of the whole blood circuit may sometimes occur&#46; TMP increases&#44; and extreme values &#40;&#62; 300 mmHg&#41; are associated to protein denaturation and hemolysis&#44; with irreversible reduction in dialyzer efficacy&#46;13 <br></br><br></br>To solve these problems&#44; systems combining the advantages of both modalities &#40;pre and postdilution&#41; and attempting to minimize their disadvantages have been devised&#46; Such systems include the mixed OL-HDF14 and mid-dilutional15&#44;16 procedures&#44; but are not still available or require special materials that increase the costs&#46; There are also sequential convective procedures combining hemofiltration and hemodiafiltration which have been shown to improve the hemodynamic tolerance of patients&#44; as well as the clearance rates of molecules of medium molecular weight&#46;17 <br></br><br></br>Patients whose vascular access allows for a real blood flow &#40;Qb&#41; of 400 mL&#47;min in OL-P-HDF will have no problems for maintaining 100 mL&#47;min of UF without technical problems&#44; thus achieving 24 L of convective transport in a 4-hour session&#46; Many patients currently have an inadequate vascular access&#44; particularly those with indwelling catheters&#46; UF would therefore have to be reduced to 60 mL&#47;min or to be converted into predilutional&#46; Since predilutional OL-HDF has a 1&#47;2 to 1&#47;3 lower performance than postdilutional OL-HDF for medium-sized molecules&#44;9 UF rates as high as 300 mL&#47;min &#40;18 L&#47;h&#41; and commensurate infusions&#44; which cannot be achieved by all machines&#44; would be required&#46; <br></br><br></br>In an attempt to achieve ultrafiltrations equivalent to 20 L in postdilution for potential future application to patients with limited Qbs&#44; we developed a procedure called &#171;on-line sequential HDF&#187; &#40;OL-S-HDF&#41;&#46; OL-S-HDF starts with infusion in postdilution&#44; at an approximate rate of 100 mL&#47;min&#44; and once TMP reaches 250 mmHg&#44; infusion is manually changed to predilution&#44; increasing the infusion rate by 50&#37; until the end of the session &#40;fig&#46; 1&#41;&#46; Hence the term &#171;sequential&#187;&#44; because infusion would not be simultaneous&#44; but sequential over time&#44; not requiring any filters or monitors different from the usual ones&#46; Our purpose was to analyze the performance of the OL-S-HDF procedure in the clearance of small and medium- sized molecules&#44; and to compare it to high-flux hemodialysis &#40;HD-HF&#41; and OL-P-HDF&#46; <br></br><br></br>STUDY DESIGN <br></br><br></br>This was a controlled&#44; prospective study where 16 patients in a chronic hemodialysis program were randomly dialyzed using HD-HF&#44; OL-P-HDF&#44; and OL-S-HDF&#46; Patients continued on their standard dialysis technique three times weekly&#44; and the above procedures were performed in each patient in the mid-week session for three consecutive weeks&#46; Procedures were analyzed and compared to each other&#46; <br></br><br></br>PATIENTS <br></br><br></br>Sixteen stable adult patients diagnosed of chronic kidney disease undergoing dialysis three times a week at the Hemodialysis Unit of Hospital G&#46; U&#46; &#171;Gregorio Mara&#241;&#243;n&#187; participated in the study&#46; <br></br><br></br>Inclusion criteria were&#58; age ranging from 18 and 80 years&#59; hemoglobin levels within normal ranges according to European guidelines for anemia management&#59;18 vascular access with a Qb3 300 mL&#47;min&#59; and urea recirculation within normal limits &#40;less than 12&#37;&#44; measured at low flow&#41;&#46; Patients provided consent for the study&#46; Poor dialysis tolerance was an exclusion criterion&#46; <br></br><br></br>MATERIALS <br></br><br></br>A Fresenius&#174; model H400-S equipment fitted with an OCM device &#40;online clearance monitor&#44; ionic dialysance&#41; and BVM &#40;blood volume monitor&#41;&#44; and a HF80S dialyzer &#40;polysulfone&#44; 1&#46;8 m2&#59; Fresenius&#174;&#44; Hamburg&#44; Germany&#41; were used in all sessions&#46; Aportable digital pressure gauge &#40;Nagano&#174;&#41; was placed between the blood pump and dialyzer to measure pre-filter pressure &#40;PFP&#41;&#46; <br></br><br></br>METHODS <br></br><br></br>In all sessions studied&#44; the theoretical blood flow rate adequate for achieving an real Qb &#40;calculated by the equipment from pre-pump negative pressure&#41; of 400 mL&#47;min was kept&#46; If this figure was not achieved&#44; Qb was increased until a pressure &#191; 200 mmHg was induced in the pre-pump arterial line&#46; A bath flow rate &#40;Qd&#41; of 800 mL&#47;min&#44; a dialysis fluid with a calcium concentration of 3 mEq&#47;L&#44; and a total conductivity of 14 mS&#47;cm were used&#46; Session duration was as usual for each patient&#46; <br></br><br></br>In OL-P-HDF sessions&#44; an infusion rate of 25&#37; of real Qb was used&#46; OL-S-HDF sessions started in postdilutional phase&#44; programming an infusion rate of 100 mL&#47;min without exceeding 30&#37; of Qb&#44; and when TMP reached 250 mmHg&#44; the infusion fluid was transferred to predilution at an infusion rate 50&#37; higher than the previous one &#40;fig&#46; 2&#41;&#46; <br></br><br></br>The following laboratory parameters were measured before and after dialysis&#58; urea&#44; creatinine&#44; B2-microglobulin&#44; myoglobin&#44; albumin&#44; and hematocrit &#40;Hct&#41;&#46; The post-dialysis sample was taken from the arterial line after reducing pump speed to 50 mL&#47;min for 2 minutes&#46; <br></br><br></br>DATA COLLECTION <br></br><br></br>The following were measured and recorded during each session&#58; calculated real Qb&#44; arterial line pressure &#40;AP&#41;&#44; venous line pressure &#40;VP&#41;&#44; TMP&#44; PFP&#44; and changes in plasma volume &#40;by BVM&#41; every hour&#46; To measure the efficacy of the different procedures&#44; clearance rates of urea&#44; creatinine&#44; B2-microglobulin&#44; and myoglobin were calculated&#46; The final Kt was measured in all sessions using the OCM &#40;ionic dialysance&#41; and Kt&#47;V was estimated&#44; calculating V by the Watson formula&#46; Kt&#47;V was calculated from pre- and post-session urea levels using the Daugirdas &#40;1993&#41; and Maduell formulas&#46; <br></br><br></br>Percent hemoconcentration &#40;HC&#41; was calculated at the end of session using the following equation&#58; &#91;&#40;Post-dialysis Hct x 100&#41;&#47;Pre-dialysis Hct&#93;-100&#46; To use this formula&#44; hematocrit was measured before dialysis in the arterial line and at the end of dialysis at dialyzer outlet&#46; <br></br><br></br>STATISTICS <br></br><br></br>Normal values were expressed as the mean &#40;&#177; standard deviation&#41;&#46; The value interval was sometimes recorded&#46; A Chisquare test or a Fisher&#191;s exact test when appropriate were used to compare qualitative variables&#46; Differences between means were tested using an analysis of variance &#40;ANOVA&#41;&#46; Normalized variables were correlated to each other &#40;Pearson&#191;s correlation coefficient&#41;&#46; A value of p &#60; 0&#46;05 was considered statistically significant&#46; Data were analyzed using SPSS software version 12 for Windows&#46; <br></br><br></br>RESULTS <br></br><br></br>The 16 patients&#44; 9 females and 7 males&#44; had a mean age of 62&#40;&#177; 14&#41; years&#44; a mean dry weight of 67 &#40;&#177; 9&#41; kg&#44; and a mean Hct of 35&#37; &#40;&#177; 4&#46;2&#41;&#46; All patients were stable and had been more than 6 months on dialysis&#46; Four patients were diabetic and two had an indwelling catheter&#44; while all other patients had a functioning arteriovenous fistula&#46; <br></br><br></br>Dialysis duration was 219 &#40;&#177; 15&#41; minutes &#40;min&#46; 195-max&#46; 240&#41;&#46; Mean transition time from post to predilution in OL-SHDF from session start was 127 &#40;&#177; 33&#41; minutes &#40;min&#46; 60 - max&#46; 165&#44; and had an inversely correlated to baseline hct levels &#40;p &#61; 0&#46;005&#41; <br></br><br></br>Table I shows data of all three procedures&#46; No significant differences were found in the real Qb reached in the three <br></br>procedures or in pre-dialysis hematocrit values&#46; Infusion volume was significantly higher in OL-S-HDF than in OL-PHDF&#46; Hemoconcentration &#40;&#37;HC&#41; was more important in OL-P-HDF than in OL-S-HDF&#44; in which it was in turn higher than in HD-HF&#46; <br></br><br></br>No differences were found in Kt &#40;ionic dialysance&#41;&#44; Kt&#47;V&#44; and urea and creatinine clearance rates between the three procedures&#44; while the clearance rates of B2-microglobulin and myoglobin were significantly greater for both OL-P-HDF and OL-S-HDF as compared to HD-HF &#40;p &#60; 0&#46;000&#41;&#46; There were no differences between both HDF procedures &#40;table II&#41;&#46; <br></br><br></br>A direct correlation existed between TMP and PFP during the session in all procedures &#40;p &#60; 0&#46;05&#41;&#44; with a TMP pressure of 145 mmHg corresponding to a PFP of 395 mmHg&#46; Both pressures gradually increased towards the end in OL-P-HDF &#40;figs&#46; 3 and 4&#41;&#46; Hourly PFP was found to have a positive correlation with baseline serum albumin levels &#40;p &#60; 0&#46;03&#41;&#44; Hct values &#40;p &#60; 0&#46;01&#41;&#44; and percent hemoconcentration in the patient at end of dialysis &#40;p &#60; 0&#46;01&#41;&#44; this finding was not demostrated for TMP&#46; Clearance rate of&#160; 2-microglobulin and myoglobin had an inverse correlation with TMP and PFP &#40;p &#61; 0&#46;003 and 0&#46;01&#41;&#46; <br></br><br></br>No clinical complications occurred in any of the sessions studied&#46; Only the presence of some clotted capillary at the end of the OL-P-HDF sessions required an increase in heparin dose in this procedure&#46; <br></br><br></br>DISCUSSION <br></br><br></br>OL-HDF is the most complete clinical hemodialysis procedure currently available&#46;19 The postdilutional modality <br></br>achieves the best performance in terms of clearance of uremic toxins&#46;14 To achieve adequate results with this modality&#44; ultrafiltrations higher than 20 L should be achieved&#46;9 In patients with an optimal vascular access&#44; blood flow rates higher than 400 mL&#47;min may be achieved&#44; which would allow for reaching that volume in about 4 hours&#44; maintaining a 25&#37; filtration fraction&#46; <br></br><br></br>As shown by the study results&#44; clearance and removal of small molecules such as urea and creatinine are similar in <br></br>HD-HF and OL-HDF procedures&#46; In some optimal cases with low filtration fractions and not very high hematocrit values&#44; up to a 10&#37; increase may be achieved&#46; <br></br><br></br>Anyway&#44; these procedures are not intended to increase clearance of small molecules&#44; but that of medium and big molecules&#44; and an up to 70&#37; increase was indeed seen in the clearance rates of B2-microglobulin and myoglobin with OL-HDF procedures&#46; It should be emphasized that the dialyzer used in this study achieves in itself a significant level of B2-microglobulin removal in hemodialysis because by retrofiltration causes a true internal OL-HDF&#46; <br></br><br></br>The number of patients with vascular access and high blood flow rates are now almost a minority&#46; With theoretical <br></br>blood flow rates of approximately 300 mL&#47;min it is very difficult to achieve 20 L of ultrafiltration in a standard <br></br>time of four hours&#46; When an attempt is made to increase postdilutional infusion to 100 mL&#47;min&#44; multiple technical <br></br>problems occur&#44; including TMP elevation&#44; partial or total clotting of the system&#44; and a decreased dialytic&#160; erformance&#46; In our study&#44; these problems were detected and related better with PFP than with TMP though&#44; as previously stated&#44; these two pressures are significantly related&#46; Factors contributing to the occurrence of these problems include high hematocrit values&#44; hyperproteinemia&#44; and hyperlipidemia&#46; On the other hand&#44; if an attempt is <br></br>made to increase pump flow&#44; we may contribute to the occurrence of complications such as a marked decrease in arterial line pressure or&#44; which is the same thing&#44; a decrease in the real Qb&#47;theoretical Qb ratio and recirculation of vascular access&#46; <br></br><br></br>In our study&#44; the factor correlating best to PFP increase was hematocrit and progressive hemoconcentration during dialysis&#46; PFP was also related to baseline albuminemia&#46; PFP sometimes reached levels higher than 700 mmHg&#46; In future OLHDF machines it would be helpful to have a pressure gauge to measure PFP&#44; which is sometimes more useful than TMP&#46; While many of our patients have high hematocrit values and normal albumin levels&#44; if a 25&#37; filtration fraction is respected no clinical complications occur in OL-P-HDF&#44; as shown in our study&#46; <br></br><br></br>In some cases where PFP and TMP are markedly increased&#44; a greater interference probably exists between both types of transport&#44; with a decrease in diffusive transport leading to a decreased clearance of small molecules&#46; This phenomenon was documented in this study also for medium-sized molecules such as B2-microglobulin and myoglobin&#44; when clearance rates were inversely related to PFP and TMP&#46; The increase in protein layer in the capillary membrane when a high filtration fraction was applied would explain this phenomenon&#46; <br></br><br></br>OL-S-HDF was shown to be better than HD-HF but similar to OL-P-HDF for removing medium-sized molecules&#46; The sequential procedure would thus be similar but not superior to the postdilutional procedure&#44; and would therefore not be recommended for stable patients and with optimal Qbs&#46; There are&#44; however&#44; patients with limited Qbs &#40;&#60; 300 mL&#47;min&#41; who do not reach the desired 20 L in the scheduled OL-P-HDF time&#46; Though this study included patients with relatively limited Qbs &#40;mean Qb of 370 mL&#47;min and only 31&#37; of patients with Qb &#60; 350 mL&#47;min&#41;&#44; we think that in patients with Qb &#60; 300 mL&#47;min&#44; OL-S-HDF could be a therapeutic alternative to achieve higher volumes with similar clearances&#46; <br></br><br></br>When switching from postdilutional to predilutional infusion&#44; the UF-infusion rate was increased by 50&#37;&#44; but we think that to achieve a better performance in patients with limited Qbs such rate could be further increased&#44; even doubled&#44; with no complications&#46; It should be noted that the predilutional system does not involve an increased use of dialysis fluid&#44; though compensated systems adjusting fluid to blood flow currently exist&#46; <br></br><br></br>From the technical viewpoint&#44; change in the infusion site is simple and does not require any accessory&#44; so that it does not involve any additional cost&#46; Based on the foregoing&#44; we think that OL-S-HDF could be a useful hemodialysis procedure in patients with limited blood flow rates &#40;&#60; 300 mL&#47;min&#41;&#46; Further studies of this procedure should therefore be designed&#46; <br></br><br></br>ACKNOWLEDGEMENTS <br></br><br></br>We thank the nursing staff from the Hemodialysis Unit of Hospital Gral&#46; &#171;Gregorio Mara&#241;&#243;n&#187;&#46; <br></br>"
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        "resumen" => "La hemodiafiltraci&#243;n en l&#237;nea proporciona una alta eficacia depurativa de mol&#233;culas de mediano y gran peso molecular&#46; Existe consenso sobre la necesidad de conseguir al menos 20 L de ultrafiltraci&#243;n en postdiluci&#243;n y tasas de reducci&#243;n de B2-microglobulina mayores del 70&#37;&#46; Desafortunadamente muchos pacientes tienen un acceso vascular inadecuado siendo muy dif&#237;cil lograr esos vol&#250;menes de ultrafiltraci&#243;n sin complicaciones cl&#237;nicas&#46; El objetivo de este trabajo fue conseguir un volumen de ultrafiltraci&#243;n equivalente a 20 L en postdilucional&#44; mediante la t&#233;cnica &#171;Secuencial&#187; &#40;HDF-OL-S&#41; que comienza siendo postdilucional y cuando la PTM alcanza los 250 mmHg se trasforma en predilucional&#46; Se realiz&#243; una sesi&#243;n de hemodi&#225;lisis de alto flujo &#40;HD-HF&#41;&#44; una de hemodiafiltraci&#243;n postdilucional &#40;HDF-OL-P&#41; y otra sesi&#243;n en modo secuencial a 16 pacientes durante 3 semanas consecutivas&#44; en la sesi&#243;n de mitad de semana&#46; Se compararon los rendimientos de eliminaci&#243;n de peque&#241;as y medianas mol&#233;culas entre las diferentes t&#233;cnicas&#46; Se midi&#243; la presi&#243;n prefiltro &#40;PPF&#41; mediante man&#243;metro predializador&#46; No encontramos diferencias en el Kt&#47;V&#44; tasa de reducci&#243;n de urea y de creatinina entre las 3 t&#233;cnicas&#46; La tasa de reducci&#243;n de B2-microglobulina y mioglobina fue significativamente mayor tanto en HDFOL-P como en HDF-OL-S con respecto a la HD-HF&#44; no habiendo diferencias entre ambas t&#233;cnicas de HDF&#46; Existi&#243; una correlaci&#243;n directa entre PTM y PPF a lo largo de la sesi&#243;n en todas las t&#233;cnicas&#46; La PPF horaria se correlacionaba mejor que PTM con los niveles basales de alb&#250;mina s&#233;rica&#44; hematocrito y porcentaje de hemoconcentraci&#243;n al final de la di&#225;lisis&#46; La HDF-OL-S es una t&#233;cnica de hemodi&#225;lisis con los mismos beneficios de la postdilucional que permite lograr vol&#250;menes de ultrafiltraci&#243;n dentro de los objetivos planteados&#46; Creemos podr&#237;a ser &#250;til en pacientes con flujos sangu&#237;neos limitados para lo cual habr&#237;a que dise&#241;ar nuevos estudios&#46; La PPF aporta informaci&#243;n complementaria a la PTM&#46;"
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On-line sequential hemodiafiltration (OL-S-HDF): a new therapeutic option
HEMODIAFILTRACION EN LINEA SECUENCIAL (HDF-OL-S): Una nueva opción terapéutica.
Julia Kantera, Marta Puerta Carreteroa, Rafael Perez Garcíaa, Juan Manuel López Gómeza, Rosa Jofréa, Patrocinio Rodríguez Beniteza
a Servicio de Nefrología. Unidad de Hemodiálisis, Hospital G. U. ¿Gregorio Marañón¿, Madrid, Madrid, España,
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    "textoCompleto" => "INTRODUCTION <br></br><br></br>On-line hemodiafiltration &#40;OL-HDF&#41; is a dialysis procedure that adds to diffusive transport characteristic of standard hemodialysis &#40;HD&#41; a significant amount of convective transport&#46; Convective transport allows for an increased clearance of medium and large-sized molecules&#44; difficult to remove by diffusion&#46; 1 Retention of these uremic molecules has traditionally been associated to various chronic complications in patients on hemodialysis&#46; Several studies have shown decreases in these complication when procedures with greater convective transport are used&#46;2-6 The disparity in the clinical results of HDF procedures reported in the literature may be accounted for by the different convective component&#46; Hemodiafiltrations of 6-8 L of ultrafiltrate per session are often compared to <br></br>HDs greater than 20 L&#46; It was recently reported that the relative mortality risk could be decreased in patients treated with HDF with a high convective transport&#44; as compared to either low or high-flux HD&#46;7&#44;8 <br></br><br></br>On-line postdilutional HDF &#40;OL-P-HDF&#41; is the most efficient renal clearance procedure in clinical practice&#44; being <br></br>more efficient&#44; the higher the infusion rate is&#46; In this regard&#44; agreement begins to exist about the need for achieving at least 20 L of ultrafiltration &#40;UF&#41;9 and B2-M clearance rates higher than 70&#37;&#46;4&#44;10 However&#44; postdilutional infusion is limited by the progressive plasma hemoconcentration in the dialyzer&#46;11 <br></br><br></br>When a filtration coefficient of 25&#37; of real Qb is exceeded in the OL-P-HDF procedure&#44; a hemoconcentration will be induced in the dialyzer that will interfere with diffusion&#44; with a subsequent decrease in clearance of small molecules and a trend to coagulability in capillaries&#44; which may further decrease clearance&#46;12 Coagulation of the whole blood circuit may sometimes occur&#46; TMP increases&#44; and extreme values &#40;&#62; 300 mmHg&#41; are associated to protein denaturation and hemolysis&#44; with irreversible reduction in dialyzer efficacy&#46;13 <br></br><br></br>To solve these problems&#44; systems combining the advantages of both modalities &#40;pre and postdilution&#41; and attempting to minimize their disadvantages have been devised&#46; Such systems include the mixed OL-HDF14 and mid-dilutional15&#44;16 procedures&#44; but are not still available or require special materials that increase the costs&#46; There are also sequential convective procedures combining hemofiltration and hemodiafiltration which have been shown to improve the hemodynamic tolerance of patients&#44; as well as the clearance rates of molecules of medium molecular weight&#46;17 <br></br><br></br>Patients whose vascular access allows for a real blood flow &#40;Qb&#41; of 400 mL&#47;min in OL-P-HDF will have no problems for maintaining 100 mL&#47;min of UF without technical problems&#44; thus achieving 24 L of convective transport in a 4-hour session&#46; Many patients currently have an inadequate vascular access&#44; particularly those with indwelling catheters&#46; UF would therefore have to be reduced to 60 mL&#47;min or to be converted into predilutional&#46; Since predilutional OL-HDF has a 1&#47;2 to 1&#47;3 lower performance than postdilutional OL-HDF for medium-sized molecules&#44;9 UF rates as high as 300 mL&#47;min &#40;18 L&#47;h&#41; and commensurate infusions&#44; which cannot be achieved by all machines&#44; would be required&#46; <br></br><br></br>In an attempt to achieve ultrafiltrations equivalent to 20 L in postdilution for potential future application to patients with limited Qbs&#44; we developed a procedure called &#171;on-line sequential HDF&#187; &#40;OL-S-HDF&#41;&#46; OL-S-HDF starts with infusion in postdilution&#44; at an approximate rate of 100 mL&#47;min&#44; and once TMP reaches 250 mmHg&#44; infusion is manually changed to predilution&#44; increasing the infusion rate by 50&#37; until the end of the session &#40;fig&#46; 1&#41;&#46; Hence the term &#171;sequential&#187;&#44; because infusion would not be simultaneous&#44; but sequential over time&#44; not requiring any filters or monitors different from the usual ones&#46; Our purpose was to analyze the performance of the OL-S-HDF procedure in the clearance of small and medium- sized molecules&#44; and to compare it to high-flux hemodialysis &#40;HD-HF&#41; and OL-P-HDF&#46; <br></br><br></br>STUDY DESIGN <br></br><br></br>This was a controlled&#44; prospective study where 16 patients in a chronic hemodialysis program were randomly dialyzed using HD-HF&#44; OL-P-HDF&#44; and OL-S-HDF&#46; Patients continued on their standard dialysis technique three times weekly&#44; and the above procedures were performed in each patient in the mid-week session for three consecutive weeks&#46; Procedures were analyzed and compared to each other&#46; <br></br><br></br>PATIENTS <br></br><br></br>Sixteen stable adult patients diagnosed of chronic kidney disease undergoing dialysis three times a week at the Hemodialysis Unit of Hospital G&#46; U&#46; &#171;Gregorio Mara&#241;&#243;n&#187; participated in the study&#46; <br></br><br></br>Inclusion criteria were&#58; age ranging from 18 and 80 years&#59; hemoglobin levels within normal ranges according to European guidelines for anemia management&#59;18 vascular access with a Qb3 300 mL&#47;min&#59; and urea recirculation within normal limits &#40;less than 12&#37;&#44; measured at low flow&#41;&#46; Patients provided consent for the study&#46; Poor dialysis tolerance was an exclusion criterion&#46; <br></br><br></br>MATERIALS <br></br><br></br>A Fresenius&#174; model H400-S equipment fitted with an OCM device &#40;online clearance monitor&#44; ionic dialysance&#41; and BVM &#40;blood volume monitor&#41;&#44; and a HF80S dialyzer &#40;polysulfone&#44; 1&#46;8 m2&#59; Fresenius&#174;&#44; Hamburg&#44; Germany&#41; were used in all sessions&#46; Aportable digital pressure gauge &#40;Nagano&#174;&#41; was placed between the blood pump and dialyzer to measure pre-filter pressure &#40;PFP&#41;&#46; <br></br><br></br>METHODS <br></br><br></br>In all sessions studied&#44; the theoretical blood flow rate adequate for achieving an real Qb &#40;calculated by the equipment from pre-pump negative pressure&#41; of 400 mL&#47;min was kept&#46; If this figure was not achieved&#44; Qb was increased until a pressure &#191; 200 mmHg was induced in the pre-pump arterial line&#46; A bath flow rate &#40;Qd&#41; of 800 mL&#47;min&#44; a dialysis fluid with a calcium concentration of 3 mEq&#47;L&#44; and a total conductivity of 14 mS&#47;cm were used&#46; Session duration was as usual for each patient&#46; <br></br><br></br>In OL-P-HDF sessions&#44; an infusion rate of 25&#37; of real Qb was used&#46; OL-S-HDF sessions started in postdilutional phase&#44; programming an infusion rate of 100 mL&#47;min without exceeding 30&#37; of Qb&#44; and when TMP reached 250 mmHg&#44; the infusion fluid was transferred to predilution at an infusion rate 50&#37; higher than the previous one &#40;fig&#46; 2&#41;&#46; <br></br><br></br>The following laboratory parameters were measured before and after dialysis&#58; urea&#44; creatinine&#44; B2-microglobulin&#44; myoglobin&#44; albumin&#44; and hematocrit &#40;Hct&#41;&#46; The post-dialysis sample was taken from the arterial line after reducing pump speed to 50 mL&#47;min for 2 minutes&#46; <br></br><br></br>DATA COLLECTION <br></br><br></br>The following were measured and recorded during each session&#58; calculated real Qb&#44; arterial line pressure &#40;AP&#41;&#44; venous line pressure &#40;VP&#41;&#44; TMP&#44; PFP&#44; and changes in plasma volume &#40;by BVM&#41; every hour&#46; To measure the efficacy of the different procedures&#44; clearance rates of urea&#44; creatinine&#44; B2-microglobulin&#44; and myoglobin were calculated&#46; The final Kt was measured in all sessions using the OCM &#40;ionic dialysance&#41; and Kt&#47;V was estimated&#44; calculating V by the Watson formula&#46; Kt&#47;V was calculated from pre- and post-session urea levels using the Daugirdas &#40;1993&#41; and Maduell formulas&#46; <br></br><br></br>Percent hemoconcentration &#40;HC&#41; was calculated at the end of session using the following equation&#58; &#91;&#40;Post-dialysis Hct x 100&#41;&#47;Pre-dialysis Hct&#93;-100&#46; To use this formula&#44; hematocrit was measured before dialysis in the arterial line and at the end of dialysis at dialyzer outlet&#46; <br></br><br></br>STATISTICS <br></br><br></br>Normal values were expressed as the mean &#40;&#177; standard deviation&#41;&#46; The value interval was sometimes recorded&#46; A Chisquare test or a Fisher&#191;s exact test when appropriate were used to compare qualitative variables&#46; Differences between means were tested using an analysis of variance &#40;ANOVA&#41;&#46; Normalized variables were correlated to each other &#40;Pearson&#191;s correlation coefficient&#41;&#46; A value of p &#60; 0&#46;05 was considered statistically significant&#46; Data were analyzed using SPSS software version 12 for Windows&#46; <br></br><br></br>RESULTS <br></br><br></br>The 16 patients&#44; 9 females and 7 males&#44; had a mean age of 62&#40;&#177; 14&#41; years&#44; a mean dry weight of 67 &#40;&#177; 9&#41; kg&#44; and a mean Hct of 35&#37; &#40;&#177; 4&#46;2&#41;&#46; All patients were stable and had been more than 6 months on dialysis&#46; Four patients were diabetic and two had an indwelling catheter&#44; while all other patients had a functioning arteriovenous fistula&#46; <br></br><br></br>Dialysis duration was 219 &#40;&#177; 15&#41; minutes &#40;min&#46; 195-max&#46; 240&#41;&#46; Mean transition time from post to predilution in OL-SHDF from session start was 127 &#40;&#177; 33&#41; minutes &#40;min&#46; 60 - max&#46; 165&#44; and had an inversely correlated to baseline hct levels &#40;p &#61; 0&#46;005&#41; <br></br><br></br>Table I shows data of all three procedures&#46; No significant differences were found in the real Qb reached in the three <br></br>procedures or in pre-dialysis hematocrit values&#46; Infusion volume was significantly higher in OL-S-HDF than in OL-PHDF&#46; Hemoconcentration &#40;&#37;HC&#41; was more important in OL-P-HDF than in OL-S-HDF&#44; in which it was in turn higher than in HD-HF&#46; <br></br><br></br>No differences were found in Kt &#40;ionic dialysance&#41;&#44; Kt&#47;V&#44; and urea and creatinine clearance rates between the three procedures&#44; while the clearance rates of B2-microglobulin and myoglobin were significantly greater for both OL-P-HDF and OL-S-HDF as compared to HD-HF &#40;p &#60; 0&#46;000&#41;&#46; There were no differences between both HDF procedures &#40;table II&#41;&#46; <br></br><br></br>A direct correlation existed between TMP and PFP during the session in all procedures &#40;p &#60; 0&#46;05&#41;&#44; with a TMP pressure of 145 mmHg corresponding to a PFP of 395 mmHg&#46; Both pressures gradually increased towards the end in OL-P-HDF &#40;figs&#46; 3 and 4&#41;&#46; Hourly PFP was found to have a positive correlation with baseline serum albumin levels &#40;p &#60; 0&#46;03&#41;&#44; Hct values &#40;p &#60; 0&#46;01&#41;&#44; and percent hemoconcentration in the patient at end of dialysis &#40;p &#60; 0&#46;01&#41;&#44; this finding was not demostrated for TMP&#46; Clearance rate of&#160; 2-microglobulin and myoglobin had an inverse correlation with TMP and PFP &#40;p &#61; 0&#46;003 and 0&#46;01&#41;&#46; <br></br><br></br>No clinical complications occurred in any of the sessions studied&#46; Only the presence of some clotted capillary at the end of the OL-P-HDF sessions required an increase in heparin dose in this procedure&#46; <br></br><br></br>DISCUSSION <br></br><br></br>OL-HDF is the most complete clinical hemodialysis procedure currently available&#46;19 The postdilutional modality <br></br>achieves the best performance in terms of clearance of uremic toxins&#46;14 To achieve adequate results with this modality&#44; ultrafiltrations higher than 20 L should be achieved&#46;9 In patients with an optimal vascular access&#44; blood flow rates higher than 400 mL&#47;min may be achieved&#44; which would allow for reaching that volume in about 4 hours&#44; maintaining a 25&#37; filtration fraction&#46; <br></br><br></br>As shown by the study results&#44; clearance and removal of small molecules such as urea and creatinine are similar in <br></br>HD-HF and OL-HDF procedures&#46; In some optimal cases with low filtration fractions and not very high hematocrit values&#44; up to a 10&#37; increase may be achieved&#46; <br></br><br></br>Anyway&#44; these procedures are not intended to increase clearance of small molecules&#44; but that of medium and big molecules&#44; and an up to 70&#37; increase was indeed seen in the clearance rates of B2-microglobulin and myoglobin with OL-HDF procedures&#46; It should be emphasized that the dialyzer used in this study achieves in itself a significant level of B2-microglobulin removal in hemodialysis because by retrofiltration causes a true internal OL-HDF&#46; <br></br><br></br>The number of patients with vascular access and high blood flow rates are now almost a minority&#46; With theoretical <br></br>blood flow rates of approximately 300 mL&#47;min it is very difficult to achieve 20 L of ultrafiltration in a standard <br></br>time of four hours&#46; When an attempt is made to increase postdilutional infusion to 100 mL&#47;min&#44; multiple technical <br></br>problems occur&#44; including TMP elevation&#44; partial or total clotting of the system&#44; and a decreased dialytic&#160; erformance&#46; In our study&#44; these problems were detected and related better with PFP than with TMP though&#44; as previously stated&#44; these two pressures are significantly related&#46; Factors contributing to the occurrence of these problems include high hematocrit values&#44; hyperproteinemia&#44; and hyperlipidemia&#46; On the other hand&#44; if an attempt is <br></br>made to increase pump flow&#44; we may contribute to the occurrence of complications such as a marked decrease in arterial line pressure or&#44; which is the same thing&#44; a decrease in the real Qb&#47;theoretical Qb ratio and recirculation of vascular access&#46; <br></br><br></br>In our study&#44; the factor correlating best to PFP increase was hematocrit and progressive hemoconcentration during dialysis&#46; PFP was also related to baseline albuminemia&#46; PFP sometimes reached levels higher than 700 mmHg&#46; In future OLHDF machines it would be helpful to have a pressure gauge to measure PFP&#44; which is sometimes more useful than TMP&#46; While many of our patients have high hematocrit values and normal albumin levels&#44; if a 25&#37; filtration fraction is respected no clinical complications occur in OL-P-HDF&#44; as shown in our study&#46; <br></br><br></br>In some cases where PFP and TMP are markedly increased&#44; a greater interference probably exists between both types of transport&#44; with a decrease in diffusive transport leading to a decreased clearance of small molecules&#46; This phenomenon was documented in this study also for medium-sized molecules such as B2-microglobulin and myoglobin&#44; when clearance rates were inversely related to PFP and TMP&#46; The increase in protein layer in the capillary membrane when a high filtration fraction was applied would explain this phenomenon&#46; <br></br><br></br>OL-S-HDF was shown to be better than HD-HF but similar to OL-P-HDF for removing medium-sized molecules&#46; The sequential procedure would thus be similar but not superior to the postdilutional procedure&#44; and would therefore not be recommended for stable patients and with optimal Qbs&#46; There are&#44; however&#44; patients with limited Qbs &#40;&#60; 300 mL&#47;min&#41; who do not reach the desired 20 L in the scheduled OL-P-HDF time&#46; Though this study included patients with relatively limited Qbs &#40;mean Qb of 370 mL&#47;min and only 31&#37; of patients with Qb &#60; 350 mL&#47;min&#41;&#44; we think that in patients with Qb &#60; 300 mL&#47;min&#44; OL-S-HDF could be a therapeutic alternative to achieve higher volumes with similar clearances&#46; <br></br><br></br>When switching from postdilutional to predilutional infusion&#44; the UF-infusion rate was increased by 50&#37;&#44; but we think that to achieve a better performance in patients with limited Qbs such rate could be further increased&#44; even doubled&#44; with no complications&#46; It should be noted that the predilutional system does not involve an increased use of dialysis fluid&#44; though compensated systems adjusting fluid to blood flow currently exist&#46; <br></br><br></br>From the technical viewpoint&#44; change in the infusion site is simple and does not require any accessory&#44; so that it does not involve any additional cost&#46; Based on the foregoing&#44; we think that OL-S-HDF could be a useful hemodialysis procedure in patients with limited blood flow rates &#40;&#60; 300 mL&#47;min&#41;&#46; Further studies of this procedure should therefore be designed&#46; <br></br><br></br>ACKNOWLEDGEMENTS <br></br><br></br>We thank the nursing staff from the Hemodialysis Unit of Hospital Gral&#46; &#171;Gregorio Mara&#241;&#243;n&#187;&#46; <br></br>"
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        "resumen" => "La hemodiafiltraci&#243;n en l&#237;nea proporciona una alta eficacia depurativa de mol&#233;culas de mediano y gran peso molecular&#46; Existe consenso sobre la necesidad de conseguir al menos 20 L de ultrafiltraci&#243;n en postdiluci&#243;n y tasas de reducci&#243;n de B2-microglobulina mayores del 70&#37;&#46; Desafortunadamente muchos pacientes tienen un acceso vascular inadecuado siendo muy dif&#237;cil lograr esos vol&#250;menes de ultrafiltraci&#243;n sin complicaciones cl&#237;nicas&#46; El objetivo de este trabajo fue conseguir un volumen de ultrafiltraci&#243;n equivalente a 20 L en postdilucional&#44; mediante la t&#233;cnica &#171;Secuencial&#187; &#40;HDF-OL-S&#41; que comienza siendo postdilucional y cuando la PTM alcanza los 250 mmHg se trasforma en predilucional&#46; Se realiz&#243; una sesi&#243;n de hemodi&#225;lisis de alto flujo &#40;HD-HF&#41;&#44; una de hemodiafiltraci&#243;n postdilucional &#40;HDF-OL-P&#41; y otra sesi&#243;n en modo secuencial a 16 pacientes durante 3 semanas consecutivas&#44; en la sesi&#243;n de mitad de semana&#46; Se compararon los rendimientos de eliminaci&#243;n de peque&#241;as y medianas mol&#233;culas entre las diferentes t&#233;cnicas&#46; Se midi&#243; la presi&#243;n prefiltro &#40;PPF&#41; mediante man&#243;metro predializador&#46; No encontramos diferencias en el Kt&#47;V&#44; tasa de reducci&#243;n de urea y de creatinina entre las 3 t&#233;cnicas&#46; La tasa de reducci&#243;n de B2-microglobulina y mioglobina fue significativamente mayor tanto en HDFOL-P como en HDF-OL-S con respecto a la HD-HF&#44; no habiendo diferencias entre ambas t&#233;cnicas de HDF&#46; Existi&#243; una correlaci&#243;n directa entre PTM y PPF a lo largo de la sesi&#243;n en todas las t&#233;cnicas&#46; La PPF horaria se correlacionaba mejor que PTM con los niveles basales de alb&#250;mina s&#233;rica&#44; hematocrito y porcentaje de hemoconcentraci&#243;n al final de la di&#225;lisis&#46; La HDF-OL-S es una t&#233;cnica de hemodi&#225;lisis con los mismos beneficios de la postdilucional que permite lograr vol&#250;menes de ultrafiltraci&#243;n dentro de los objetivos planteados&#46; Creemos podr&#237;a ser &#250;til en pacientes con flujos sangu&#237;neos limitados para lo cual habr&#237;a que dise&#241;ar nuevos estudios&#46; La PPF aporta informaci&#243;n complementaria a la PTM&#46;"
      ]
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        "resumen" => "Background&#58; On line haemodiafiltration provides the greatest clearance for low and high-molecular weight uremic toxins&#44; which is associated with a lower risk of mortality in our patients&#46; Nowadays&#44; there&#191;s increasing evidence about the need of achieving at least 20 litters ultrafiltration in postdilution mode and 70&#37; reduction of beta-2-microglobulin &#40;B2M&#41;&#44; however it requires a vascular access&#191;s high blood flow&#46; Unfortunately&#44; we do not succeed in these objectives because of our patients being older&#44; diabetic and with poor vascular access&#59; in this situation high blood flows are more difficult to get at the expense of lower postdilution exchange volumes&#46; The aim of this study was to assess the efficiency of OL-S-HDF to obtain an equivalent ultrafiltration volume as 20 L in OL-postdilution-HDF &#40;OL-P-HDF&#41;&#46; OL-SHDF initially begins in postdilution mode changing to predilution once the transmembrane pressure &#40;TMP&#41; reached 250 mmHg&#46; Methods&#58; We performed one high-flux HD session &#40;HF-HD&#41;&#44; one OL-P-HDF session and one OL-S-HDF session in each of the 16 adult patients who participated during 3 consecutive weeks&#46; We compared the clearance rates of low and middle molecules such as urea&#44; creatinine&#44; B2M&#44; myoglobulin and levels of albumin and haematocrit between the 3 different techniques&#46; We measured the pre-filter pressure &#40;PFP&#41; by a manometer set before the dialyzer&#46; Results&#58; The main characteristics of the sessions are described in table N&#186;1&#46; There wasn&#191;t significant difference in Kt&#47;V&#44; urea and creatinine removal between the three techniques&#46; B2M and myoglobulin&#191;s clearance rates were significantly higher in both hemodiafiltration modes than in HF-HD &#40;p &#61; 0&#46;000&#41;&#44; however we didn&#191;t find differences between OL-P-HDF and OL-S-HDF&#46; There was a direct correlation between PFP and TMP along the sessions in every technique &#40;p &#60; 0&#46;05&#41;&#46; We found that PFP was better than TMP to correlate with pre-dialysis levels of albumin and haematocrit and also with the haemoconcentration percentage at the end of the sessions&#46; Conclusions&#58; This study confirms that OL-S-HDF is as good as OL-P-HDF and it could be a useful technique to treat patients with suboptimal access&#191;s blood flow to get to achieve ultrafiltration volumes within the objectives&#46; PFP could offer extra information than TMP&#46;"
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Article information
ISSN: 20132514
Original language: English
DOI:
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