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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Although the physical and chemical concepts of diffusion and convection have been well known since the beginning&#44; dialysis has been carried out mainly by diffusion during its first four decades&#46; This form of dialysis&#44; haemodialysis &#40;HD&#41;&#44; has ensured the survival of millions of patients worldwide with advanced kidney disease and has met the increasing needs generated in the 50 years since dialysis was considered as a chronic renal replacement therapy&#46;</p><p class="elsevierStylePara">The delay in incorporating convection techniques as routine treatment has technological and economic reasons&#46; Haemofiltration &#40;HF&#41; or haemodiafiltration &#40;HDF&#41; modalities require the use of dialysers of high permeability and&#44; at the same time&#44; monitors with volume control and a dual pump&#46; Replacement fluid is a further cost&#44; and is the main reason for abandoning HF &#40;replacement volumes exceed 20 litres&#41;&#44; and was a key constraint on the initial HDF technique with volumes ranging between 3 and 10 litres&#46; Finally&#44; in the 1990s&#44; the introduction of &#191;on-line&#191; HDF techniques using the dialysis fluid itself as a replacement solution has meant a revolution in HD units&#46; It has taken another 10 years to renovate and upgrade water treatment&#44; have specific monitors and incorporate safety filters to ensure the quality of this replacement fluid &#40;ultrapure dialysate&#41;&#46;</p><p class="elsevierStylePara">HD can be considered as a renal replacement therapy that ensures reasonable short-term results&#46; However&#44; long-term clinical results could be improved&#46; Malnutrition and inflammation are common&#44; hyperphosphoraemia control is poor and hypertension and heart failure are common&#44; while rehabilitation and quality of life are less than optimal and rates of hospitalisation and mortality are high&#46; The most common cause of mortality in patients on chronic HD is cardiovascular disease&#44; which is the attributed cause of death in approximately 50&#37; of patients&#46; In other words&#44; the dialysis patient in this condition has the so-called residual syndrome&#46;<span class="elsevierStyleSup">1</span> This includes a greater susceptibility to infections&#44; decreased oxygen consumption during exercise&#44; problems with sleeping or the ability to concentrate&#44; depression&#44; decreased endurance and an increased risk of cardiovascular complications&#46; Residual syndrome has been attributed to incomplete potentially dialysable solute clearance and an accumulation of high molecular weight solutes that are difficult to remove by conventional dialysis&#46; HDF with increased fluid replacement provides an optimal way to remove uraemic substances with a molecular weight range from small solutes to low molecular weight proteins&#46;<span class="elsevierStyleSup">2&#44;3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">WHY SHOULD WE INTRODUCE CONVECTION AND SYSTEMATICALLY IMPLEMENT HAEMODIAFILTRATION&#63;</span></p><p class="elsevierStylePara">HDF can be indicated for all patients on haemodialysis&#44; as there are no contraindications&#46; High convection volume HDF techniques constitute progress towards renal replacement therapy which is most similar to the native kidney&#46;</p><p class="elsevierStylePara">These techniques offer a higher clearance of uraemic substances with a greater range of molecular size&#44; they require the use of biocompatible membranes and ultrapure dialysis fluid&#44; which has been associated with additional clinical benefits&#46; Recent large observational studies&#44; adjusted for demographic and comorbidity factors&#44; have shown a lower risk of death is associated with HDF using more than 15 litres of replacement fluid&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">Possible clinical benefits that convection techniques can provide are&#58; better control of hyperphosphoraemia&#44; malnutrition and inflammation&#44; anaemia&#44; infectious complications&#44; joint pain&#44; amyloidosis associated with dialysis&#44; intradialytic tolerance&#44; insomnia&#44; irritability&#44; restless leg syndrome&#44; polyneuropathy and itching&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Hyperphosphoraemia</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"></span>HDF improves phosphorus removal and could be considered as an option for the treatment of hyperphosphoraemia&#46;<span class="elsevierStyleSup">6</span> Several authors<span class="elsevierStyleSup">7&#44;8</span> have reported that online HDF achieves greater phosphorus purification than conventional HD&#46; However&#44; we must not forget that it is more important to gain pre-dialysis phosphorus control and&#44; although two studies<span class="elsevierStyleSup">9&#44;10 </span>have observed a decrease of 8&#37;&#44; other studies find no changes&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Malnutrition and inflammation</span></p><p class="elsevierStylePara">Anorexia in uraemic patients has been associated with the accumulation of uraemic substances&#46; In uraemic rats&#44; Anderstam et al<span class="elsevierStyleSup">12</span> isolated and identified toxins in the range of 1&#44;000-5&#44;000 Da in uraemic plasma that suppressed the appetite in a dose-dependent fashion&#46; The administration of leptin&#44; 16&#44;000 Da in monkeys&#44; decreased food intake and increased energy expenditure&#44; so its accumulation in dialysis patients may have an appetite suppression effect&#46;<span class="elsevierStyleSup">13</span> Convection techniques are better at purifying these much larger toxins&#46; Prospective and cross-sectional studies comparing HD with &#191;on-line&#191; HDF have reported a reduction of markers of inflammation and endothelial injury with convection techniques&#46;<span class="elsevierStyleSup">14&#44;15</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anaemia</span></p><p class="elsevierStylePara">Online HDF may improve the response to erythropoietin as a result of purifying large and medium-sized molecules that may inhibit erythropoiesis&#46; Bonforte et al<span class="elsevierStyleSup">16</span> demonstrated an improvement in the anaemia of 32 patients with high convection volumes&#46; Osawa et al<span class="elsevierStyleSup">17</span> were able to decrease the dose of erythropoietin in patients with push&#47;pull HDF&#46; Maduell et al<span class="elsevierStyleSup">11</span> noted a correction of anaemia in 37 patients with lower doses of erythropoietin when they changed from conventional HDF &#40;4L&#41; to online haemodiafiltration &#40;24L&#41;&#46; Ward et al<span class="elsevierStyleSup">18</span> and Wizemann et al<span class="elsevierStyleSup">19</span> were not able to confirm these observations in 24 and 23 patients&#44; respectively&#44; treated with online HDF compared with 21 patients treated with high-flow HD and 21 patients treated with low flow HD&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Infectious complications</span></p><p class="elsevierStylePara">Uraemic patients are at significant risk of infectious complications&#46; In fact&#44; these complications are the leading cause of hospitalisation and the second leading cause of death in HD patients&#46; Several granulocyte-inhibiting proteins are present in uraemic patients and may contribute to the high incidence of infectious complications&#46; Degranulation inhibiting proteins I &#40;DIP I&#41; and granulocyte inhibiting proteins &#40;GIP II&#41; inhibit in vitro glucose uptake and chemotaxis of polymorphonuclear leukocytes&#46; Complement factor D decreases the clearance of immune complexes and inhibits degranulation of granulocytes&#46; All these uraemic toxins are removed better with high-volume convection HDF&#46;<span class="elsevierStyleSup">18&#44;20</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Joint pain</span></p><p class="elsevierStylePara">Maeda et al<span class="elsevierStyleSup">21</span> observed a significant increase in the range of arm movement and improvement in pain in the shoulder joint in 30 patients after renal replacement therapy was changed from HD to push&#47;pull HDF &#40;30l convection volume&#41;&#46; Clinical observations from Kim et al<span class="elsevierStyleSup">22</span> support the hypothesis that substances related to joint pain have a molecular size larger than the beta-2-microglobulin&#46; They investigated the relationship between joint pain improvement and the purification pattern of lower molecular weight proteins&#44; and found higher rates of clearance for alpha-1-microglobulin and alpha-1-acid glycoprotein with on-line HDF than with high flow HD&#46; Sato et al<span class="elsevierStyleSup">23</span> also observed a decrease in joint pain and significant improvements in the range of adduction and abduction movements in upper limbs when they changed 6 patients receiving haemodialysis to online HDF&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Amyloidosis related with dialysis</span></p><p class="elsevierStylePara">Patients treated with dialysis for more than 5 years develop a progressive form of amyloidosis&#44; mainly osteoarticular&#44; due to the deposition of beta-2-microglobulin fibrils&#46; Using data from the Japanese registry of dialysis patients&#44; Nakai et al<span class="elsevierStyleSup">24</span> investigated which mode of renal replacement therapy was more effective in the treatment of dialysis-related amyloidosis in 1&#44;196 patients&#46; Taking low-flow HD as a baseline&#44; the risk of carpal tunnel syndrome was reduced by 51&#37; for patients using high-flux HD&#44; while it was 99&#37; with on-line haemodiafiltration&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Intradialytic tolerance</span></p><p class="elsevierStylePara">Convective treatments are characterised by providing better cardiovascular stability&#44; reducing intradialytic hypotension even in patients at high cardiovascular risk&#46;<span class="elsevierStyleSup">25</span> Donauer et al<span class="elsevierStyleSup">26</span> described a reduction of hypotension side effects during treatment with online HDF and HD at low temperature&#46; In some patients with severe hypotension&#44; we have observed improvements in predialysis blood pressure with highly convective treatments &#40;data unpublished&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Neurological complications</span></p><p class="elsevierStylePara">Insomnia&#44; irritability&#44; restless leg syndrome&#44; polyneuropathy or itching may be due to the accumulation of medium-sized or large molecules&#46; High-volume HDF replacement improves these symptoms due to improved clearance&#46;<span class="elsevierStyleSup">27&#44;28</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DOES HAEMODIAFILTRATION IMPROVE SURVIVAL&#63;</span></p><p class="elsevierStylePara">En 2005&#44; Rabindranath et al<span class="elsevierStyleSup">29</span> conducted a meta-analysis of HD&#44; HDF and Acetate-Free Biofiltration &#40;AFB&#41; and found no significant differences between them&#46; However&#44; even if it is a systematic review&#44; this work does not confront the reality of the problem&#44; as in the end they only included 19 studies with a total of 588 patients&#46; Of these patients&#44; 205 &#40;35&#37;&#41; were from the Locatelli study published in 1996 with a short follow-up that compared low-flux HD with high-flux HD &#40;whether or not HDF techniques were used&#41;&#46; If the patients who received HDF with more than 15 litres of replacement volume are included&#44; the number drops to below 50&#46; Comparing 588 patients who received a mixture of low-flux HD&#44; high-flux HD&#44; HDF with less than 15 litres of replacement fluid &#40;some with AFB&#41; and HDF with more than 15 litres&#44; without differentiating the infusion mode &#40;dilutional or post-dilutional&#41;&#44; does not seem appropriate from a methodological point of view&#46; Also&#44; the follow-up period&#44; ranging from one session to a year in 84&#37; of the studies&#44; does not seem adequate&#46;</p><p class="elsevierStylePara">We have already commented that there are two large multicentre observational studies&#44; adjusted for confounding demographic and comorbidity factors&#44; which show a 35&#37; reduction in mortality for patients receiving haemodiafiltration with more than 15 litres of replacement fluid&#46;<span class="elsevierStyleSup">4&#44;5</span> Being retrospective and nonrandomised studies&#44; they may not provide the degree of evidence required to be sure that this treatment is superior to HD&#46; More recently&#44; the prospective observational study RISCAVID<span class="elsevierStyleSup">30</span> also showed a reduction in mortality for patients receiving on-line HDF compared with patients receiving HDF with replacement bags&#44; which was even more significant when compared with those receiving HD&#46;</p><p class="elsevierStylePara">Santoro et al<span class="elsevierStyleSup">31</span> recently published a randomised study which concluded that patients who received HDF had improved survival over the HD group&#46; The main limitations of this study were the total number of patients &#40;n &#61; 64&#41; and the fact that it was held in a single centre&#46;</p><p class="elsevierStylePara">There are currently several multicentre&#44; prospective randomised studies in progress which may help us to analyse whether the convective techniques are superior to HD or not&#46; However&#44; it should be borne in mind that each has a different design&#46; They are discussed below&#58;</p><p class="elsevierStylePara">Italian multicentre study&#46;<span class="elsevierStyleSup">32</span> The aim was to include 246 patients&#44; 50&#37; with low-flux HD&#44; 25&#37; with on-line HDF with dilutional infusion and 25&#37; with dilutional HF&#46; A follow-up period of over 2 years has been proposed&#46;</p><p class="elsevierStylePara">The Dutch Convective Transport Study &#40;CONTRAST&#41;&#46;<span class="elsevierStyleSup">33</span> Published in 2005&#44; it aims to include 800 patients&#44; 50&#37; on low-flow HD&#44; and 50&#37; with on-line HDF with postdilutional infusion&#46; The monitoring period is 3 years and the primary objective is survival&#46;</p><p class="elsevierStylePara">French multicentre study&#46;<span class="elsevierStyleSup">34</span> The aim was to include 600 patients over 65 years of age&#44; 50&#37; with high-flux HD and 50&#37; with online HDF with post-dilutional infusion&#46; The monitoring period is 2 years and the primary purpose is intradialytic tolerance&#46;</p><p class="elsevierStylePara">A Catalan multicentre study of survival using on-line HDF &#40;ESHOL&#41;&#46; This is as yet unpublished and includes more than 900 patients&#44; 50&#37; with high-flux HD and 50&#37; with on-line HDF with post-dilutional infusion&#46; With a follow-up period of 3 years&#44; the primary objective is survival&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IS IT TIME TO CHANGE FROM DIFFUSION TECHNIQUES ONLY TO CONVECTION&#63;</span></p><p class="elsevierStylePara">For all the reasons given in this review&#44; we conclude that now is the time to change to convective techniques&#46; Firstly&#44; because technological development in water treatment and advances in monitors&#44; as well as the widespread use of synthetic high-flux dialysers make this a feasible proposition&#46; In fact&#44; the latest generation monitors&#44; known as therapeutic systems&#44; are designed to work under convective conditions at all times using the dialysis fluid itself as replacement solution&#46; And secondly&#44; because we have listed the possible clinical benefits these treatments can provide and have found no published literature showing any undesirable effects&#46; However&#44; we are awaiting the results from the multicentre studies to provide increased scientific evidence&#46;</p>"
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Convection versus diffusion: Is it time to make a change?
Convección versus difusión: ¿ha llegado el momento del cambio?
Francisco Maduell Canalsa
a Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Barcelona, España,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Although the physical and chemical concepts of diffusion and convection have been well known since the beginning&#44; dialysis has been carried out mainly by diffusion during its first four decades&#46; This form of dialysis&#44; haemodialysis &#40;HD&#41;&#44; has ensured the survival of millions of patients worldwide with advanced kidney disease and has met the increasing needs generated in the 50 years since dialysis was considered as a chronic renal replacement therapy&#46;</p><p class="elsevierStylePara">The delay in incorporating convection techniques as routine treatment has technological and economic reasons&#46; Haemofiltration &#40;HF&#41; or haemodiafiltration &#40;HDF&#41; modalities require the use of dialysers of high permeability and&#44; at the same time&#44; monitors with volume control and a dual pump&#46; Replacement fluid is a further cost&#44; and is the main reason for abandoning HF &#40;replacement volumes exceed 20 litres&#41;&#44; and was a key constraint on the initial HDF technique with volumes ranging between 3 and 10 litres&#46; Finally&#44; in the 1990s&#44; the introduction of &#191;on-line&#191; HDF techniques using the dialysis fluid itself as a replacement solution has meant a revolution in HD units&#46; It has taken another 10 years to renovate and upgrade water treatment&#44; have specific monitors and incorporate safety filters to ensure the quality of this replacement fluid &#40;ultrapure dialysate&#41;&#46;</p><p class="elsevierStylePara">HD can be considered as a renal replacement therapy that ensures reasonable short-term results&#46; However&#44; long-term clinical results could be improved&#46; Malnutrition and inflammation are common&#44; hyperphosphoraemia control is poor and hypertension and heart failure are common&#44; while rehabilitation and quality of life are less than optimal and rates of hospitalisation and mortality are high&#46; The most common cause of mortality in patients on chronic HD is cardiovascular disease&#44; which is the attributed cause of death in approximately 50&#37; of patients&#46; In other words&#44; the dialysis patient in this condition has the so-called residual syndrome&#46;<span class="elsevierStyleSup">1</span> This includes a greater susceptibility to infections&#44; decreased oxygen consumption during exercise&#44; problems with sleeping or the ability to concentrate&#44; depression&#44; decreased endurance and an increased risk of cardiovascular complications&#46; Residual syndrome has been attributed to incomplete potentially dialysable solute clearance and an accumulation of high molecular weight solutes that are difficult to remove by conventional dialysis&#46; HDF with increased fluid replacement provides an optimal way to remove uraemic substances with a molecular weight range from small solutes to low molecular weight proteins&#46;<span class="elsevierStyleSup">2&#44;3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">WHY SHOULD WE INTRODUCE CONVECTION AND SYSTEMATICALLY IMPLEMENT HAEMODIAFILTRATION&#63;</span></p><p class="elsevierStylePara">HDF can be indicated for all patients on haemodialysis&#44; as there are no contraindications&#46; High convection volume HDF techniques constitute progress towards renal replacement therapy which is most similar to the native kidney&#46;</p><p class="elsevierStylePara">These techniques offer a higher clearance of uraemic substances with a greater range of molecular size&#44; they require the use of biocompatible membranes and ultrapure dialysis fluid&#44; which has been associated with additional clinical benefits&#46; Recent large observational studies&#44; adjusted for demographic and comorbidity factors&#44; have shown a lower risk of death is associated with HDF using more than 15 litres of replacement fluid&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">Possible clinical benefits that convection techniques can provide are&#58; better control of hyperphosphoraemia&#44; malnutrition and inflammation&#44; anaemia&#44; infectious complications&#44; joint pain&#44; amyloidosis associated with dialysis&#44; intradialytic tolerance&#44; insomnia&#44; irritability&#44; restless leg syndrome&#44; polyneuropathy and itching&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Hyperphosphoraemia</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"></span>HDF improves phosphorus removal and could be considered as an option for the treatment of hyperphosphoraemia&#46;<span class="elsevierStyleSup">6</span> Several authors<span class="elsevierStyleSup">7&#44;8</span> have reported that online HDF achieves greater phosphorus purification than conventional HD&#46; However&#44; we must not forget that it is more important to gain pre-dialysis phosphorus control and&#44; although two studies<span class="elsevierStyleSup">9&#44;10 </span>have observed a decrease of 8&#37;&#44; other studies find no changes&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Malnutrition and inflammation</span></p><p class="elsevierStylePara">Anorexia in uraemic patients has been associated with the accumulation of uraemic substances&#46; In uraemic rats&#44; Anderstam et al<span class="elsevierStyleSup">12</span> isolated and identified toxins in the range of 1&#44;000-5&#44;000 Da in uraemic plasma that suppressed the appetite in a dose-dependent fashion&#46; The administration of leptin&#44; 16&#44;000 Da in monkeys&#44; decreased food intake and increased energy expenditure&#44; so its accumulation in dialysis patients may have an appetite suppression effect&#46;<span class="elsevierStyleSup">13</span> Convection techniques are better at purifying these much larger toxins&#46; Prospective and cross-sectional studies comparing HD with &#191;on-line&#191; HDF have reported a reduction of markers of inflammation and endothelial injury with convection techniques&#46;<span class="elsevierStyleSup">14&#44;15</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anaemia</span></p><p class="elsevierStylePara">Online HDF may improve the response to erythropoietin as a result of purifying large and medium-sized molecules that may inhibit erythropoiesis&#46; Bonforte et al<span class="elsevierStyleSup">16</span> demonstrated an improvement in the anaemia of 32 patients with high convection volumes&#46; Osawa et al<span class="elsevierStyleSup">17</span> were able to decrease the dose of erythropoietin in patients with push&#47;pull HDF&#46; Maduell et al<span class="elsevierStyleSup">11</span> noted a correction of anaemia in 37 patients with lower doses of erythropoietin when they changed from conventional HDF &#40;4L&#41; to online haemodiafiltration &#40;24L&#41;&#46; Ward et al<span class="elsevierStyleSup">18</span> and Wizemann et al<span class="elsevierStyleSup">19</span> were not able to confirm these observations in 24 and 23 patients&#44; respectively&#44; treated with online HDF compared with 21 patients treated with high-flow HD and 21 patients treated with low flow HD&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Infectious complications</span></p><p class="elsevierStylePara">Uraemic patients are at significant risk of infectious complications&#46; In fact&#44; these complications are the leading cause of hospitalisation and the second leading cause of death in HD patients&#46; Several granulocyte-inhibiting proteins are present in uraemic patients and may contribute to the high incidence of infectious complications&#46; Degranulation inhibiting proteins I &#40;DIP I&#41; and granulocyte inhibiting proteins &#40;GIP II&#41; inhibit in vitro glucose uptake and chemotaxis of polymorphonuclear leukocytes&#46; Complement factor D decreases the clearance of immune complexes and inhibits degranulation of granulocytes&#46; All these uraemic toxins are removed better with high-volume convection HDF&#46;<span class="elsevierStyleSup">18&#44;20</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Joint pain</span></p><p class="elsevierStylePara">Maeda et al<span class="elsevierStyleSup">21</span> observed a significant increase in the range of arm movement and improvement in pain in the shoulder joint in 30 patients after renal replacement therapy was changed from HD to push&#47;pull HDF &#40;30l convection volume&#41;&#46; Clinical observations from Kim et al<span class="elsevierStyleSup">22</span> support the hypothesis that substances related to joint pain have a molecular size larger than the beta-2-microglobulin&#46; They investigated the relationship between joint pain improvement and the purification pattern of lower molecular weight proteins&#44; and found higher rates of clearance for alpha-1-microglobulin and alpha-1-acid glycoprotein with on-line HDF than with high flow HD&#46; Sato et al<span class="elsevierStyleSup">23</span> also observed a decrease in joint pain and significant improvements in the range of adduction and abduction movements in upper limbs when they changed 6 patients receiving haemodialysis to online HDF&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Amyloidosis related with dialysis</span></p><p class="elsevierStylePara">Patients treated with dialysis for more than 5 years develop a progressive form of amyloidosis&#44; mainly osteoarticular&#44; due to the deposition of beta-2-microglobulin fibrils&#46; Using data from the Japanese registry of dialysis patients&#44; Nakai et al<span class="elsevierStyleSup">24</span> investigated which mode of renal replacement therapy was more effective in the treatment of dialysis-related amyloidosis in 1&#44;196 patients&#46; Taking low-flow HD as a baseline&#44; the risk of carpal tunnel syndrome was reduced by 51&#37; for patients using high-flux HD&#44; while it was 99&#37; with on-line haemodiafiltration&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Intradialytic tolerance</span></p><p class="elsevierStylePara">Convective treatments are characterised by providing better cardiovascular stability&#44; reducing intradialytic hypotension even in patients at high cardiovascular risk&#46;<span class="elsevierStyleSup">25</span> Donauer et al<span class="elsevierStyleSup">26</span> described a reduction of hypotension side effects during treatment with online HDF and HD at low temperature&#46; In some patients with severe hypotension&#44; we have observed improvements in predialysis blood pressure with highly convective treatments &#40;data unpublished&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Neurological complications</span></p><p class="elsevierStylePara">Insomnia&#44; irritability&#44; restless leg syndrome&#44; polyneuropathy or itching may be due to the accumulation of medium-sized or large molecules&#46; High-volume HDF replacement improves these symptoms due to improved clearance&#46;<span class="elsevierStyleSup">27&#44;28</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DOES HAEMODIAFILTRATION IMPROVE SURVIVAL&#63;</span></p><p class="elsevierStylePara">En 2005&#44; Rabindranath et al<span class="elsevierStyleSup">29</span> conducted a meta-analysis of HD&#44; HDF and Acetate-Free Biofiltration &#40;AFB&#41; and found no significant differences between them&#46; However&#44; even if it is a systematic review&#44; this work does not confront the reality of the problem&#44; as in the end they only included 19 studies with a total of 588 patients&#46; Of these patients&#44; 205 &#40;35&#37;&#41; were from the Locatelli study published in 1996 with a short follow-up that compared low-flux HD with high-flux HD &#40;whether or not HDF techniques were used&#41;&#46; If the patients who received HDF with more than 15 litres of replacement volume are included&#44; the number drops to below 50&#46; Comparing 588 patients who received a mixture of low-flux HD&#44; high-flux HD&#44; HDF with less than 15 litres of replacement fluid &#40;some with AFB&#41; and HDF with more than 15 litres&#44; without differentiating the infusion mode &#40;dilutional or post-dilutional&#41;&#44; does not seem appropriate from a methodological point of view&#46; Also&#44; the follow-up period&#44; ranging from one session to a year in 84&#37; of the studies&#44; does not seem adequate&#46;</p><p class="elsevierStylePara">We have already commented that there are two large multicentre observational studies&#44; adjusted for confounding demographic and comorbidity factors&#44; which show a 35&#37; reduction in mortality for patients receiving haemodiafiltration with more than 15 litres of replacement fluid&#46;<span class="elsevierStyleSup">4&#44;5</span> Being retrospective and nonrandomised studies&#44; they may not provide the degree of evidence required to be sure that this treatment is superior to HD&#46; More recently&#44; the prospective observational study RISCAVID<span class="elsevierStyleSup">30</span> also showed a reduction in mortality for patients receiving on-line HDF compared with patients receiving HDF with replacement bags&#44; which was even more significant when compared with those receiving HD&#46;</p><p class="elsevierStylePara">Santoro et al<span class="elsevierStyleSup">31</span> recently published a randomised study which concluded that patients who received HDF had improved survival over the HD group&#46; The main limitations of this study were the total number of patients &#40;n &#61; 64&#41; and the fact that it was held in a single centre&#46;</p><p class="elsevierStylePara">There are currently several multicentre&#44; prospective randomised studies in progress which may help us to analyse whether the convective techniques are superior to HD or not&#46; However&#44; it should be borne in mind that each has a different design&#46; They are discussed below&#58;</p><p class="elsevierStylePara">Italian multicentre study&#46;<span class="elsevierStyleSup">32</span> The aim was to include 246 patients&#44; 50&#37; with low-flux HD&#44; 25&#37; with on-line HDF with dilutional infusion and 25&#37; with dilutional HF&#46; A follow-up period of over 2 years has been proposed&#46;</p><p class="elsevierStylePara">The Dutch Convective Transport Study &#40;CONTRAST&#41;&#46;<span class="elsevierStyleSup">33</span> Published in 2005&#44; it aims to include 800 patients&#44; 50&#37; on low-flow HD&#44; and 50&#37; with on-line HDF with postdilutional infusion&#46; The monitoring period is 3 years and the primary objective is survival&#46;</p><p class="elsevierStylePara">French multicentre study&#46;<span class="elsevierStyleSup">34</span> The aim was to include 600 patients over 65 years of age&#44; 50&#37; with high-flux HD and 50&#37; with online HDF with post-dilutional infusion&#46; The monitoring period is 2 years and the primary purpose is intradialytic tolerance&#46;</p><p class="elsevierStylePara">A Catalan multicentre study of survival using on-line HDF &#40;ESHOL&#41;&#46; This is as yet unpublished and includes more than 900 patients&#44; 50&#37; with high-flux HD and 50&#37; with on-line HDF with post-dilutional infusion&#46; With a follow-up period of 3 years&#44; the primary objective is survival&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IS IT TIME TO CHANGE FROM DIFFUSION TECHNIQUES ONLY TO CONVECTION&#63;</span></p><p class="elsevierStylePara">For all the reasons given in this review&#44; we conclude that now is the time to change to convective techniques&#46; Firstly&#44; because technological development in water treatment and advances in monitors&#44; as well as the widespread use of synthetic high-flux dialysers make this a feasible proposition&#46; In fact&#44; the latest generation monitors&#44; known as therapeutic systems&#44; are designed to work under convective conditions at all times using the dialysis fluid itself as replacement solution&#46; And secondly&#44; because we have listed the possible clinical benefits these treatments can provide and have found no published literature showing any undesirable effects&#46; However&#44; we are awaiting the results from the multicentre studies to provide increased scientific evidence&#46;</p>"
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