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Bernard Canaud - One of the best experts on this subject based on the ideXlab platform.
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Hemodiafiltration to Address Unmet Medical Needs ESKD Patients
Clinical Journal of the American Society of Nephrology, 2018Co-Authors: Bernard Canaud, Jörg Vienken, Stephen Ash, Richard WardAbstract:Hemodiafiltration combines diffusive and convective solute removal in a single therapy by ultrafiltering 20% or more of the blood volume processed using a high-flux hemodialyzer and maintaining fluid balance by infusing sterile nonpyrogenic replacement fluid directly into the patient's blood. In online Hemodiafiltration, the large volumes of replacement fluid required are obtained by online filtration of standard dialysate through a series of bacteria- and endotoxin-retaining filters. Currently available systems for online Hemodiafiltration are on the basis of conventional dialysis machines with added features to safely prepare and infuse replacement fluid and closely control fluid balance. Hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis, and recently completed randomized, controlled clinical trials suggest better patient survival with online Hemodiafiltration compared with standard high-flux hemodialysis when a high convection volume is delivered. Hemodiafiltration is also associated with improvements in other clinical outcomes, such as a reduction in intradialytic hypotension, and it is now used routinely to treat >100,000 patients, mainly in Europe and Japan.
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Hemodiafiltration reduces all cause and cardiovascular mortality in incident hemodialysis patients a propensity matched cohort study
American Journal of Nephrology, 2017Co-Authors: Francisco Maduell, Bernard Canaud, Javier Varas, Rosa Ramos, Alejandro Martinmalo, Rafael Perezgarcia, Isabel Berdud, Francesc Moreso, Stefano Stuard, Adelheid GaulyAbstract:Background: The majority of studies suggesting that online Hemodiafiltration reduces the risk of mortality compared to hemodialysis (HD) have been performed in dialysis-prevalent populations. In this report, we conducted an epidemiologic study of mortality in incident dialysis patients, comparing post-dilution online Hemodiafiltration and high-flux HD, with propensity score matching (PSM) used to correct indication bias. Methods: Our study cohort comprised 3,075 incident dialysis patients treated in 64 Spanish Fresenius Medical Care clinics between January 2009 and December 2012. The primary outcome of this study was to investigate the impact of the type of renal replacement on all-cause mortality. An analysis of cardiovascular mortality was defined as the secondary outcome. To achieve these objectives, patients were followed until December 2016. Patients were categorized as high-flux HD patients if they underwent this treatment exclusively. If >90% of their treatment was with online Hemodiafiltration, then the patient was grouped to that modality. Results: After PSM, a total of 1,012 patients were matched. Compared with patients on high-flux HD, those on online Hemodiafiltration received a median replacement volume of 23.45 (interquartile range 21.27–25.51) L/session and manifested 24 and 33% reductions in all-cause and cardiovascular mortality (all-cause mortality hazards ratio [HR] 0.76, 95% CI 0.62–0.94 [ p = 0.01]; and cardiovascular mortality HR 0.67, 95% CI 0.50–0.90 [ p = 0.008]). Conclusions: This study shows that post-dilution online Hemodiafiltration reduces all-cause and cardiovascular mortality compared to high-flux HD in an incident HD population.
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survival of incident patients on high volume online Hemodiafiltration compared to low volume online Hemodiafiltration and high flux hemodialysis
International Urology and Nephrology, 2014Co-Authors: Goran Imamovic, Rajko Hrvacevic, Sonja Kapun, Daniele Marcelli, Inga Bayh, Aileen Grassmann, Laura Scatizzi, Jelena Maslovaric, Bernard CanaudAbstract:Hemodiafiltration is becoming a preferred treatment modality for dialysis patients in many countries. The volume of substitution fluid delivered has been indicated as an independent mortality risk factor. The aim of this study is to compare patient survival on three different treatment modalities: high-flux hemodialysis, low-volume online HDF (oHDF) and high-volume oHDF. Incident hemodialysis and oHDF patients treated in 13 NephroCare centers in Bosnia and Herzegovina, Serbia and Slovenia between January 1, 2007, and December 31, 2011, were included in this epidemiological cohort study. High-volume oHDF was defined as substitution volume higher than the median substitution volume infused, otherwise low-volume. Main predictor was treatment modality at baseline and in time-dependent model. Other predictors were age, gender, diabetes mellitus, cerebrovascular accident, arrhythmia, hemoglobin and C-reactive protein. Four hundred and forty-two patients were included in the study. Median substitution fluid volume was 20.4 L. Mean difference between the oHDF groups in substitution fluid volume was 8.3 ± 5.2 L [95 % confidence intervals (95 % CI) 7.1–9.5, p < 0.0001]. The unadjusted hazard ratios (HR) with 95 % CI compared to high-flux HD were 0.87 (0.5–1.5) for low-volume oHDF and 0.29 (0.13–0.63) for high-volume oHDF. After the adjustment for covariates, the HR for patients on low-volume oHDF remained statistically insignificant compared to high-flux HD (0.84; 95 % CI 0.46–1.53), while patients on high-volume oHDF showed a marked and significantly lower HR (0.29; 95 % CI 0.13–0.68) than patients on high-flux HD in baseline model. While this effect failed to reach significance in the time-dependent model (HR 0.477; 95 % CI 0.196–1.161), possibly due to an inadequate sample size here, the consistency of results in both models supports the robustness of the findings. After switching from high-flux hemodialysis to oHDF, mean hemoglobin and albumin levels did not change significantly. Mean erythropoietin resistance index (ERI) and erythropoiesis stimulating agents (ESA) consumption decreased significantly (p = 0.02, p = 0.03, respectively). The median substitution volume used in these three countries for post-dilutional oHDF is 20.4 L. oHDF is associated with significant reductions in ERI and ESA consumption. Only high-volume oHDF is associated with improved survival compared to high-flux hemodialysis.
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whole blood viscosity increases significantly in small arteries and capillaries in Hemodiafiltration does acute hemorheological change trigger cardiovascular risk events in hemodialysis patient
Hemodialysis International, 2010Co-Authors: Bernard Canaud, Marion Morena, Helene Leraymoragues, Leila Chenine, Annie Rodriguez, Isabelle Jaussent, Annie Picard, Jeanpaul CristolAbstract:Whole-blood viscosity is increasingly being recognized as a factor implicated in the vascular disease progression in high-risk chronic kidney disease patients. Intermittent hemodialysis and Hemodiafiltration sessions, characterized by rapid volume changes and anemia correction by erythropoietin stimulating agents, are favorable conditions for enhancing whole-blood viscosity changes and consequently triggering cardiovascular events. To evaluate whole-blood viscosity changes induced by Hemodiafiltration, a cross-sectional study has been performed in a group of 28 stable patients. In order to assess the impact of vessel size on whole-blood viscosity changes, we performed a dynamic whole viscosity analysis on a wide spectrum of shear rates reproducing vasculature hemorheologic conditions. Blood viscosity changes are dependent on patient characteristics, hemoglobin, and total plasma protein concentrations. Whole blood viscosity increases significantly during Hemodiafiltration over the complete spectrum of shear rates. Dynamic whole-blood viscosity (WBV) increases up to 60%, predominantly at low shear rates in small arterioles and capillary beds. This observation underlines the potential pathogenic contribution of WBV increase in capillaries triggering cardiovascular events in the postdialysis period. Eight patients died from cardiovascular events. Higher WBV increase was noted in this group but did not reach statistical significance due to the insufficient power of the study. Hemorheological changes associated with WBV increase in capillary beds may contribute to aggravate silent tissue hypoxemia and precipitate cardiovascular events in chronic kidney disease patients. Prospective studies specifically designed and powered to evaluate the impact of WBV changes on cardiovascular events in dialysis patients are required.
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Hemodiafiltration clinical evidence and remaining questions
Kidney International, 2010Co-Authors: Peter J. Blankestijn, Ingrid Ledebo, Bernard CanaudAbstract:Currently, about two-thirds of hemodialysis patients worldwide are treated with high-flux membranes. This is most likely based on the assumption that the extended solute clearance that can be obtained with more open membranes will contribute to improved clinical outcome. To have full advantage of convective solute removal, Hemodiafiltration offers a superior modality as compared to both low-flux and high-flux hemodialysis. However, this technique is offered to only a minority of patients. In this review, we summarize the available clinical evidence on Hemodiafiltration and define still remaining questions.
Michiaki Mishima - One of the best experts on this subject based on the ideXlab platform.
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living donor liver transplantation with noninvasive ventilation for exertional heat stroke and severe rhabdomyolysis
Liver Transplantation, 2005Co-Authors: Kenichi Takahashi, Kazuo Chin, Kohei Ogawa, Mureo Kasahara, Takanori Sakaguchi, Satoshi Hasegawa, Kensuke Sumi, Takaya Nakamura, Akira Tamaki, Michiaki MishimaAbstract:A 16-year-old male with exertional heat stroke (EHS) had extensive hepatocellular damage, severe rhabdomyolysis, renal failure, and coma. Hemodiafiltration was started on day 2 and living donor liver transplantation was performed on day 3. He received continuous mechanical ventilation with intubation before and after the surgery. As his mental status improved, he could not tolerate intubation, and he was extubated on postoperative day (POD) 26. He received facial noninvasive positive pressure ventilation until POD 50. Hemodiafiltration was discontinued on POD 52. He was discharged on POD 67 and is currently well more than a year after transplantation. A literature search indicates that this patient is the first long-term survivor (>1 year) after liver transplantation for exertional heat stroke.
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living donor liver transplantation with noninvasive ventilation for exertional heat stroke and severe rhabdomyolysis
Liver Transplantation, 2005Co-Authors: Kenichi Takahashi, Kazuo Chin, Kohei Ogawa, Mureo Kasahara, Takanori Sakaguchi, Satoshi Hasegawa, Kensuke Sumi, Takaya Nakamura, Akira Tamaki, Michiaki MishimaAbstract:A 16-year-old male with exertional heat stroke (EHS) had extensive hepatocellular damage, severe rhabdomyolysis, renal failure, and coma. Hemodiafiltration was started on day 2 and living donor liver transplantation was performed on day 3. He received continuous mechanical ventilation with intubation before and after the surgery. As his mental status improved, he could not tolerate intubation, and he was extubated on postoperative day (POD) 26. He received facial noninvasive positive pressure ventilation until POD 50. Hemodiafiltration was discontinued on POD 52. He was discharged on POD 67 and is currently well more than a year after transplantation. A literature search indicates that this patient is the first long-term survivor (>1 year) after liver transplantation for exertional heat stroke. (Liver Transpl 2005;11:570–572.)
Peter J. Blankestijn - One of the best experts on this subject based on the ideXlab platform.
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why choose high volume online post dilution Hemodiafiltration
Journal of Nephrology, 2017Co-Authors: Carlo Basile, Andrew Davenport, Peter J. BlankestijnAbstract:The mortality rate of patients on maintenance dialysis remains alarmingly high, at approximately 15-20 % per year. Increasing dialyzer urea clearance has not been shown to improve survival and hence interest has shifted towards convective therapies, such as Hemodiafiltration (HDF) which can remove middle molecular weight uremic toxins, which have been suggested to increase mortality in patients with end-stage kidney disease. During the last few years, four large prospective randomized controlled trials (RCTs) have been conducted in different European countries to compare survival outcomes in prevalent patients receiving conventional hemodialysis with online post-dilution HDF (OL HDF). Furthermore, a pooled individual participant data analysis from four RCTs was performed and four large meta-analyses on convective therapies have been published in the last 2 years. Taken together, these studies support the conclusion that high volume post-dilution OL HDF is associated with improved overall survival. This advantage results predominantly from a lower cardiovascular mortality, possibly due to better preservation of left ventricle mass and function. Improved intra-dialytic blood pressure stability may contribute to the beneficial effect of high volume post-dilution OL HDF on survival. The beneficial effect is not restricted to selected subgroups, such as age, comorbidity or dialysis vintage. There is no compelling evidence that high volume post-dilution OL HDF reduces mortality by improvements in traditional and non-traditional risk factors. There are still no studies or case reports published describing adverse clinical outcomes in more than 20 years of HDF clinical experience. In conclusion, most of the available data support the choice of high volume post-dilution HDF over the current dialysis techniques. However, considering that we live in the era of evidence-based medicine, the evidence supporting the superiority of high volume post-dilution OL HDF in comparison to hemodialysis is still missing: in fact, a new RCT targeting different convection volumes would be needed to definitively examine the dose-response effect shown in previous studies.
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online Hemodiafiltration reduces systemic inflammation compared to low flux hemodialysis
Kidney International, 2014Co-Authors: Claire Den H Hoedt, Muriel P C Grooteman, Michiel L Bots, Lars E Penne, Neelke C Van Der Weerd, Albert H A Mazairac, Renee Levesque, Menso J Nube, Piet M Ter Wee, Peter J. BlankestijnAbstract:Online Hemodiafiltration may diminish inflammatory activity through amelioration of the uremic milieu. However, impurities in water quality might provoke inflammatory responses. We therefore compared the long-term effect of low-flux hemodialysis to Hemodiafiltration on the systemic inflammatory activity in a randomized controlled trial. High-sensitivity C-reactive protein and interleukin-6 were measured for up to 3 years in 405 patients of the CONvective TRAnsport STudy, and albumin was measured at baseline and every 3 months in 714 patients during the entire follow-up. Differences in the rate of change over time of C-reactive protein, interleukin-6, and albumin were compared between the two treatment arms. C-reactive protein and interleukin-6 concentrations increased in patients treated with hemodialysis, and remained stable in patients treated with Hemodiafiltration. There was a statistically significant difference in rate of change between the groups after adjustments for baseline variables (C-reactive protein difference 20%/year and interleukin-6 difference 16%/year). The difference was more pronounced in anuric patients. Serum albumin decreased significantly in both treatment arms, with no difference between the groups. Thus, long-term Hemodiafiltration with ultrapure dialysate seems to reduce inflammatory activity over time compared to hemodialysis, but does not affect the rate of change in albumin.
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has the time now come to more widely accept Hemodiafiltration in the united states
Journal of The American Society of Nephrology, 2013Co-Authors: Peter J. BlankestijnAbstract:In this issue of JASN , the Spanish Hemodiafiltration study is published.[1][1] What new information has become available and what might be its relevance? Today, most patients with ESRD in the United States are treated with hemodialysis (HD). During low-flux HD, small uremic toxins are removed by
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Hemodiafiltration clinical evidence and remaining questions
Kidney International, 2010Co-Authors: Peter J. Blankestijn, Ingrid Ledebo, Bernard CanaudAbstract:Currently, about two-thirds of hemodialysis patients worldwide are treated with high-flux membranes. This is most likely based on the assumption that the extended solute clearance that can be obtained with more open membranes will contribute to improved clinical outcome. To have full advantage of convective solute removal, Hemodiafiltration offers a superior modality as compared to both low-flux and high-flux hemodialysis. However, this technique is offered to only a minority of patients. In this review, we summarize the available clinical evidence on Hemodiafiltration and define still remaining questions.
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haemodiafiltration optimal efficiency and safety
Ndt Plus, 2010Co-Authors: Ingrid Ledebo, Peter J. BlankestijnAbstract:Haemodiafiltration (HDF) is the blood purification therapy of choice for those who want significant removal of uraemic solutes beyond the traditional range of small molecules. Combining diffusive and convective solute transport, a HDF treatment comprises the largest number of variables among blood purification therapies, and it is important to understand how they interact in order to optimize the therapy. This review discusses the parameters that determine the efficiency of HDF and how they can be controlled in the different forms of HDF and ‘HDF-like’ therapies practised today. The key to safe and effective HDF therapy is to have access to large volumes of high-quality fluids. Starting with ultrapure dialysis fluid, on-line preparation of a sterile, non-pyrogenic substitution solution can be made an integral part of the treatment, and we describe the necessary conditions for this. On-line HDF can provide the largest removal of the widest range of solutes among available dialysis therapies, and the potential clinical benefits of this are within practical reach for the increasing number of patients dialysed with high-flux membranes and ultrapure dialysis fluid.
Kenichi Takahashi - One of the best experts on this subject based on the ideXlab platform.
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living donor liver transplantation with noninvasive ventilation for exertional heat stroke and severe rhabdomyolysis
Liver Transplantation, 2005Co-Authors: Kenichi Takahashi, Kazuo Chin, Kohei Ogawa, Mureo Kasahara, Takanori Sakaguchi, Satoshi Hasegawa, Kensuke Sumi, Takaya Nakamura, Akira Tamaki, Michiaki MishimaAbstract:A 16-year-old male with exertional heat stroke (EHS) had extensive hepatocellular damage, severe rhabdomyolysis, renal failure, and coma. Hemodiafiltration was started on day 2 and living donor liver transplantation was performed on day 3. He received continuous mechanical ventilation with intubation before and after the surgery. As his mental status improved, he could not tolerate intubation, and he was extubated on postoperative day (POD) 26. He received facial noninvasive positive pressure ventilation until POD 50. Hemodiafiltration was discontinued on POD 52. He was discharged on POD 67 and is currently well more than a year after transplantation. A literature search indicates that this patient is the first long-term survivor (>1 year) after liver transplantation for exertional heat stroke.
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living donor liver transplantation with noninvasive ventilation for exertional heat stroke and severe rhabdomyolysis
Liver Transplantation, 2005Co-Authors: Kenichi Takahashi, Kazuo Chin, Kohei Ogawa, Mureo Kasahara, Takanori Sakaguchi, Satoshi Hasegawa, Kensuke Sumi, Takaya Nakamura, Akira Tamaki, Michiaki MishimaAbstract:A 16-year-old male with exertional heat stroke (EHS) had extensive hepatocellular damage, severe rhabdomyolysis, renal failure, and coma. Hemodiafiltration was started on day 2 and living donor liver transplantation was performed on day 3. He received continuous mechanical ventilation with intubation before and after the surgery. As his mental status improved, he could not tolerate intubation, and he was extubated on postoperative day (POD) 26. He received facial noninvasive positive pressure ventilation until POD 50. Hemodiafiltration was discontinued on POD 52. He was discharged on POD 67 and is currently well more than a year after transplantation. A literature search indicates that this patient is the first long-term survivor (>1 year) after liver transplantation for exertional heat stroke. (Liver Transpl 2005;11:570–572.)
Neil Boyce - One of the best experts on this subject based on the ideXlab platform.
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acute renal failure in the critically i11 management by continuous veno venous Hemodiafiltration
Journal of Critical Care, 1993Co-Authors: Rinaldo Bellomo, Geoffrey Parkin, Neil BoyceAbstract:The consequences of newer techniques of continuous renal replacement therapy in critically ill patients are not yet fully known. The clinical and biochemical impact of continuous veno-venous Hemodiafiltration (CVVHD) was, therefore, prospectively studied in 60 critically ill patients with acute renal failure. Prospective clinical, biochemical, and hematological data were collected from patients receiving CVVHD. Over the initial 24 hours of therapy, CVVHD resulted in a decrease in mean plasma urea from 34.5 mmol/L (95% confidence interval [CI], 29.4 to 39.6) to 25 mmol/L (95% CI, 21.8 to 28.2). With continued CVVHD, the mean plasma urea reached a plateau level of 17.6 mmol/L (95% CI, 15.8 to 19.4) at 72 hours. This degree of azotemia control was achieved with ease and essentially without complications during 8,360 hours of therapy despite the presence of multi-organ failure and the aggressive administration of protein nitrogen (0.25 to 0.35 g/kg/day). No abnormalities of serum electrolytes developed during treatment. Survival to intensive care discharge was 46.6% and to hospital discharge 41.6%, despite a mean Acute Physiology and Chronic Health Evaluation (APACHE) II score at presentation of 27.7. Continuous veno-venous Hemodiafiltration offers superior azotemia control and a safe approach to renal replacement therapy in critically ill patients. Its use is associated with a comparatively favorable outcome. CVVHD may be regarded as the treatment of choice in such patients.