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      Clinical Benefits of Predilution On-Line Hemodiafiltration


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          There are two types of hemodiafiltration (HDF) treatments, predilution and postdilution. In Japan, clinical doctors have been using the on-line HDF treatment for renal replacement therapy for 20 years. However, this treatment is not popular in Japan because it has not been recognized by the government. Generally, the advantage of postdilution HDF over predilution HDF resides in the fact that it removes low-weight molecular proteins (LWMPs) and protein-binding uremic toxin. Thus, postdilution on-line HDF has been widely used in the world, but in Japan predilution on line-HDF has been the preferred treatment. There are several reasons why predilution on-line HDF has been the preferred treatment in Japan. Predilution on-line HDF is superior to postdilution on-line HDF in removing LWMPs and protein-binding uremic toxin, for example p-cresol and homocysteine. In addition, there are several reports on the biocompatibilities in predilution on-line HDF. Predilution on-line HDF is associated with reduced shear stress, and the synthesis of cytokine and cellular adhesion molecules. Moreover, with predilution on-line HDF/hemofiltration, blood pressure remains stable during treatment. In Japan, over 90% of dialysis patients have been receiving hemodialysis (HD) therapy with the ultra-high flux dialysis membrane. These ultra-high flux dialysis membranes achieve β<sub>2</sub>-microglobulin clearance rates of >50 ml/min. In addition, these membranes have the same power as postdilution HDF because they allow automatic internal filtration. Thus, in spite of HD treatment, as a result, the effect is the same as with postdilution HDF treatment. There have been small and retrospective studies on predilution on-line HDF, and we must use a hemodiafilter during the on-line HDF treatment. However, the hemodiafilter has been unsuccessful in reaching the LWMP removal rates which we demand. And the most important point is to carry out a prospective multicenter randomized controlled trial of predilution on-line HDF in the near future.

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          Overview of regular dialysis treatment in Japan (as of 31 December 2009).

          A nationwide statistical survey of 4196 dialysis facilities was conducted at the end of 2009, and 4133 facilities (98.5%) responded. The number of patients undergoing dialysis at the end of 2009 was determined to be 290 661, an increase of 7240 patients (2.6%) compared with that of 2008. The number of dialysis patients per million at the end of 2009 was 2279.5. The crude death rate of dialysis patients from the end of 2008 to the end of 2009 was 9.6%. The mean age of the new patients introduced into dialysis was 67.3 years old and the mean age of the entire dialysis patient population was 65.8 years old. Primary diseases such as diabetic nephropathy and chronic glomerulonephritis for new dialysis patients, showed a percentage of 44.5% and 21.9%, respectively. Based on the facilities surveyed, 84.2% of the facilities that responded to the questionnaire satisfied the microbiological quality standard for dialysis fluids for the Japanese Society for Dialysis Therapy (JSDT), with an endotoxin concentration of less than 0.05 EU/mL in the dialysis fluid. Similarly, 98.2% of the facilities surveyed satisfied another standard of the society of a bacterial count of less than 100 cfu/mL in the dialysis fluid. The facility survey indicated that the number of patients who were treated by blood purification by both peritoneal dialysis and extracorporeal circulation, such as hemodialysis, was 1720. Among the total number of patients, 24.8% were satisfied with the management target recommended in the treatment guidelines for secondary hyperparathyroidism. These standards are set by the JSDT, based on the three parameters, i.e. serum calcium concentration, serum phosphorus concentration, and serum intact parathyroid hormone concentration. According to the questionnaire, 9.8% of the patients were considered to have a complication of dementia. © 2012 The Authors. Therapeutic Apheresis and Dialysis © 2012 International Society for Apheresis.
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            Outcomes of hemodiafiltration based on Japanese dialysis patient registry.

            Effectiveness of various therapeutic modalities was analyzed among 1,196 patients entered in the registry of the Japanese Society for Dialysis Therapy who were on hemopurification therapy as of the end of 1998 and developed dialysis-related amyloidosis during 1999. In the investigation, the effectiveness of various hemopurification modalities on the dialysis-related amyloidosis was ranked as exacerbation, unchanged, or alleviation, so as to analyze the possible relationship between the hemopurification modality and its effectiveness. The analysis was performed using a logistic regression approach, and the results were shown as "the risk of a worse therapeutic ranking" among the hemopurification modalities. The smaller "the risk of a worse therapeutic effect" was, the more effective the treatment modality. When the risk of a worse therapeutic effect for the hemodialysis patients treated by a regular membrane was put at 1.0, the risk for hemodialysis patients using high-flux membrane was 0.489, the off-line hemodiafiltration risk was 0.117, the on-line hemodiafiltration risk was 0.013, and the risk of push/pull hemodiafiltration was 0.017. For hemodialysis with a beta(2)-microglobulin adsorption column, a low risk of 0.054 was found. The results indicated that hemodiafiltration therapy and simultaneous hemodialysis with beta(2)-microglobulin adsorption therapy were more effective treatment for dialysis-related amyloidosis.
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              Acetate-free blood purification can impact improved nutritional status in hemodialysis patients.

              Effects of online hemodiafiltration (HDF) using acetate-free bicarbonate dialysis (AFD) fluid on microinflammation, resulting in improved nutritional status in hemodialysis patients, were examined and compared with conventional acetate-containing bicarbonate dialysis (ACD) fluid. A total of 24 hemodialysis patients were registered for a cross-over design study for a 6-month period. These patients were subjected to ACD for the first 3 months followed by AFD fluid for the latter 3 months. Blood variables of C-reactive protein (CRP), interleukin-6 (IL-6), leptin, neuropeptide Y (NPY), protein catabolic rate (PCR) and %creatinine (Cr) index were determined after the first and last 3-month period. The filters and the conditions of HDF and drug regimens including erythropoiesis-stimulating agents were unchanged throughout the cross-over study. Predialysis blood pH and bicarbonate were significantly higher in the AFD phase than in the ACD phase. Blood CRP and IL-6 levels were significantly decreased in the AFD group compared to the ACD group. Concerning nutritional evaluation, leptin and NPY were significantly lower and higher, respectively, in the AFD phase than in the ACD phase. PCR tended to be higher in the AFD phase than in the ACD phase. A significantly higher %Cr index level was observed in the AFD phase than in the ACD phase. These results suggest that online HDF using AFD fluid contributes to alleviating bioincompatible events associated with microinflammation, leading to improvement in the nutritional status in hemodialysis patients.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                February 2013
                25 February 2013
                : 35
                : Suppl 1
                : 18-22
                Kawashima Hospital, Department of Kidney Disease (Artificial Kidney and Kidney Transplantation), Tokushima, Japan
                Author notes
                *Kenji Tsuchida, 1-39, Kitasako-ichiban cho, Tokushima City, 770-8548 Tokushima (Japan), E-Mail ktsuchida@khg.or.jp
                346221 Blood Purif 2013;35(suppl 1):18-22
                © 2013 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 4, Pages: 5

                Cardiovascular Medicine,Nephrology
                Predilution on-line hemodiafiltration,Albumin leakage, Separation abilities,α1-Microglobulin,Cytokine,Shear stress,Intradialytic hypotension,ZEBRA pattern


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