The Janus-faced nature of complement in hemodialysis: interplay between complement, inflammation, and bioincompatibility unveiling a self-amplifying loop contributing to organ damage.

In hemodialysis (HD), complement activation, bioincompatibility, and inflammation are intricately intertwined. In the 1970s, as HD became a routine therapy, the observation of complement pathway activation and transient leukopenia by cellulosic dialysis membranes triggered the bioincompatibility debate and its clinical relevance. Extensive deliberations have covered definitions, assessment markers, scope, and long-term clinical consequences of membrane-dependent bioincompatibility reactions.

Hemoincompatibility in Hemodialysis-Related Therapies and Their Health Economic Perspectives.

Hemobiologic reactions associated with the hemoincompatibility of extracorporeal circuit material are an undesirable and inevitable consequence of all blood-contacting medical devices, typically considered only from a clinical perspective. In hemodialysis (HD), the blood of patients undergoes repetitive (at least thrice weekly for 4 h and lifelong) exposure to different polymeric materials that activate plasmatic pathways and blood cells. There is a general agreement that hemoincompatibility reactions, although unavoidable during extracorporeal therapies, are unphysiological contributors to non-hemodynamic dialysis-induced systemic stress and need to be curtailed.

Personalized Management of Sodium and Volume Imbalance in Hemodialysis to Mitigate High Costs of Hospitalization.

The primary objective of hemodialysis (HD) is lowering concentrations of organic uremic toxins that accumulate in blood in end-stage kidney disease (ESKD) and redress imbalances of inorganic compounds in particular sodium and water. Removal by ultrafiltration of excess fluid that has accumulated during the dialysis-free interval is a vital aspect of each HD session. Most HD patients are volume overloaded, with ∼25% of patients having severe (>2.

Switching from high-flux dialysis to hemodiafiltration: Cost-consequences for patients, providers, and payers.

Hemodiafiltration (HDF) achieves a more efficient reduction of the uremic toxic load compared to standard high-flux hemodialysis (HF-HD) by virtue of the combined diffusive and convective clearances of a broad spectrum of uremic retention solutes. Clinical trials and registry data suggest that HDF improves patient outcomes. Despite the acknowledged need to improve survival rates of dialysis patients and the survival benefit HDF offers, there is little to no utilization in some countries (such as the US) in prescribing HDF to their patients.

Clinical relevance of abstruse transport phenomena in haemodialysis.

Haemodialysis (HD) utilizes the bidirectional properties of semipermeable membranes to remove uraemic toxins from blood while simultaneously replenishing electrolytes and buffers to correct metabolic acidosis. However, the nonspecific size-dependent transport across membranes also means that certain useful plasma constituents may be removed from the patient (together with uraemic toxins), or toxic compounds, e.g.

Blood-incompatibility in haemodialysis: alleviating inflammation and effects of coagulation.

Blood-incompatibility is an inevitability of all blood-contacting device applications and therapies, including haemodialysis (HD). Blood leaving the environment of blood vessels and the protection of the endothelium is confronted with several stimuli of the extracorporeal circuit (ECC), triggering the activation of blood cells and various biochemical pathways of plasma. Prevention of blood coagulation, a major obstacle that needed to be overcome to make HD possible, remains an issue to contend with.

Flummoxed by flux: the indeterminate principles of haemodialysis.

In haemodialysis (HD), unwanted substances (uraemic retention solutes or 'uraemic toxins') that accumulate in uraemia are removed from blood by transport across the semipermeable membrane. Like all membrane separation processes, the transport requires driving forces to facilitate the transfer of molecules across the membrane. The magnitude of the transport is quantified by the phenomenon of 'flux', a finite parameter defined as the volume of fluid (or permeate) transferred per unit area of membrane surface per unit time.

The membrane perspective of uraemic toxins: which ones should, or can, be removed?

Informed decision-making is paramount to the improvement of dialysis therapies and patient outcomes. A cornerstone of delivery of optimal dialysis therapy is to delineate which substances (uraemic retention solutes or 'uraemic toxins') contribute to the condition of uraemia in terms of deleterious biochemical effects they may exert. Thereafter, decisions can be made as to which of the accumulated compounds need to be targeted for removal and by which strategies.

The scientific principles and technological determinants of haemodialysis membranes.

In most biological or industrial (including medical) separation processes, a membrane is a semipermeable barrier that allows or achieves selective transport between given compartments. In haemodialysis (HD), the semipermeable membrane is in a tubular geometry in the form of miniscule pipes (hollow fibres) and separation processes between compartments involve a complex array of scientific principles and factors that influence the quality of therapy a patient receives. Several conditions need to be met to accomplish the selective and desired removal of substances from blood in the inner cavity (lumen) of the hollow fibres and across the membrane wall into the larger open space surrounding each fibre.

Deciphering the core elements around haemodialysis therapy.

The projected future demand for renal replacement therapies for patients with end-stage renal failure requires preparedness at different levels. The deliberations focus predominantly on the disproportionately high financial burden of care for patients on routine dialysis therapy compared with other chronic conditions. However, even today there are concerns regarding the shortage of healthcare workers in the field of nephrology.

Chronic Kidney Disease: Exploring Value-Based Healthcare as a Potential Viable Solution.

Background: Increasing healthcare expenditures have triggered a trend from volume to value by linking patient outcome to costs. This concept first described as value-based healthcare (VBHC) by Michael Porter is especially applicable for chronic conditions. This article aims to explore the applicability of the VBHC framework to the chronic kidney disease (CKD) care area.

Precise Quantitative Assessment of the Clinical Performances of Two High-Flux Polysulfone Hemodialyzers in Hemodialysis: Validation of a Blood-Based Simple Kinetic Model Versus Direct Dialysis Quantification.

Highly permeable dialysis membranes with better design filters have contributed to improved solute removal and dialysis efficacy. However, solute membrane permeability needs to be well controlled to avoid increased loss of albumin that is considered to be detrimental for dialysis patients. A novel high-flux dialyzer type (FX CorDiax; Fresenius Medical Care) incorporating an advanced polysulfone membrane modified with nano-controlled spinning technology to enhance the elimination of a broader spectrum of uremic toxins has been released.

Clinical Performance Assessment of CorDiax Filters in Hemodialysis and Hemodiafiltration.

In this study, we evaluate the in vivo clinical performances of CorDiax FX 100 and CorDiax FX 1000 filters incorporating a high-flux membrane (Helixone Plus) designed for use in high-flux hemodialysis (HD) as well as in hemodiafiltration (HDF) in 6 stable end-stage kidney disease patients. In the HDF mode, various substitution modalities (post-, pre-, and mixed) were compared. In addition to conventional markers of efficacy of dialysis dose (urea, ionic dialysance, Kt/V), several additional middle- and large-size solute (β2-microglobulin, myoglobin, serum-free light-chain kappa and lambda, α1-microglobulin, and FGF23) compounds were explored in order to cover the spectrum of uremic toxins that are involved in uremia.

What Is the Optimal Target Convective Volume in On-Line Hemodiafiltration Therapy?

Conventional diffusion-based dialysis modalities including high-flux hemodialysis are limited in their capacity to effectively remove large uremic toxins and to improve outcomes for end-stage chronic kidney disease (ESKD) patients. By increasing convective solute transport, hemodiafiltration (HDF) enhances solute removal capacity over a broad range of middle- and large-size uremic toxins implicated in the pathophysiology of chronic kidney disease. Furthermore, by offering flexible convection volume, on-line HDF permits customizing the treatment dose to the patient's needs.

Optimal convection volume for improving patient outcomes in an international incident dialysis cohort treated with online hemodiafiltration.

Online hemodiafiltration (OL-HDF), the most efficient renal replacement therapy, enables enhanced removal of small and large uremic toxins by combining diffusive and convective solute transport. Randomized controlled trials on prevalent chronic kidney disease (CKD) patients showed improved patient survival with high-volume OL-HDF, underlining the effect of convection volume (CV). This retrospective international study was conducted in a large cohort of incident CKD patients to determine the CV threshold and range associated with survival advantage.

The case for treating refractory congestive heart failure with ultrafiltration.

Extracellular fluid retention and congestion is a fundamental manifestation of heart failure (HF) and cardiorenal syndrome (CRS). Patients are normally hospitalized and treated with diuretics, but their outcomes are often poor as severe congestion and diuretics resistance is the primary cause of HF-related hospital admissions and readmissions. Isolated ultrafiltration (UF), which can be considered as a 'mechanical diuretic and natriuretic' tool, offers promise in achieving safe and effective fluid volume removal in HF patients with CRS who are resistant to stepwise guided diuretic therapy.

Achieving high convective volumes in on-line hemodiafiltration.

On-line hemodiafiltration (OL-HDF) has established itself as a highly efficient and safe form of renal replacement therapy, providing clinical benefits for several conditions that afflict end-stage chronic kidney disease patients. Additionally, evidence now ascribes a survival benefit to OL-HDF. The first indication that mortality rates decline with high-efficiency OL-HDF was provided by the European results from the DOPPS.

Emerging clinical evidence on online hemodiafiltration: does volume of ultrafiltration matter?

Online hemodiafiltration (OL-HDF), first described in 1985, is today a widely prescribed treatment modality for end-stage chronic kidney disease (CKD) patients. Other than in the United States, prescription of the treatment modality is widespread with a steady increase since its inception. Indeed, in Western Europe, more CKD patients receive OL-HDF than peritoneal dialysis, hitherto the second most prescribed therapy after conventional hemodialysis.

Membrane requirements for high-flux and convective therapies.

Worldwide, high-flux dialysis (HF-HD) has now surpassed low-flux dialysis (LF-HD) as the predominant treatment modality, recognition that removal of larger uremic retention solutes is desirable for the treatment of patients with end-stage chronic kidney disease (CKD). An even more advanced form of HF-HD in terms of removal of a broad spectrum of uremic toxins is on-line hemodiafiltration (HDF), involving convective transport mechanisms for solute removal. With the modality reaching considerable technical maturity over the last two decades, on-line HDF is now recognized for its clinical efficiency and effectiveness, versatility and safety.

Contribution of polysulfone membranes to the success of convective dialysis therapies.

The majority of patients with chronic kidney disease are currently treated with dialyzers containing synthetic membranes. Of all the dialysis membranes made from these polymers, 93% are from the parent polyarylsulfone family of which 71% are from polysulfone (PSu) and 22% from polyethersulfone. The preference of nephrologists for PSu dialyzers signifies their versatility in terms of meeting the solute and fluid removal demands for all treatment modalities (low-and high-flux dialysis, online hemodiafiltration, hemofiltration).

Impact of hemodialysis therapy on anemia of chronic kidney disease: the potential mechanisms.

A significant and increasing number of chronic kidney disease (CKD) patients are treated with online hemodiafiltration (OL-HDF), even in the absence of more conclusive survival data. OL-HDF affords several clinical benefits including control of anemia of CKD, a common affliction in dialysis patients. In efforts to understand the underlying mechanisms that contribute to the purported benefits of OL-HDF, we examined the potential role and impact of OL-HDF on key stages of anemia and its correction: erythropoiesis of bone marrow, circulating erythrocytes and on anemia therapy.