Is High-Volume On-line Hemodiafiltration the best treatment for patients with Chronic Kidney Disease Stage V?

Abstract

Introduction: High-volume online hemodiafiltration (HV-OL-HDF) is an effective technique to remove uremic toxins with higher molecular weight through convective transport. In correlation with hemodialysis (HD), through this method, greater hemodynamic stability, lower inflammatory parameters and a smaller risk of death due to cardiovascular or any other factors are achieved. These benefits are obtained when substitution volume (SV) is higher than 21L/session; that is the reason why the technique is called high-volume hemodiafiltration (HVHDF). Objectives: To assess the effectiveness of HVHDF as compared to HD and to determine if changing the type of therapy results in greater hemodynamic stability, better lab test results, a lower number of hospital admissions and a superior quality of life. Methods: This retrospective observational study was conducted in only one center and included 53 patientswho underwent HVHDF during 6 months after having hemodialysis (HD) for at least 6 months. We analyzed demographic variables, number of hypotension events, number of hospital admissions, and length of stay for each type of treatment. The following were compared: hemoglobin (Hb), phosphate (P), intact parathormone (iPTH), albumin (ALB), C-reactive protein (CRP), Kt/V and erythropoietin dose during the last month of HD and the sixth month of HVHDF. The Kidney Disease Quality of Life-36 (KDQOL-36™) questionnaire was completed at the beginning and after 6 months of HVHDF. Results: The average age was 60.6 years old and 67.9% of the participants were men. The vascular access was created using an arteriovenous fistula in 69.8% of patients and 38 of them (71.1%) had substitution volume of > 21L/session. Some patients (39.6 %) experienced a hypotension event during HD and others (30.2%) during HVHDF (p<0.001). The number of hypotension events was significantly higher in patients treated with HD than in patients treated with HV-OL-HDF: 40 (18-68) vs. 11 (3-33) (p< 0.001). The percentage of patients admitted to hospital was the following: 32% for HD and 11% for HVHDF. A conside rable improvement was observed in Hb (10.7 to 11.3 [p<0.01]) and Kt/V (1.4 to 1.5 [p<0.03]; a lower dose of EPO was needed after 6 months of HVHDF (p< 0.02). Only patients with substitution volume of > 21L/session showed statistically significant improvement in the symptoms/problems section of KDQOL-36 and in the Short Form-12 (SF-12) Physical and Mental Health Summary. Conclusion: When changing from HD to HVHDF, our study group had a lower number of hypotension events; greater hemodynamic stability; a smaller number of hospital admissions; better Hb levels and Kt/V, and they needed a lower dose of erythropoietin.