HD vs HDF

[Des]

Our unit are replacing all the HD machines with HDF ones and I have two minds about it. (getting them most probably in August)

Firstly they do have a few of the HDF machines in the unit and I have been on it 3 times Of which one = I was rushed to ICU with a SVT just after the first hour. The second time I was given oxygien because I battled to breath and the third was the most uncomfortable tingling feeling all over and a pressure on my chest.

Now as I understand this machine takes out "more" than 40% more than the normal HD machine. ... but this also means it takes out 40% more GOOD stuff as well and most of the other people in my unit feels sucked dry like a prune and very tired and some even feel sick afterwards.

They have done studies on this thing and they found that there were less hospitalizations and the positive longterm effects on the heart was absolutaly proven.

So...... has anyone of you had any experience in this or have some info to share?   

[Des]

June 27, 2005



   
 

 
 

Istanbul, Turkey - Online hemodiafiltration (HDF) reduces mortality risk by approximately 35% compared with standard, high-flux hemodialysis, according to an analysis of a large cohort of end-stage renal-disease (ESRD) patients enrolled in EuCliD [ 1 ]. EuClid is a clinical database that monitors quality of treatment across many European-based dialysis clinics.


Findings suggest that the use of convective as opposed to diffusion dialysis may represent the treatment of choice for ESRD patients. "Hemodiafiltration is, for physiological reasons, the most advanced form of extracorporeal renal-replacement therapy we have," Dr Tomas Jirka (Fresenius Medical Care, Prague, Czech Republic) told delegates, "and I think this new approach means it is possible to improve the still poor prognosis of hemodialysis patients [over standard hemodialysis]."

Results from the analysis were presented here during the XLII Congress of the European Renal Association-European Dialysis and Transplant Association.




Multicenter investigators
Multicenter investigators evaluated the impact of online HDF and other factors on mortality risk in 2564 patients; 394 received online HDF and the rest received high-flux hemodialysis. "Only patients with an average eKt/V >1.20 on three or more sessions per week were considered," investigators point out, "and all patients were treated with polysulfone membranes."

Several important differences were observed between those receiving HDF and their counterparts on standard hemodialysis, they report. HDF patients were, for example, significantly younger than hemodialysis patients and significantly heavier. However, the proportion of patients with diabetes was not significantly different between groups.

Differences in baseline characteristics between groups



Variable
 Hemodiafiltration group
 Hemodialysis group
 
Mean age (y)
 58.4
 64.4
 
Mean weight (kg)
 67.9
 64.9
 
Patients with diabetes (%)
 18.3
 19.6
 
 

[Des]

The prevalence of other comorbid conditions, including ischemic heart and other forms of vascular disease, were also comparable between the two groups. Overall, patients had spent an average of 5.3 years on renal-replacement therapy, but those receiving online HDF had spent, on average, two years more on treatment than those on hemodialysis.

Logistic regression analysis showed that age, the presence of diabetes, and the presence of neoplasm were all associated with an increased mortality risk. Male gender was also associated with a 17% increased risk of mortality. Interestingly, on further regression analysis, the presence of cerebral or heart disease did not result in a significantly increased risk of death, Jirka added. Time spent undergoing renal-replacement therapy was also associated with a 2% increase in the relative risk of death for each year spent on therapy.

However, even when investigators took all of these variables into account, "online HDF was found to be associated with a 35% reduction in the relative risk of mortality compared with standard hemodialysis, and this result remained significant after adjusting for differences in age, gender, comorbidities, and time on renal-replacement therapy," Jirka said.

This difference was seen despite the fact that the high-flux polysulfone membrane used for standard hemodialysis therapy in the cohort is considered to be state of the art, they note. The adequacy of the dialysis received similarly did not influence results.

"Hemodiafiltration online has become a technical reality that is safe and obtained at a reasonable cost," Jirka said, "and it represents another step toward an improvement in outcome and quality of life for hemodialysis patients."




Potential advantages?
Session cochair Dr Karl Leunissen (University Hospital, Maastricht, the Netherlands) told renalwire that he thinks the conclusions reached by the group are "probably right," but he was not convinced the two groups were comparable and thus couldn't be sure results weren't biased.

He also pointed out that investigators did not censor their data for patients who received a kidney transplant and that patients who were treated with online HDF were younger and therefore more likely to have received a donor kidney than hemodialysis patients. "I would have also liked to have asked whether they compared the quality of water used in both groups, because hemodialysis is done with water that is not ultrapure while HDF is performed with ultrapure water, and quality of water could influence mortality risk quite substantially," Leunissen added.

Nevertheless, Leunissen conceded that there are potential advantages inherent in HDF over hemodialysis, including better blood-pressure control, improved nutritional status, and less anemia—"all of which in the end could affect mortality."

HDF equipment is also relatively easy to use and with online preparation of infusion fluids, costs are substantially reduced relative to hemodialysis.

Also commenting on the study for renalwire was Dr Alfred K Cheung (University of Utah Health Sciences Center, Salt Lake City). "These are intriguing results that are not definitive," he said, noting that retrospective, nonrandomized data "must always raise caution." The two groups in the study were "indeed different in some characteristics, notably, the younger age in the HDF group that gives that group a tremendous advantage," Cheung said. "The authors, however, did adjust for age in their analysis." Similar results were seen in a previous paper by Locatelli et al published in Kidney International in 1999 [ 2 ], he noted.

Cheung said that it would be preferable to have more details about the specific HDF and hemodialysis techniques used that might help to explain the differences seen in outcomes. "For example, what were the average removal rates of middle molecules in the two techniques? And if they were different, did that explain the difference in outcome?" he pointed out.

The HDF technique is not widely used in the US. However, Cheung notes, "I feel that if there is a technique out there that [is] used quite commonly in other countries and might improve clinical outcomes, US nephrologists and dialysis personnel ought to know about it. Otherwise, how do we ever adopt those technologies and lobby the third-party payers to make them available in the US?"

[Zach]

I think one of the concerns with HDF is the "in-line" dialysate which is infused into the patients' bloodline during the dialysis treatment.  If the solution is not sterile, as it is supposed to be, patient complications can arise.  A more diligent and professional dialysis staff may be necessary.

When properly maintained and performed, HDF is superior to standard high-flux hemodialysis, as you have already noted.

[Des]

Some news!!!!


The whole unit has now been updated with the HDF machines! It looks very fancy.

Luckily for me they can still use the HD settings otherwise I would not have been able to use it.

I will try to put a pic.

[Rerun]

Interesting.  I doubt out unit would change over.  It would cost them money.

             

[Zach]

Interesting.  I doubt out unit would change over.  It would cost them money.

             

HDF is not approved as yet here in the U.S.

[Des]

Our Fresenius Clinic imported it. I wonder from where then?  I thought it came from the US?

These machines are brilliant (so far) it even "fixes" the bloodpressure  when it drops and it keeps a full history of the pasient on a card that gets inserted everytime you go on it. Each pasient has his own card. The machine can even "test"(count) your levels of certain  things while you are on the machine.(They crapped on the lady next door because they saw she ate too much salt)
It works out your dry weight automatically as it knows what your weight was when you came off.
These machines do not use an external saline bag but makes its own from tap water.

Everyone I spoke to so far says it feels so much better coming off as you don't feel so "drained" afterwards.

[Zach]

Britain uses these machines.  Perhaps that's from where they were imported.

Hemodiafiltration (HDF) removes more toxins from the blood, including the middle molecule solutes, which are believed to cause some of the long-term problems faced by those on hemodialysis.

From British Dialysis Guidelines:

"Guideline 2.1
The use of synthetic high-flux membranes should
be considered to delay long-term complications
of haemodialysis therapy. Specific indications include;
(i) To reduce dialysis-related amyloidosis (III)
(ii) To improve control of hyperphosphataemia (II)
(iii) To reduce the increased cardiovascular risk (II)
(iv) To improve control of anaemia (III)

Guideline 2.2
In order to exploit the high permeability of high-flux
membranes, on-line haemodiafiltration or haemofil-
tration should be considered.
The exchange volumes should be as high as
possible, with consideration of safety. (Evidence level II)."

IHD member, AlasdairUK was on HDF for several years before receiving a transplant.
He did quite well on HDF.

[Des]

Thanks Zach,

It seems that these machines are promoting a better longterm outcome.... Some good news then...