Abstract
Background and Aims
High flux hemodialysis has largely replaced low flux hemodialysis in developed countries. Clinical trials, in particular the Hemo and the MPO studies, conducted many years ago, showed that the survival benefit was mainly for patients on long term hemodialysis for the first one and for high risk patients with low albumin level (less than 40g/dl) for the latter. Moreover, the effect on hematopoiesis or mineral balance is not unequivocally established in the literature. In Lebanon, following the recommendations of the ministry of health, we switched patients undergoing hemodialysis at our center from low to high flux starting April 2019. We aimed in this study to assess the effect of this switch on hemoglobin level, dose of ESA used, mineral metabolism parameters and nutritional parameters.
Method
This is an observational pre-post study where each patient is his own control. Subjects included are adults on chronic hemodialysis for more than 6 months at Hotel Dieu de France University Hospital. Patients who needed transfusion for bleeding, admission to the hospital or parathyroidectomy during the study period were excluded from the study. Demographic parameters, medical history and laboratory values were extracted from the patients’ files.
Paired t- test was used to compare values obtained in the 6 months on low flux compared to the 6 months on high flux hemodialysis.
Results
Seventy four patients received sequentially both techniques (45 males and 29 females). Mean age was 66 years, mean dialysis vintage 65 months, diabetic and vascular diseases were the most frequent causes of ESRD found in 27 and 15% of the cases. Hemoglobin level significantly increased from 11 +/- 0.82 to 11.26 +/- 0.67 mg/dl (p=0.04) with a non-significant trend towards a lower ESA dose: 11620 UI/week (+/-2275 UI) in the first period versus 10860 UI/week (+/-2609 UI) during the second period (p=0.15). Ferritin levels were higher in the second part of the study (416 v/s 476 ng/ml) which may have contributed to the increase in hemoglobin. Phosphorus level decreased from 1.55 to 1.48 mmol/l (p=0.008) at the same doses of binders and practically stable levels of calcium and PTH. Most interestingly, albumin level increased from 38 to 40.3 g/dl (p<0.001). Finally urea reduction ratio increased from 73.1% to 74.5% with a p value of 0.001.
Conclusion
Assuring quality ultrapure water is still a challenge in many developing countries. Lack of firm evidence on beneficial effect in terms of mortality may delay sanitary authorities from imposing high flux hemodialysis. In our study, switching from low to high flux hemodialysis showed positive impact on phosphorus levels but most interestingly increased albumin levels a major predictor of mortality in hemodialysis patients.
Benefits of the Nephros Dual Stage Ultrafilter in Chronic Hemodialysis Patients: Evidence for Improved ESA Responsiveness