hemodiafiltration versus mixed hemodiafiltration: what’s place...2016/04/03 · outlook of the...
TRANSCRIPT
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Hemodiafiltrationversus Mixed Hemodiafiltration:
What’s Place ?
Hemodiafiltrationversus Mixed Hemodiafiltration:
What’s Place ?
Prof. Bernard CanaudCMO, Centre of Excellence Medical, FMC EMEA, Bad Homburg, Germany
& School of Medicine, Montpellier University I, Montpellier, France
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Speaker name: Prof. Bernard Canaud
� I have the following potential conflicts of interest to report:
� Consulting
⌧ Employment in industry (FMC)
� Shareholder in a healthcare company
� Owner of a healthcare company
� Other(s)
� I do not have any potential conflict of interest
Disclosure
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Outlook of the Presentation
1. What is optimal in convective therapies ?
‒ Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
‒ Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
‒ Medical & engineering rationale
4. How to use mixed-HDF ?‒ Technical aspects
‒ Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
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Outlook of the Presentation
1. What is optimal in convective therapies ?
‒ Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
‒ Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
‒ Medical & engineering rationale
4. How to use mixed-HDF ?‒ Technical aspects
‒ Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
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From Dialyzer Clearance to Body Mass TransferEffective Solute Mass Removal per Session
Solute
Mass Transfer
KB.CS (mmol/ses/wk)
Frequency
Time Duration
Effective
Treatment Time
Solute Dialyzer
Clearance
KD ΣD+C+A (ml/min)
Solute CharacteristicsSolute
Dialyzer
Membrane Permeability
Surface Area - Filter Design
Operational
Conditions
Blood Flow
Dialysate Flow
Ultrafiltration Flow
Diffusive
+ Convective Dose
Diffusive
+ Convective Dose
Solute Body
Clearance
Metabolic profile
Vascular access performances
Treatment tolerance, Weight loss…
Patient
Characteristics
Effective flow/time/dialysate flow/substitution flow
Recirculation…
Practice Patterns
KB (mmol/min)
D
C
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From Mass Transfer to Patient NeedsRRT Adequacy: Effective Solute Mass Removal per Week
HD HD HD HD
Intermittent
treatment
Patient’s Needs
RRT Efficacy Homeostasis
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Cubic Spline Analysis of Relative Survival Rate VsConvection Volume Non Adjusted
Canaud B et al, Kidney Int. 2015;88:1108-1116
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HRs for CardioVascular Mortality In Patients Receiving HDF Versus HD, Overall and in Subgroups
Peters SAE et al, Nephrol Dial Transplant 2015; 0: 1–7 ePub Nov2015.
2793 prevalent ESKD pts
-23%
-31%
-30%
-41%
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Simulated Benefits of Convective Volume on Relative Risk of Mortality in CKD Patients
Imamovic G et al, ‘Rational for Improved Patients' Survival on Hemodiafiltration’ in InTech Chapter, 2016 In Press
HDF Pooled Project
EUDIAL
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Outlook of the Presentation
1. What is optimal in convective therapies ?
‒ Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?‒ Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
‒ Medical & engineering rationale
4. How to use mixed-HDF ?‒ Technical aspects
‒ Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
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Post-dilution Hemodiafiltration
QDinQDout
QBinQBOut
QUF
QSUB
KUFQUF = Ultrafiltration Rate
QSUB = Substitution Rate
Kuf = WL/tHD Weight Loss
QF = Total Ultrafiltration Rate
DF = Dilution Factor
S = Sieving Coefficient
QBIN = Blood Flow In
QBOUT = Blood Flow Out
QDIN = Dialysate Flow In
QDOUT = Dialysate Flow Out
Tattersall JE et al, Nephrol Dial Transplant. 2013 ;28(3):542-50
Sieving Coefficient = CSB/CSF
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Different Modalities of HDFDefined from Substitution Sites
Post-Dilution HDF
Pre-Dilution HDF
Mixed-Dilution HDF
Mid-Dilution HDF
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Postdilution HemodiafiltrationFlow and Fluid Transfer
Qbin = 400 QBOut = 390
QUF = 100
QSUB = 100
KUF = 10
QDin = 500QDout= 500
QUF = Ultrafiltration Rate
QSUB = Substitution Rate
Kuf = WL/tHD Weight Loss
QBIN = Blood Flow In
QBOUT = Blood Flow Out
QDIN = Dialysate Flow In
QDOUT = Dialysate Flow In
400 290
Total QUF = 110
FF = 110/400 = 27.5%
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Postdilution Hemodiafiltration
Tattersall JE et al, Nephrol Dial Transplant. 2013 ;28(3):542-50
QBinQBOut
QUF
QSUB
KUF
QDinQDout
QUF = Ultrafiltration Rate
QSUB = Substitution Rate
Kuf = WL/tHD Weight Loss
QF = Total Ultrafiltration Rate
DF = Dilution Factor
S = Sieving Coefficient
QBIN = Blood Flow In
QBOUT = Blood Flow Out
QDIN = Dialysate Flow In
QDOUT = Dialysate Flow Out
Diffusive Clearance, KD
Convective Clearance, KC
Total Solute Clearance
KoA = Solute Mass Transfer Coefficient
QDIN = Dialysate Flow In
QDOUT = Dialysate Flow Out
Sieving Coefficient = CSB/CSF
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Postdilution HemodiafiltrationSolute Profile & Convective Clearance
Total Solute Clearance
DF = 1.0
DF = 400/400 = 1.0
100
50
0
100
50
0
Solute Conc. (%)
Urea, 60d
B2M, 12.8Kd
FGF23, 32.0Kd
Qb/(QD+QF)
KT
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Predilution HemodiafiltrationFlow and Fluid Transfer
Qbin = 400 QBOut = 390
QUF = 100
QSUB = 100
KUF = 10
QDin = 500QDout= 500
QUF = Ultrafiltration Rate
QSUB = Substitution Rate
Kuf = WL/tHD Weight Loss
QBIN = Blood Flow In
QBOUT = Blood Flow Out
QDIN = Dialysate Flow In
QDOUT = Dialysate Flow In
500 390
Total QUF = 110
FF = 110/500 = 22.0%
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Predilution HemodiafiltrationSolute Profile & Convective Clearance
Total Solute Clearance
DF = 0.25
DF = 100/400 = 0.25
100
50
0
100
50
0
Solute Conc. (%)
Urea, 60dB2M, 12.8Kd
FGF23, 32.0Kd
Qb/(QD+QF)
KT �Qf & �QSUB
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Qbin = 400 QBOut = 390
Predilution HemodiafiltrationFlow and Fluid Transfer Matching Post-HDF
QUF = 200
QSUB = 200
KUF = 10
QDin = 500QDout= 500
QUF = Ultrafiltration Rate
QSUB = Substitution Rate
Kuf = WL/tHD Weight Loss
QBIN = Blood Flow In
QBOUT = Blood Flow Out
QDIN = Dialysate Flow In
QDOUT = Dialysate Flow In
600 390
Total QUF = 210
FF = 210/600 = 35.0%
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Advantages & Disadvantages of Substitution Modalities
Pro:• High solute clearance & removal
- Small, Middle & High MW solutes
• Reduce consumption of substitution
volume
Con:• Hemoconcentration
- Increase protocrit & hematocrit
- Increase viscosity & oncotic
pressure
- Fibers and membrane fouling
• Reduce hydraulic & solute membrane
permeability
- Increase transmembrane pressure
- Reduce sieving coefficient
- Fibers clotting
- Potential alarms
• Increase membrane stress
- Potential albumin leakage
Post-dilution HDF
Pro:
• Avoid drawbacks of both post & pre-
dilution methods
Con:
• Require specific hardware equipment
- Two infusion pumps
- Specific blood tubing set
• Require specific software & algorithm
- Accounting for hematocrit &
protocrit changes
- Adjusting post/pre infusion ratio
keeping transmembrane
pressure in target
- Increase consumption of
substitution volume
Pre-dilution HDF
Pro:• Hemodilution
- Decrease protocrit & hematocrit
- Reduce viscosity & oncotic pressure
- Reduce fibers & membrane fouling
• Facilitate protein-bound solute
clearance & removal
• Preserve hydraulic & solute
membrane permeability
• Reduce membrane stress
Con:• Reduce solute clearance & removal
- Small > Middle & High MW solutes
• Increase consumption of substitution
volume
Mixed-dilution HDF
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Some Clinical Indicators for Choosing Best Substitution Modality
• Good vascular access flow
• High blood flow
• Hematocrit 30-35% or Hb 10-11g/dl
• Albumin concentration (35-40g/l)
• Standard weight loss or UFR <15ml/Hr/kg
• No inflammation, No active infection
• No paraproteinemia
• No hyperlipidemia, no hypertriglyceridemia
• No hyperviscosity: fibrinogen <3g/l, leukocytes <5.103, Platelets <150.103
• No clotting disorders
• Unfavorable probing
Favorable to Post-HDF
• Poor vascular access flow or veno-venous
access
• Low blood flow (<300ml/min)
• Hematocrit >35% or Hb >12g/dl
• Albumin concentration >40g/l
• High weight loss or UFR >15ml/Hr/kg
• Inflammation, Active infection
• Paraproteinemia
• Hyperlipidemia, Hypertriglyceridemia
• Hyperviscosity
• Clotting disorders
Favorable to Pre or Mixed-HDF
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Convective Dose Delivered in Postdilution HDF with Automatic Ultrafiltration Control (AutoSub+)
Marcelli D et al, Int J Artif Organs 2015; 38(5):244-50.
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Modifiable Factors with Achievement of Optimal Convective Dose in Postdilution HDF
4176 sessions - 366 patients on postdilution HDF
1-month observational cohort study
Marcelli D et al, Artif Organs 2015, 39(2):142–149
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Vascular Access Type and Achievement of Optimal Convective Dose in Postdilution HDF
Marcelli D et al, Artif Organs 2015, 39(2):142–149
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Hematocrit & Albumin and Achievement of Optimal Convective Dose in Postdilution HDF
Marcelli D et al, Artif Organs 2015, 39(2):142–149
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Mode of Substitution Matters
Post-Dilution
Post-Dilution HDF: reference
Manual versus
Automated Delivery
Manual versus
Automated Delivery
Manual
Management
Ultrafiltration
Control
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Substitution Flow and TMP ProfilesHF80 filter and Manual Post-HDF
HF80S, Manual Post-HDF
Vaussenat F et al, ASAIO J. 1997 ;43(6):910-5.
Vaussenat F et al, Nephrol Dial Transplant. 2000;15(4):511-6.
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Innovative Technology & Intelligent HDF Machine Facilitate Achievement of High Convective Volume
Continuous analysis of hemorheological
conditions
Continuous adaptation of
ultrafiltration flow
UF constant
Ultrafiltration control by AutoSubplus with FX CorDiax
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Substitution Flow and TMP ProfilesPost-HDF Manual vs Pre-HDF AutoSub
Post-HDF Manual Post-HDF AutoSub
Marcelli D et al, Int J Artif Organs 2015; 38(5):244-50.
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Substitution Flow and TMP ProfilesPost-HDF Manual vs Post-HDF AutoSub Plus
Post-HDF AutoSub PlusPost-HDF Manual
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Post-HDF Manual
Substitution Flow and TMP ProfilesPost-HDF Manual vs Pre-HDF AutoSub Plus
Pre-HDF AutoSub Plus
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Automatic Control of Ultrafiltration by AutoSub PlusIncreases Filtration Fraction and Convective Volume
Marcelli D et al, Int J Artif Organs 2015; 38(5):244-50.
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Mode of Substitution Matters
Pre-Dilution Post-Dilution
Mixed-Dilution HDF: as alternative
Automated DeliveryAutomated Delivery
Ultrafiltration
Control
TMP Control
Substitution
Adjustment
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Mixed-Dilution HemodiafiltrationOriginal Setting During Clinical Trial
Pedrini LA et al, Kidney Int. 2003;64:1505–1513
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Mixed-Dilution Hemodiafiltration
Substitute
Substitute
Feedback
Control
Blood Pump
HDF Pump
Pre
HDF Pump
Post
Ultra
filtrate
Pedrini LA et al, Kidney Int. 2003;64:1505–1513
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Typical Behavior of Substitution Flow (post/pre) in Mixed-HDF
Pedrini LA et al, Kidney Int. 2006;69:573–579
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Protein Cake Formation onto the MembraneProtein Gel Layer Formation During Convective Therapy
Ultrafiltration
Membrane
1. Blood Flow
2. Ultrafiltration
3. Hematocrit
4. Protein concentration
UFRJf
Blood Flow
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Protein Gel Layer FormationEffects of Blood Flow, Shear Rate/Stress & TMP
Ultrafiltration
Membrane
Protein Gel
Layer
x
Protein toward membrane
= Protein away from membrane
Blood Flow
Protein toward membrane
> Protein away from membrane
3x
Protein toward membrane
< Protein away from membrane
1/2x
TMP
Hydraulic
Pressure
Blood FlowBlood Flow
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Protein Gel Layer FormationHemodialysis, Postdilution vs Mixeddilution HDF
x 3x 1/2x
TMP
Hydraulic
Pressure
Pressure Regime
Hemodialysis
Pressure Regime
Postdilution HDF
Pressure Regime
Mixed or Pre-dilution HDF
Qb 400-400
TMP 100
Qb 400-300
TMP 300
Qb 600-400
TMP 200
Blood Flow Blood FlowBlood Flow
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Ultrafiltration Flow & Protein Gel Layer Formation Reduces Solutes Sieving Coefficient
1.0
0.8
0.6
0.4
0.2
0.0
3 5 10 20 30 50
Dextrans, Molecular Weight x 103
Sieving Coefficient, SC
Hemofilter, PC-HFRinger
Plasma
QUF, ml/mn
10030
209
Henderson LW et al, ASAIO
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Outlook of the Presentation
1. What is optimal in convective therapies ?
‒ Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
‒ Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?‒ Medical & engineering rationale
4. How to use mixed-HDF ?‒ Technical aspects
‒ Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
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Mixed-Dilution HDF Machine vs Standard HDF
Predilution Pump
Postdilution Pump
Blood Pump
Substitution Port
Blood Pump
Substitution Port
Uniponcture Blood Pump
5008 Mixed HDF 5008 & 5008S HDF Post or Pre-HDF
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Mixed-Dilution HDF MachinePrescription & Monitoring Screen
Mode HDF Auto-Sub I/O
Expected
Substitution
Volume
Cumulative
Substitution Volume Post Substitution Flow
Pre Substitution Flow
Effective Qb
Automated
Adaptation I/O
Filtration Ratio
Postdilution Subs. Flow/Qb,
(% Qb)
Effective TMP
Nom HDF Filter (no
impact on loop)
Trans Membrane Ratio
Total Substitution Flow/Qb , (%Qb)
Hematocrit
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Outlook of the Presentation
1. What is optimal in convective therapies ?
‒ Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
‒ Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
‒ Medical & engineering rationale
4. How to use mixed-HDF ?‒ Technical aspects
‒ Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
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Mixed-Dilution HDF Machine vs Standard HDF
Predilution Pump
Postdilution Pump
Blood Pump
Substitution Port
Blood Pump
Substitution Port
Uniponcture Blood Pump
5008 Mixed HDF 5008 & 5008S HDF Post or Pre-HDF
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Plasma Water and Water Flow Rates
Plasma Water
Hematocrit
Protocrit
TMR
FR
Plasma Water Fraction = (1 – H) x (1 – PT)
Plasma Water Fraction = (1 – 0,33) x (1 – 0,07) = 0,62
H = 33 %
(Hb = 11 g/dl)
TP = 70 g/l
Plasma Water Flow Rates
QB
QPW
post
preFR
Qsubs.Pla
sma
Wa
ter
Fra
ctio
n 6
2%
Plasma Water Flow = QB x Plasma Water Fraction
Plasma Water Flow = 400 x 0.62 = 248 ml/min
QB = 400 ml/min
TMR : Transmembrane Ratio
FR : Filtration Ratio
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Mixed-Dilution HDF MachinePrescription & Monitoring Screen
Mode HDF Auto-Sub I/O
Expected
Substitution
Volume
Cumulative
Substitution Volume Post Substitution Flow
Pre Substitution Flow
Effective Qb
Automated
Adaptation I/O
Filtration Ratio
Postdilution Subs. Flow/Qb,
(% Qb)
Effective TMP
Nom HDF Filter (no
impact on loop)
Trans Membrane Ratio
Total Substitution Flow/Qb , (%Qb)
Hematocrit
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Outlook of the Presentation
1. What is optimal in convective therapies ?
1. Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
1. Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
1. Medical & engineering rationale
4. How to use mixed-HDF ?1. Technical aspects
2. Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
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HDF Predilution vs Mixeddilution with Low Blood Flow
VA: 31 AVF, 7 CVC
G : 22 M, 16 F
73.8 ±12.8ys
Dry weight 74.1±10.7 kg
HD : 4:00 x 3 wk
38 ESKD patients – 6 centers
HDF pre
Qb250
HDF pre
Qb250
HDF pre
Qb350
HDF pre
Qb350 Qb250
HDF mixed
Qb250 Qb300
HDF mixed
Qb300
Low blood flow ≤300ml/min
eKt/v, PR-P, PR-B2M, PR-Myogl.
Albumin Lost
FX1000HDF
Cross-Over RCT
Potier J et al, Blood Purif 2013;36:78–8
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Albumin Lost per Session
Potier J et al, Blood Purif 2013;36:78–8
MIX250 MIX300 PRE300PRE250
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eKt/V
Potier J et al, Blood Purif 2013;36:78–8
MIX250 MIX300 PRE300PRE250
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Percent Reduction of B2-Microglobulin
Potier J et al, Blood Purif 2013;36:78–8
MIX250 MIX300 PRE300PRE250
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Substitution Volumes Achieved in the Different Modalities
Potier J et al, Blood Purif 2013;36:78–8
PBV, processed blood volume
UF, weight loss
VS total, total ultrafiltration per session
VS pre, ultrafiltration in predilution
VS post, ultrafiltration in postdilution
VS Post eq., L 18.2±3.8 20.7±5.5 27.3±2.3 33.5±3.9
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Outlook of the Presentation
1. What is optimal in convective therapies ?
1. Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
1. Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
1. Medical & engineering rationale
4. How to use mixed-HDF ?1. Technical aspects
2. Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
![Page 54: Hemodiafiltration versus Mixed Hemodiafiltration: What’s Place...2016/04/03 · Outlook of the Presentation 1. What is optimal in convective therapies ? ‒Convective dose : postdilution](https://reader034.vdocument.in/reader034/viewer/2022050513/5f9d7e60da19f749d21e86eb/html5/thumbnails/54.jpg)
ß2-Microglobuline Removal Post vs Mixed-HDF with Different Regimes
Pedrini LA et al, Kidney Int. 2003;64:1505–1513
Direct dialysis quantification by dialysate collection
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Performances Comparison Post vs Mixed-HDF
Pedrini LA et al, Kidney Int. 2003;64:1505–1513
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Transmembrane Pressure Behavior According to HDF Modalities
Pedrini L et al, Kidney Int. 2000;58:2155–2165
Mixed-HDF
Post-HDF
Pre-HDF
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Transmembrane Modulation to Optimize Performances and Reduce Albumin Loss
Pedrini L et al, Kidney Int. 2006;69:573-579
Constant TMP at around 300mmHg Profiled TMP
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Albumin Loss at the Start and the End of HDF with Different Procedures
Pedrini L et al, Kidney Int. 2006;69:573-579
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Instantaneous ß2-M Clearance at the Start and the End of HDF
Pedrini L et al, Kidney Int. 2006;69:573-579
Co
nst
an
t T
MP
Pro
file
d T
MP
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Behavior of Ultrafiltration Coefficient (KUF)
Pedrini L et al, Kidney Int. 2006;69:573-579
a. Constant
TMP
b. Profiled TMP
KUF = QUF/TMP
HF80S FX100
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• Prospective open randomized study
• 6 stable anuric ESKD patients on regular RRT
• Treatment schedule 3 x 240 min per week
• All AVF – Needles 15 gauges
• Cordiax HDF5008, FMC
• Qb = 350 ml/min - Qd = 600 ml/min - Qsub = AutoSub
• Study protocolEach patient explored over two sessions one week apart : HD vs HDF
− 2 pat HD Cordiax100 - HFD POST Cordiax1000 (AS)
− 2 pat HD Cordiax100 - HFD PRE Cordiax1000 (AS)
− 2 pat HD Cordiax100 - HFD MIXED Cordiax1000 (Auto)
Pre and post dialysis blood samples
• Percent reduction of selected solutes normalized for hemoconcentration
*Approved by Medical Ethical Committee of CH Caen
Pilot Study
Courtesy Dr J Potier, Cherbourg
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Characteristics of FX Dialyzers
FX100 Cordiax 100 FX1000 Cordiax 1000
Membrane material
Helixone Helixone plus Helixone Helixone plus
Surface Area,m2 2.2 2.2 2.2 2.3
KoA Urea, ml/min
1354 1545 1354 1421
Diameter, µm 185 185 210 210
Kuf, ml/h/mmHg
73 68 75 76
SC-ß2M 0.8 0.9 0.8 0.9
SC-Myog 0.5 0.5
SC-Alb 0.001 <0.001 0.001 <0.001
Courtesy Dr J Potier, Cherbourg
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Prescription and Operational Conditions
Dialysis duration 240 min
Substitution flow prescription
• QSub Pre = Qsub Post x 2
• Qsub Mixed = QSub Post x 1.4
Blood flow, QB (ml/min)
Volume Blood Processed, VBP (l/ses)
Substitution Flow, QSub (ml/min)
Volume Substituted, VS (l/ses)
0
10
20
30
40
50
60
70
80
90
VSE Q s T
HDF PRE
HDF POST
HDF MIX
HD
38.2±±±±2.5
26.9±±±±0.6
52.0±±±±0.6
QB 350 ml/min
Qsub, ml/minVBP, l/ses
Courtesy Dr J Potier, Cherbourg
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50
55
60
65
70
75
80
85
90
RRb2M
HDF PRE
HDF POST
HDF MIX
HD
NephelometryN <2.4mg/L
X±±±±SD 28.3±±±±5.4 (21,2 à 38)
PR ß2M, % 74.3±±±±3.3
83.8±±±±2.6
84.3±±±±0.1
82.2±±±±3.4
29.3 ±±±±6.6sß2M���� 31.7 ±±±±3.7 24.3 ±±±±1.6 26.1 ±±±±3.7
ß2-Microglobulin, 12.8Kda
Courtesy Dr J Potier, Cherbourg
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TNF αααα, 17-50 KDa
Elisa R&DN: < 1.9 pg/mL
X±±±±SD: 12.3 ±±±±3.2 (8.8 à 19.4)
40
45
50
55
60
65
70
75
80
RR TNF
HDF PRE
HDF POST
HDF MIX
HD
PR TNF-a, % 58.6±±±±7.0
65.5±±±±1.3
57.3±±±±10.6
62.6±±±±3.0
14.4 ±±±±3.6sTNFa���� 14.0 ±±±±1.4 10.0 ±±±±1.7 12.0 ±±±±2.7
Courtesy Dr J Potier, Cherbourg
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Myoglobin, 17.2KDa
NephelometryN : 24-72 ng/mL
X±±±±SD: 199 ±±±±79 (88 à 345)
40
45
50
55
60
65
70
75
80
85
RRmyo
HDF PRE
HDF POST
HDF MIX
HD
PR Myog, % 48.7±±±±2.6
78.3±±±±1.7
81.2±±±±0.6
56.5±±±±3.0
166 ±±±±52sMyog���� 251 ±±±±128 278 ±±±±94 169 ±±±±56
Courtesy Dr J Potier, Cherbourg
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ELISA BiomerieuxN M 2 à 15 – F 3-20 ng/mL
X±±±±SD 29.5 ±±±±25.3 (9.2 à 84.1)
30
40
50
60
70
80
90
100
RRPro
HDF PRE
HDF POST
HDF MIX
HD
PR Prol, % 54.7±±±±8.3
79.2±±±±6.7
86.8±±±±4.4
64.7±±±±7.4
29.5 ±±±±25.3sProl���� 23.4 ±±±±11.6 52.8 ±±±±44.3 12.2 ±±±±4.2
Prolactin, 23.0 KDa
Courtesy Dr J Potier, Cherbourg
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Elisa R&DN < 2.1 pg/mL
X±±±±SD: 1.41 ±±±±0.72 (0.35 à
2.47)
0
10
20
30
40
50
60
70
80
90
100
RR IL6
HDF PRE
HDF POST
HDF MIX
HD
PR IL-6, % 29.3±±±±30.4
12.3±±±±36.8
50.2±±±±38.6
36.2±±±±12.5
1.51 ±±±±0.69sIL6���� 0.95 ±±±±0.62 1.27 ±±±±1.29 1.74 ±±±±0.71
IL-6, 24.5KDa
Courtesy Dr J Potier, Cherbourg
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Free Light-Chain Kappa, 25.0KDa
Free LiteN 3.3 à 19.4mg/L
X±±±±SD 122.7 ±±±±63.1 (25.5 à 229)
50
55
60
65
70
75
80
85
90
RR CL K
HDF PRE
HDF POST
HDF MIX
HD
139.5 ±±±±62.8sFLCK���� 154.3 ±±±±79.9 67.3 ±±±±59.0 95.9 ±±±±53.8
PR FLCK, %70.9±±±±7.1
80.4±±±±7.9
74.5±±±±4.9
73.1±±±±2.5
Courtesy Dr J Potier, Cherbourg
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Free Light Chain Lambda, 50.0KDa
Free Lite
N 5.7 à 26.3 mg/L
X±±±±SD 75.3 ±±±±35.9 (29.4 à 161)
0
10
20
30
40
50
60
70
80
RR CL L
HDF PRE
HDF POST
HDF MIX
HD
PR FLCL, % 33.5±±±±15.6
59.1±±±±10.7
45.4±±±±16.9
36.0±±±±0.0
75.8 ±±±±23.4sFLCL���� 102.3 ±±±±83.0 66.5 ±±±±4.7 55.9 ±±±±37.4
Courtesy Dr J Potier, Cherbourg
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0
10
20
30
40
50
60
70
80
RR FGF23
HDF PRE
HDF POST
HDF MIX
HD
FGF23, 32.KDa
Elisa merck/milliporeN: pg/mL
X±±±±SD 919 ±±±±1558 (52 à 4280)
RR% 38.7±±±±7.8
68.3±±±±0.5
67.6±±±±0.9
66.3±±±±11.8
901 ±±±±1670Cp���� 2089 ±±±±2804 651 ±±±±648 71 ±±±±26
Courtesy Dr J Potier, Cherbourg
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0
5
10A
lb
0 5 10 15 20 25 30QsPost
FX1000
FX CORDIAX1000
FX1000HDF vs Cordiax1000
2.5
Albumin Loss as Function of QSubstitution
Courtesy Dr J Potier, Cherbourg
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Outlook of the Presentation
1. What is optimal in convective therapies ?
‒ Convective dose : postdilution HDF as reference
2. What’s matter in HDF ?
‒ Dilution mode : Post - Pre - Mixed - Mid
3. Why mixed-HDF is necessary ?
‒ Medical & engineering rationale
4. How to use mixed-HDF ?‒ Technical aspects
‒ Nursing & Doctor perspectives
5. What indications ?
6. What results ?
7. Take home message
![Page 74: Hemodiafiltration versus Mixed Hemodiafiltration: What’s Place...2016/04/03 · Outlook of the Presentation 1. What is optimal in convective therapies ? ‒Convective dose : postdilution](https://reader034.vdocument.in/reader034/viewer/2022050513/5f9d7e60da19f749d21e86eb/html5/thumbnails/74.jpg)
Take Home Message
• Benefits of HDF are depending on convective dose delivered
• Postdilution HDF is still the reference method for convective therapies in RRT
• Minimum threshold total ultrafiltered volume to improve better outcome is closed to 40L/m2/wk or 70L/1.73m2
• Automated ultrafiltration control by AutoSubPlus permits to achieve this volume in more than 75% of CKD patients
• Mixed-HDF main facilitate implementation of HDF in the remaining 25% of CKD patients with hemorheologic unfavorable profile
• Poor blood flow, catheters, elderly and kids may benefit from mixed-HDF
• Long-term studies are still missing to define specific indications and benefits