Disruptive technologies for hemodialysis: medium and high cutoff membranes. Is the future now? / Tecnologias disruptivas para hemodiálise: membranas de ponto de corte médio e alto. O futuro é agora?

Abstract In the past decade, a new class of hemodialysis (HD) membranes (high retention onset class) became available for clinical use. The high cutoff (HCO) and the medium cutoff (MCO) membranes have wider pores and more uniformity in pore size, allowing an increased clearance of uremic toxins. Owing to the mechanism of backfiltration/internal filtration, middle molecules are dragged by the convective forces, and no substitution solution is needed. The HCO dialyzer is applied in septic patients with acute kidney injury requiring continuous kidney replacement therapy. The immune response is modulated thanks to the removal of inflammatory mediators. Another current application for the HCO dialyzer is in hematology, for patients on HD secondary to myeloma-kidney, since free light chains are more efficiently removed with the HCO membrane, reducing their deleterious effect on the renal tubules. In its turn, the MCO dialyzer is used for maintenance HD patients. A myriad of clinical trials published in the last three years consistently demonstrates the ability of this membrane to remove uremic toxins more efficiently than the high-flux membrane, an evolutionary disruption in the HD standard of care. Safety concerns regarding albumin loss as well as blood contamination from pyrogens in the dialysate have been overcome. In this update article, we explore the rise of new dialysis membranes in the light of the scientific evidence that supports their use in clinical practice.

Resumo Na última década, uma nova classe de membranas de hemodiálise (HD) (classe de início de alta retenção) tornou-se disponível para uso clínico. As membranas de ponto de corte alto (HCO) e ponto de corte médio (MCO) têm poros mais largos e maior uniformidade no tamanho dos poros, permitindo uma maior depuração de toxinas urêmicas. Devido ao mecanismo de retrofiltração/filtração interna, as moléculas médias são arrastadas pelas forças convectivas, não sendo necessária uma solução de substituição. O dialisador de HCO é aplicado em pacientes sépticos com lesão renal aguda que requerem terapia renal substitutiva contínua. A resposta imunológica é modulada graças à remoção de mediadores inflamatórios. Outra aplicação atual para o dialisador de HCO é em hematologia, para pacientes em HD secundária ao rim do mieloma, uma vez que as cadeias leves livres são removidas mais eficientemente com a membrana de HCO, reduzindo seu efeito deletério sobre os túbulos renais. Por sua vez, o dialisador de MCO é utilizado para pacientes em HD de manutenção. Uma miríade de ensaios clínicos publicados nos últimos três anos demonstra consistentemente a capacidade desta membrana de remover toxinas urêmicas de forma mais eficiente do que a membrana de alto fluxo, uma ruptura evolutiva no padrão de cuidado em HD. As preocupações de segurança em relação à perda de albumina, bem como a contaminação do sangue por pirogênios no dialisato foram superadas. Neste artigo de atualização, exploramos o surgimento de novas membranas de diálise à luz das evidências científicas que apoiam seu uso na prática clínica.

Disruptive technologies for hemodialysis: medium and high cutoff membranes. Is the future now?

In the past decade, a new class of hemodialysis (HD) membranes (high retention onset class) became available for clinical use. The high cutoff (HCO) and the medium cutoff (MCO) membranes have wider pores and more uniformity in pore size, allowing an increased clearance of uremic toxins. Owing to the mechanism of backfiltration/internal filtration, middle molecules are dragged by the convective forces, and no substitution solution is needed. The HCO dialyzer is applied in septic patients with acute kidney injury requiring continuous kidney replacement therapy. The immune response is modulated thanks to the removal of inflammatory mediators. Another current application for the HCO dialyzer is in hematology, for patients on HD secondary to myeloma-kidney, since free light chains are more efficiently removed with the HCO membrane, reducing their deleterious effect on the renal tubules. In its turn, the MCO dialyzer is used for maintenance HD patients. A myriad of clinical trials published in the last three years consistently demonstrates the ability of this membrane to remove uremic toxins more efficiently than the high-flux membrane, an evolutionary disruption in the HD standard of care. Safety concerns regarding albumin loss as well as blood contamination from pyrogens in the dialysate have been overcome. In this update article, we explore the rise of new dialysis membranes in the light of the scientific evidence that supports their use in clinical practice.

Incidence of Contrast-Induced Nephropathy after Coronary Procedures in the United Arab Emirates: A Single-Center Study.

Contrast-induced nephropathy (CIN) is a major cause of morbidity and mortality in patients undergoing coronary procedures. The reported incidence of CIN ranges from ~3% to 30%. The profile of patients undergoing coronary procedures in the United Arab Emirates (UAE) differs from those included in published reports of CIN, and the incidence of CIN after coronary procedures in the UAE remains unknown. We conducted a retrospective analysis of all adult patients who underwent coronary procedures at a large tertiary care facility in the UAE in 2013-2014. Patients on dialysis or missing creatinine values were excluded. CIN was defined as an increase of creatinine of ≥44 µmol/L within 48-72 h after coronary procedures. Most patients (84.8%) underwent coronary procedures for urgent/emergent indications. The incidence of CIN was 44 out of 1010 (4.35%), with 17 out of 44 (38%) of CIN patients requiring dialysis. After adjusting for baseline differences, older patients, use of angiotensin-converting enzyme inhibitors, and oxygen use during the procedure were associated with a 20.6% increased risk of development of CIN. The risk of in-hospital mortality was significantly higher in the CIN group (29.5% vs. 1.8%).

Update on systemic vasculitides.

Management of systemic vasculitis has been revolutionised over the last decade with the introduction of targeted biological agents. With an increase in both the prevalence and the recognition of vasculitis as well as the high cost of these agents, it is important to ensure their most optimal utilisation. The goals of vasculitis therapy include the induction and maintenance of remissions, preventing relapses, reducing the toxicity of therapy with the aim of reducing morbidity and mortality as well as improving the quality of life of those afflicted. This review focuses on the recent advances in the diagnosis, surveillance and treatment of these conditions.

A case report of adrenocorticotropic hormone to treat recurrent focal segmental glomerular sclerosis post-transplantation and biomarker monitoring.

BACKGROUND: Recurrent focal segmental glomerular sclerosis (rFSGS) in renal transplant recipients (RTR) is difficult to predict and treat. Early rFSGS is likely from circulating factors and preformed antibodies. METHODS: We present the case of a 23-year-old white man who presented with rFSGS and acute renal failure, requiring dialysis 9-months after a 1-haplotype matched living-related transplant. We retrospectively analyzed serum samples from various clinical stages for rFSGS biomarkers: serum glomerular albumin permeability (Palb), soluble urokinase-type plasminogen activator receptor (suPAR) serum level with suPAR-ß3 integrin signaling on human podocytes, and angiotensin II type I receptor-antibody (AT1R-Ab) titer. RESULTS: All biomarkers were abnormal at 1-year pre-transplant prior to initiation of dialysis and at the time of transplant. After initiation of hemodialysis, ß3 integrin activity on human podocytes, in response to patient serum, as well as AT1R-Ab were further elevated. At the time of biopsy-proven recurrence, all biomarkers were abnormally high. One week after therapy with aborted plasmapheresis (secondary to intolerance), and high dose steroids, the Palb and suPAR-ß3 integrin activity remained significantly positive. After 12-weeks of treatment with high-dose steroids, rituximab, and galactose, the patient remained hemodialysis-dependent. Three-months after his initial presentation, we commenced adrenocorticotropic hormone (ACTH, Acthar(®) Gel), 80 units subcutaneously twice weekly. Four-weeks later, he was able to discontinue dialysis. After 8-months of maintenance ACTH therapy, his serum creatinine stabilized at 1.79 mg/dL with <1 g of proteinuria. CONCLUSION: ACTH therapy was associated with improvement in renal function within 4 weeks. The use of rFSGS biomarkers may aid in predicting development of rFSGS.

Clinicopathological course of acute kidney injury following brown recluse (Loxoscles reclusa) envenomation.

We report a case of severe systemic loxoscelism in a previously healthy young man. This was associated with a Coombs-positive hemolytic anemia, striking leukomid reaction, renal failure, respiratory failure and cardiovascular collapse. This is the first documented case of a renal biopsy in a patient with renal failure after envenomation by the brown recluse spider. Associated systemic toxicity usually resolves but requires prompt recognition and supportive care in an intensive care setting. We also discuss the potential mechanism by which the venom of this small spider can lead to multiorgan failure and possibly death.