Online hemodiafilteration use in children: a single center experience with a twist.

BACKGROUND: Haemodiafilteration (HDF) is a promising new modality of renal replacement therapy (RRT). It is an improvement in the quality of hemodialysis (HD) and thus in the quality of patients'lives. The main obstacle to using HDF is the cost, especially in developing countries. The purpose of this study was to evaluate the benefits of incorporating HDF with different regimens in the treatment of children with end stage renal disease (ESRD). METHODS: Thirty-four children with ESRD on regular HD in Pediatric Dialysis Unit, Children's Hospital, Ain Shams University were followed up in 2 phases: initial phase (all patients: HD thrice weekly for 3 months) and second phase, patients were randomized into 2 groups, HDF group and HD group, the former was subdivided into once and twice weekly HDF subgroups. Evaluation using history, clinical and laboratory parameters at 0, 3, 9 and 18 months was carried out. RESULTS: On short term, we found that the HDF group was significantly superior to HD group regarding all clinical and laboratory parameters. Also, twice HDF subgroup was significantly superior to once HDF subgroup. This was confirmed on long term follow up, but the once HDF proved comparable to twice subgroup. CONCLUSIONS: Incorporating online hemodiafilteration (OL-HDF) in the RRT of children was beneficial in most of the clinical and laboratory parameters measured. It's not all or non; OL-HDF, even once a week, can improve outcomes of HD without significantly affecting the cost.

Predilution On-Line Hemodiafiltration Improves Albumin Redox in Maintenance Hemodialysis Patients.

BACKGROUND/AIM: In this study, we compared the dialysis efficiency, oxidative stress, and nutritional conditions between predilution on-line hemodiafiltration (pre-OL-HDF) and conventional hemodialysis (HD) using a super-flux dialyzer (CHD). METHOD: This was a crossover study of 38 maintenance HD patients. All patients were treated with CHD for the first 4 months (1st CHD period), then were switched to pre-OL-HDF for 4 months (pre-OL-HDF period), and were returned to CHD for the next 4 months (2nd CHD period). RESULTS: We found no significant difference in the removal ratio of small uremic substances or the indices of inflammation or nutritional states between the pre-OL-HDF and CHD periods. However, we found higher removal of ß2 micro-globulin in the pre-OL-HDF period, and the human mercapto-albumin (Alb)/human serum Alb ratio was significantly higher in the pre-OL-HDF period. CONCLUSION: Treatment with pre-OL-HDF enabled enhanced removal of middle molecule uremic toxins and better Alb redox than did CHD.

Are There Any Downsides, Barriers, or Challenges in Delivering Hemodiafiltration in Everyday Clinical Practice?

There is considerable evidence to suggest that on-line hemodiafiltration (HDF) is superior to standard hemodialysis when comparing effects on clinical end points, especially when a certain minimum convection volume can be achieved. In this chapter we address the question of whether there are any downsides, challenges, or barriers in delivering on-line HDF in everyday clinical practice. We discuss the subject from a medical/practical point of view and briefly from a financial/economic perspective.

Peritoneal dialysis for the management of pediatric patients with acute kidney injury.

Renal replacement therapy (RRT) is the most important supportive measure used in the management of acute kidney injury (AKI). Peritoneal dialysis (PD) is a safe, simple and inexpensive procedure and has been used in pediatric AKI patients, ranging from neonates to adolescents. It is the modality of choice for RRT in developing countries with cost constraints and limited resources. However, its use has declined with the availability of newer types of extracorporeal modalities for RRT in the developed world. Much controversy exists regarding the dosing and adequacy of PD in the management of AKI. Data in infants and children have shown that PD can provide adequate clearance, ultrafiltration and correction of metabolic abnormalities even in those who are critically ill. Although there are no prospective studies in children, data from retrospective studies reveal no differences in mortality rates between different modalities of RRT. In this review, we discuss the advantages and limitations of PD, indications for acute PD, strategies to improve the efficiency of acute PD and outcomes of PD in children with AKI.

What is the optimum dialysate flow in post-dilution online haemodiafiltration?

INTRODUCTION: In post-dilution online hemodiafiltration (OL-HDF), the only recommendation concerning the dialysate, or dialysis fluid, refers to its purity. No study has yet determined whether using a high dialysate flow (Qd) is useful for increasing Kt or ultrafiltration-infusion volume. OBJECTIVE: Study the influence of Qd on Kt and on infusion volume in OL-HDF. MATERIAL AND METHODS: This was a prospective crossover study. There were 37 patients to whom 6 sessions of OL-HDF were administered at 3 different Qds: 500, 600 and 700ml/min. A 5008(®) monitor was used for the dialysis in 21 patients, while an AK-200(®) was used in 17. The dialysers used were: 20 with FX 800(®) and 17 with Polyflux-210(®). The rest of the parameters were kept constant. Monitor data collected were effective blood flow, effective dialysis time, final Kt and infused volume. RESULTS: We found that using a Qd of 600 or 700ml/min increased Kt by 1.7% compared to using a Qd of 500ml/min. Differences in infusion volume were not significant. Increasing Qd from 500ml/min to 600 and 700ml/min increased dialysate consumption by 20% and 40%, respectively. CONCLUSIONS: With the monitors and dialysers currently used in OL-HDF, a Qd higher than 500ml/min is unhelpful for increasing the efficacy of Kt or infusion volume. Consequently, using a high Qd wastes water, a truly important resource both from the ecological and economic points of view.

Cost-Effectiveness Analysis of High-Efficiency Hemodiafiltration Versus Low-Flux Hemodialysis Based on the Canadian Arm of the CONTRAST Study.

AIM: The aim of this study was to assess the cost effectiveness of high-efficiency on-line hemodiafiltration (OL-HDF) compared with low-flux hemodialysis (LF-HD) for patients with end-stage renal disease (ESRD) based on the Canadian (Centre Hospitalier de l'Université de Montréal) arm of a parallel-group randomized controlled trial (RCT), the CONvective TRAnsport STudy. METHODS: An economic evaluation was conducted for the period of the RCT (74 months). In addition, a Markov state transition model was constructed to simulate costs and health benefits over lifetime. The primary outcome was costs per quality-adjusted life-year (QALY) gained. The analysis had the perspective of the Quebec public healthcare system. RESULTS: A total of 130 patients were randomly allocated to OL-HDF (n = 67) and LF-HD (n = 63). The cost-utility ratio of OL-HDF versus LF-HD was Can$53,270 per QALY gained over lifetime. This ratio was fairly robust in the sensitivity analysis. The cost-utility ratio was lower than that of LF-HD compared with no treatment (immediate death), which was Can$93,008 per QALY gained. CONCLUSIONS: High-efficiency OL-HDF can be considered a cost-effective treatment for ESRD in a Canadian setting. Further research is needed to assess cost effectiveness in other settings and healthcare systems.

Cost-effectiveness of hemodialysis in Japan.

Evaluation of the socioeconomic value of medical intervention and establishment of the resources necessary for clinical practice are important for continued development of the medical system. The purpose of this study was to investigate the cost-effectiveness of maintenance hemodialysis (MHD) for end-stage kidney disease in Japan. There were two aims: a socioeconomic evaluation of online hemodiafiltration (HDF) in the medical system and an analysis of MHD with respect to the primary diseases of chronic kidney disease. We performed a cost-effectiveness analysis based on quality-adjusted life years (QALY) and the incremental cost-effectiveness ratio (ICER). QALY were estimated using the EuroQOL-5 dimension. Reimbursement for medical fees in the national health insurance system was used as an indicator of costs. In a comparative analysis of hemodialysis and online HDF, a total of 288 dialysis interventions were observed for 4 weeks in 3 clinics. Among the subjects, nine patients were assigned to the HDF group. Consequently, the incremental cost-effectiveness ratio of HDF to hemodialysis was 20,589 ΔUSD/ΔQALY. In a comparative analysis of diabetic nephropathy and glomerulonephritis, seventeen patients (with a total of 243 dialysis sessions and a mean age of 63.2 ± 11.7 years) who underwent MHD for end-stage kidney disease (primary diseases: chronic glomerulonephritis [64.7%], diabetic nephropathy [35.3%]) were enrolled. After stratification for primary disease, the cost-effectiveness values for diabetic nephropathy were 88,774 ± 27,801 USD/QALY for 1 month and 97,416 ± 36,156 USD/QALY for 36 months. These results suggest that HDF is a cost-effective therapy. Additionally, the cost-effectiveness after 36 months of observation increased mainly among diabetic nephropathy patients.

Online-haemodiafiltration vs. conventional haemodialysis: a cross-over study.

BACKGROUND: The main short-term advantages of haemodiafiltration (HDF) are supposedly better removal of Beta2-microglobulin (ß2-m) and phosphate, and better haemodynamic stability. The main disadvantage is higher costs. The aim of the study was to compare the clinical and biological parameters associated with HDF and high-flux haemodialysis (HD), using a cross-over design, while maintaining the same dialysis parameters. METHODS: All patients on a 3 × 4 hours schedule were observed during 3 identical 6-months periods: HDF1 - HD - HDF2. The mean values for the 2 last months of each period were compared. RESULTS: A total of 51 patients (76 % males, 45 % diabetic) with a mean age of 74 ± 15 years, and who had been on dialysis for 49 ± 60 months were included. The mean blood flow (329 ± 27 ml/min), dialysate flow (500 ml/min), and convection volumes (21.6 ± 3.2 L) were recorded. Patient medications were not changed. Predialysis blood pressure, phosphataemia, calcaemia, iPTH, Kt/V, nPNA and intradialytic events were similar throughout the 3 periods. Only serum albumin (34. 4 ± 3.6, 35.9 ± 3.4, 34.1 ± 4 g/L, p < 0. 0001) and ß2-m serum levels (26.1 ± 5.4, 28 ± 6, 26.5 ± 5 mg/L, p < 0.001, values shown for HDF1, HD, HDF2, respectively) were significantly lower during the HDF periods. Factor associated with higher delta serum albumin levels between HD and HDF periods was mainly a lower convection volume. CONCLUSION: Comparing HDF and HD, we did not observe any differences in haemodynamic stability or in serum phosphate levels. Only serum ß2-m (-6% vs. HD) and albumin (-5% vs. HD) levels changed. The long-term clinical consequences of these biochemical differences should be prospectively assessed.

The cost-utility of haemodiafiltration versus haemodialysis in the Convective Transport Study.

BACKGROUND: Despite the growing interest in haemodiafiltration (HDF), there is no information on the costs and cost-utility of this dialysis modality yet. It was therefore our objective to study the cost-utility of HDF versus haemodialysis (HD). METHODS: A cost-utility analysis was performed using a Markov model. It included data from the Convective Transport Study (CONTRAST), a randomized controlled trial that compared online HDF with low-flux HD. Costs were estimated using a societal perspective. Probabilistic sensitivity analyses were performed to study uncertainty. RESULTS: Total annual costs for HDF and HD were €88 622±19,272 and €86,086±15,945, respectively (in 2009 euros). When modelled over a 5-year period, the incremental cost per quality-adjusted life year (QALY) of HDF versus HD was €287,679. Sensitivity analyses revealed that this amount will not fall below €140,000, even under the most favourable assumptions like a high-convection volume (>20.3 L). CONCLUSIONS: Based on accepted societal willingness-to-pay thresholds, HDF cannot be considered a cost-effective treatment for patients with end-stage renal disease at present. Apparently, minor additional costs of HDF are not counterbalanced by a relevant QALY gain.

[Online hemodiafiltration: is it really more expensive?]. / Hémodiafiltration en ligne : y a-t-il réellement un surcoût ?

Online hemodiafiltration has been shown to have many benefits in terms of morbi-mortality and to increase middle weight molecules removal. However, this technique is supposed to have an additional cost which may be an obstacle to increase its development in hemodialysis centers. The aim of the study is to achieve an accurate pharmaco-economic evaluation for determining the real overcost of online hemodiafiltration (OL-HDF) in comparison with high flux hemodialysis (HF-HD) using standard priming. We have identified the additional costs related to the consumables and monitors and the additional costs imposed by the technique itself (water consumption and microbiological analysis). In the center, more than 28,000 sessions per year are performed with 70% in OL-HDF (90% post-dilution). The consumable overcost ranges from -2.55 to +3.35 euros per session depending on the monitor and on the HDF modality. The overcost of microbiological analysis is +1.1 euros per session. The theoretical additional water consumption is calculated from different dialysat flow rates and OL-HDF modality. Its ranges from +50.8L to +74.8L per session increasing the water overcost from +0.15 to +0.23 euros per session. This accurate evaluation shows that the cost difference of OL-HDF depends on monitor used and on the OL-HDF modality. In our center, it ranges from -1.29 to +4.58 euros per session.

What can we expect from on-line hemodiafiltration?

On-line hemodiafiltration (ol-HDF) may improve clinical outcome in ESRD. The supposed mechanism is the improved clearance of uremic toxins by convective transport which is added to the diffusion transport. However, recent marked improvement in the performance of dialyzers has allowed higher removal rate of middle to large solutes by diffusion. It is inaccurate to define substances with a higher molecular weight such as uremic toxins. In addition, new methods should be developed for the removal of protein-bound substances. A technical fee for on-line HDF was newly established on the revision of the reimbursement for medical services Japan in 2012 and clearly separated from off-line HDF. As a facility requirement, the calculation of 'addition for maintaining dialysis fluid water quality' was added. Evidence for the clinical effects of ol-HDF have been reported mainly in Europe but is still inaccurate. To confirm the effectiveness of ol-HDF, randomized comparative trials on hemodialysis using super high-flux dialyzers and ol-HDF with same performance hemodiafilter are necessary.

What have we learned from CONTRAST?

The CONvective TRAnsport STudy (CONTRAST) is a large randomized controlled trial which compared on-line postdilution hemodiafiltration and low-flux hemodialysis in terms of mortality and cardiovascular events. This review summarizes and discusses currently available knowledge acquired by CONTRAST, including the main outcome, comparisons of hemodiafiltration to hemodialysis as well as studies performed in subgroups of CONTRAST.

The economic issue of on-line hemodiafiltration within the Japanese medical reimbursement system.

One major issue of Japan's health care system is that the Ministry of Health, Labor and Welfare (MHLW) centrally decides on the prices of medical services. Because of this, even if a treatment is deemed superior by the actual medical service provider, it may not be economically feasible to carry out. On-line hemodiafiltration has been reported to be an effective and favorable treatment modality, but the number of treated patients has declined since its approval in 2010 due to its low reimbursement price determined by MHLW. In this way, the problem with the Japanese medical reimbursement system is that MHLW's policy measures can thus affect the details of actual medical practices.

Cost-effectiveness analysis of on-line hemodiafiltration in Japan.

BACKGROUND/AIMS: Evaluation of the socioeconomic value of medical intervention and establishment of the resources necessary for clinical practice are important for new developments in medical technology. The aim of this study was to determine the socioeconomic value of on-line hemodiafiltration (HDF). METHODS: The subjects were 24 patients who underwent hemodialysis (HD) (9 HDF, 15 HD) for chronic renal failure. A total of 288 dialysis interventions were observed for 4 weeks in three clinics. Cost-effectiveness was evaluated based on quality-adjusted life years (Qaly) and a visual analog scale. RESULTS: EuroQOL-5D (0.776 ± 0.015) and visual analog scale (67.9 ± 1.2) in the HDF group were higher than those in the HD group at baseline. The incremental cost utility ratio for HDF was 641.7 (JPY 10,000/Qaly) based on Qaly (0.776 ± 0.015) and reimbursement for medical fees (JPY 4,982,736 ± 7,852), and was lower than the incremental cost utility ratio for HD. CONCLUSION: These results suggest that on-line HDF could be cost-effective.

Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration--a comparison between 2 citrate modalities and unfractionated heparin.

PURPOSE: To determine bioenergetic gain of 2 different citrate anticoagulated continuous hemodiafiltration (CVVHDF) modalities and a heparin modality. MATERIALS AND METHODS: We compared the bio-energetic gain of citrate, glucose and lactate between 29 patients receiving 2.2% acid-citrate-dextrose with calcium-containing lactate-buffered solutions (ACD/Ca(plus)/lactate), 34 on 4% trisodium citrate with calcium-free low-bicarbonate buffered fluids (TSC/Ca(min)/bicarbonate), and 18 on heparin with lactate buffering (Hep/lactate). RESULTS: While delivered CVVHDF dose was about 2000 mL/h, total bioenergetic gain was 262 kJ/h (IQR 230-284) with ACD/Ca(plus)/lactate, 20 kJ/h (8-25) with TSC/Ca(min)/bicarbonate (P < .01) and 60 kJ/h (52-76) with Hep/lactate. Median patient delivery of citrate was 31.2 mmol/h (25-34.7) in ACD/Ca(plus)/lactate versus 14.8 mmol/h (12.4-19.1) in TSC/Ca(min)/bicarbonate groups (P < .01). Median delivery of glucose was 36.8 mmol/h (29.9-43) in ACD/Ca(plus)/lactate, and of lactate 52.5 mmol/h (49.2-59.1) in ACD/Ca(plus)/lactate and 56.1 mmol/h (49.6-64.2) in Hep/lactate groups. The higher energy delivery with ACD/Ca(plus)/lactate was partially due to the higher blood flow used in this modality and the calcium-containing dialysate. CONCLUSIONS: The bioenergetic gain of CVVHDF comes from glucose (in ACD), lactate and citrate. The amount substantially differs between modalities despite a similar CVVHDF dose and is unacceptably high when using ACD with calcium-containing lactate-buffered solutions and a higher blood flow. When calculating nutritional needs, we should account for the energy delivered by CVVHDF.

Long-term efficacy of pre- and post-dilution online hemodiafiltration with dialyzer reuse.

OBJECTIVE: Growing evidence has demonstrated the potential survival benefit of online hemodiafiltration (HDF) over conventional hemodialysis (HD). Previous studies regarding online HDF utilized single-use dialyzer The present study was conducted to compare the long-term clinical parameters between pre- and post-dilution online HDF with the reuse dialyzer MATERIAL AND METHOD: This 2-year historical cohort study was conducted in 20 chronic hemodialysis patients who had undergone thrice-a-week pre-dilution online HDF for at least one year. The patients were switched to post-dilution online HDF for another year. Reuse dialyzers were utilized in both methods. RESULTS: No pyrogenic reactions had been detected throughout the 2-year study period. The C-reactive protein (CRP) and nutritional parameters were in good normal ranges. The normalization of protein equivalent of nitrogen appearance (nPNA) was significantly higher during the post-dilution period (1.25 +/- 0.22 vs. 1.11 +/- 0.14 g/kg/d, p < 0.01). Regarding adequacy of hemodialysis, the post-dilution online HDF showed significantly better Kt/V than the pre-dilution mode (2.46 +/- 0.35 vs. 2.35 +/- 0.35, p < 0.05) whereas the predialysis beta2-microglobulin levels were not different (23.43 +/- 5.35 vs. 23.73 +/- 5.55 mg/L, NS). The numbers of reuse were comparable (17.3 +/- 2.6 vs. 16.4 +/- 2.7, NS). CONCLUSION: Utilizing reuse dialyzer in online HDF could provide efficacy, safety, cost saving, and environmental benefit. The post-dilution technique yielded the better adequacy and nutritional status without causing the limitation in the reuse number and would be the standard mode-of-choice for online HDEF

Cost comparison of online haemodiafiltration with high-flux haemodialysis.

INTRODUCTION: Haemodiafiltration increases convective clearances, and online haemodiafiltration (OL-HDF) was introduced to reduce costs of producing large volumes of ultrapure water. Previous reports have suggested that OL-HDF may be a cost-saving therapy by reducing recombinant human erythropoietin requirements and those for other medications. We therefore costed OL-HDF with high-flux haemodialysis. METHODS: Thirty-four patients dialysing (Tue/Thu/Sat) switched to OL-HDF, and 44 dialysing (Mon/Wed/Fri) remained on high-flux haemodialysis (HD) in a satellite dialysis centre. They were then prospectively followed for 12 months. RESULTS: Depending upon whether blood lines with a cuvette for measuring relative blood volume were used, OL-HDF was either slightly more expensive per session, by £1.16, as the cost of the reinfusion line outweighed any potential savings in 0.9% saline usage, or cheaper by £0.78 if standard blood lines were used. Although there were initial increased costs for more frequent testing of dialysis machine water quality. It could be argued that similar water quality is required for high-flux haemodialysis using dialysers with increased internal filtration. There was no cost saving in terms of recombinant human erythropoietin prescription, but whereas weekly phosphate binder costs increased in the high-flux haemodialysis cohort from £3.8 (range 1.9-14.8) to £5.0 (range 1.9-21.3; p=0.01), costs did not change with OL-HDF (£3.8, range 1.9-11.9). CONCLUSION: Depending upon the choice of blood lines, OL-HDF was either a slightly more expensive or a cheaper treatment per session compared with high-flux haemodialysis in our centre. Treatment with OL-HDF also led to modest cost savings on phosphate binders.