Comparison of High-Flux, Super High-Flux, Medium Cut-Off Hemodialysis and Online Hemodiafiltration on the Removal of Uremic Toxins

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Background: Middle molecules (MM) that are inadequately removed by highflux (HF) hemodialysis (HD) strategies are thought to contribute to the high morbidity and mortality of HD patients. On-line hemodiafiltration (OL-HDF) and HD using highperformance membranes such as adsorptive, medium cut-off (MCO), super high-flux (SHF) or protein permeable dialyzers have been implemented to enhance the removal of MM. The aim of this study was to compare the efficacy of these dialyzers used under different dialysis strategies on small solutes and MM reduction ratio (RR) and mass removal. Methods: We performed a prospective study in 8 HD patients. Each patient underwent 9 dialysis sessions: seven sessions on HD using either Theranova 500TM, Elisio 21HTM, Renak PS-2.0WTM, Filtryzer BK-2.1FTM, Vie 21XTM, TS-2.1ULTM or FDY 210-GWTM dialyzers and two sessions on OL-HDF using Elisio 21HTM or Renak PS-2.0WTM dialyzers. Results: Urea mass removal and RR were similar between all dialysis strategies. The lowest beta2-microglobulin RR was achieved with Filtryzer BK-2.1FTM HD (p<0.05). Compared to Elisio 21HTM HD, Renak PS-2.0WTM OL-HDF produced higher beta2-microglobulin mass removal (181±46 vs 317±161 mg, p<0.05). Theranova 500TM HD, Vie 21XTM HD, FDY 210-GWTM HD, Elisio 21HTM OL-HDF and Renak PS-2.0WTM OL-HDF induced higher RR for kappa and lambda FLC, as compared to Elisio 21HTM HD and Filtryzer BK-2.1FTM HD (p<0.05). TS-2.1ULTM HD and Renak PS-2.0WTM HD produced higher lambda FLC RR compared to Elisio 21HTM HD (p<0.05). Renak PS-2.0WTM OL-HDF achieved higher kappa FLC mass removal compared to Elisio 21HTM HD (563±515 vs 141±47 mg, p<0.01) and to Renak PS-2.0WTM HD (563±515 vs 153±25 mg, p<0.05). Albumin loss varied from 0.02±0.05 to 7.6±3.8 g/session with Elisio 21HTM HD and Renak PS-2.0WTM OL-HDF, respectively. Compared to all other strategies, Renak PS-2.0WTM OL-HDF induced a significantly higher albumin loss (p<0.05). Conclusions: This study confirms that albumin loss and the removal of MM, are similar using conventional Elisio 21HTM OL-HDF, MCO-HD (Theranova 500) and SHF type V dialyzers (Vie 21X and FDY 210-GW). Although Renak PS-2.0WTM OL-HDF provides high performance for MM depuration, this protein-permeable dialyzer should not be used in post-dilution OL-HDF because of albumin loss exceeding the theoretical acceptable limit of 5 g per session.

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