Kidney international · 2026
A randomized cross-over trial of pre-and post-filter hemodiafiltration modalities in children on maintenance dialysis -- effects on solute removal and blood pressure.
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Agbas Ayse, Canpolat Nur, Ranchin Bruno, Schmitt Claus Peter, Flammier Sacha, Scwetlick Miriam, Stronach Lynsey, Waters Kathryn, Saygili Seha, Snauwaert Evelien, Eloot Sunny, Paglialonga Fabio, Prodam Flavia, Tini Sabrina, Çalıskan Salim, Shroff Rukshana
Аннотация
INTRODUCTION: Children on post-filter hemodiafiltration (post-HDF) have reduced cardiovascular damage and improved growth compared to conventional hemodialysis. High convection volumes in post-HDF are associated with improved outcomes. Even higher convection volumes can be reached with pre-filter HDF (pre-HDF). However, data is limited. Here, we compare the effect of pre- vs post-HDF on solute removal, inflammation, nutrition markers and blood pressure in a randomized, multicenter cross-over trial.
METHODS: After a four-week wash-out period in post-HDF, 24 children on maintenance dialysis were randomized either to four-weeks pre- then four-weeks post-HDF, or vice-versa, keeping all other dialysis related parameters constant. The primary outcome measure was reduction in α1-microglobulin, a large-middle molecular weight (MW) uremic retention solute.
RESULTS: Twenty-one patients completed the study. The median age was 15.1 years, with 15(71%) girls. Median convection volumes were 36.2 (inter quartile range 32;40) vs 14.3 (12.9;15.8) l/m2 body surface area per session in pre-HDF and post-HDF respectively. Pre-dialysis α1- microglobulin [median difference -17.0 ng/ml (95% confidence interval (CI) -27.0;-3.5)], ß2-microglobulin [-5.19 mg/l (95%CI -9.34;-1.76)] and myoglobin [-76.0 ng/ml (95%CI-100;-44.5)] concentrations were significantly lower, and reduction ratios (RR) were significantly higher in pre-HDF compared with post-HDF. Interleukin-10, tumor necrosis factor-α and high sensitivity C-reactive protein were significantly lower in pre-HDF. Pre-HDF achieved significantly higher RRs of total indoxyl sulfate and p-cresyl sulfate. The RR for small MW solutes, Kt/V and serum albumin did not differ meaningfully between modalities. Diastolic blood pressure was significantly higher in pre-HDF, correlating with higher replacement volume and higher post-dialysis serum sodium concentration.
CONCLUSIONS: Pre-HDF achieves superior removal of middle and larger-middle MW uraemic retention solutes and was associated with a more favorable inflammatory profile, without compromising small MW retention solute removal or albumin levels, compared to post-HDF. Pre-HDF may be associated with higher blood pressure in a sub-set of patients, potentially due to greater sodium load from higher replacement volumes.
METHODS: After a four-week wash-out period in post-HDF, 24 children on maintenance dialysis were randomized either to four-weeks pre- then four-weeks post-HDF, or vice-versa, keeping all other dialysis related parameters constant. The primary outcome measure was reduction in α1-microglobulin, a large-middle molecular weight (MW) uremic retention solute.
RESULTS: Twenty-one patients completed the study. The median age was 15.1 years, with 15(71%) girls. Median convection volumes were 36.2 (inter quartile range 32;40) vs 14.3 (12.9;15.8) l/m2 body surface area per session in pre-HDF and post-HDF respectively. Pre-dialysis α1- microglobulin [median difference -17.0 ng/ml (95% confidence interval (CI) -27.0;-3.5)], ß2-microglobulin [-5.19 mg/l (95%CI -9.34;-1.76)] and myoglobin [-76.0 ng/ml (95%CI-100;-44.5)] concentrations were significantly lower, and reduction ratios (RR) were significantly higher in pre-HDF compared with post-HDF. Interleukin-10, tumor necrosis factor-α and high sensitivity C-reactive protein were significantly lower in pre-HDF. Pre-HDF achieved significantly higher RRs of total indoxyl sulfate and p-cresyl sulfate. The RR for small MW solutes, Kt/V and serum albumin did not differ meaningfully between modalities. Diastolic blood pressure was significantly higher in pre-HDF, correlating with higher replacement volume and higher post-dialysis serum sodium concentration.
CONCLUSIONS: Pre-HDF achieves superior removal of middle and larger-middle MW uraemic retention solutes and was associated with a more favorable inflammatory profile, without compromising small MW retention solute removal or albumin levels, compared to post-HDF. Pre-HDF may be associated with higher blood pressure in a sub-set of patients, potentially due to greater sodium load from higher replacement volumes.