Effect of hemoperfusion plus hemodialysis on uremic toxins and anemia in patients with maintenance hemodialysis.

Objectives: This study aimed to compare the clearance of middle-molecular and protein-bound toxins among high-flux hemodialysis (HFHD), hemodiafiltration (HDF), and hemoperfusion combined with HD (HP-HD), and assess the impact of HP-HD on anemia management in patients with maintenance hemodialysis (MHD). Methods: This prospective single-arm interventional study involved 39 stable MHD patients. We evaluated the serum levels of intact parathyroid hormone (iPTH), β2-microglobulin (β2-MG), hepcidin, hippuric acid (HA), indoxyl sulfate (IS), and p-cresyl sulfate (pCS) before and after individual sessions of HFHD, HDF, and HP-HD, separately. Linear mixed-effects model with Tukey-adjusted comparisons was applied to compare the effects of three modalities on intra-dialysis reduction ratios (RRs). Results: Both HP-HD and HDF achieved greater RRs of iPTH, β2-MG, hepcidin, HA, and IS than HFHD (all p < 0.05), with no significant difference between HP-HD and HDF (all p > 0.05). Unlike the former five toxins, HP-HD performed better than HFHD in removing pCS (41.48 vs. 29.76%, p = 0.044), while HDF was not superior to HFHD (34.73 vs. 29.76%, p = 0.16). After the 6-month treatment with HP-HD weekly, the anemia and nutritional status were improved significantly, indicating by increasing hemoglobin (p = 0.006) and albumin (p = 0.043), and decreasing erythropoiesis-stimulating agent (ESA) resistance index (ERI) (p = 0.032). Conclusions: Our findings suggested that the HP-HD might perform best in eliminating pCS, and HP-HD and HDF achieved equal clearances of middle-molecular toxins. The integrated blood purification protocol might improve anemia and nutritional status in MHD patients.