Kidney medicine · 2026
Comparable Efficacy of Medium Cut-Off Dialysis Plus HA130 Hemoadsorption and Postfilter Hemodiafiltration in Removing Protein-Bound Uremic Toxins.
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Ramírez-Guerrero Gonzalo, Pedreros-Rosales Cristian, Cáceres María José, Saravia Katherine, Urizar Alejandra, Rojas Armando, Reis Thiago, Müller-Ortiz Hans, Ronco Claudio
Аннотация
RATIONALE & OBJECTIVE: Protein-bound uremic toxins, including indoxyl sulfate and p-cresyl sulfate, are poorly removed by conventional dialysis and contribute to cardiovascular, inflammatory, and neurological complications in end-stage kidney disease. Although postfilter hemodiafiltration enhances middle molecule clearance, its availability is limited. We evaluated whether combining medium cut-off dialysis with HA130 hemoadsorption achieves protein-bound uremic toxin removal comparable with that of optimized postfilter hemodiafiltration.
STUDY DESIGN: Prospective, single-center, parallel-group, single-session comparative study.
SETTING & PARTICIPANTS: Twenty anuric adult patients undergoing maintenance hemodialysis treated at a tertiary dialysis center were allocated to medium cut-off dialysis with hemoadsorption (n = 10) or postfilter hemodiafiltration (n = 10).
EXPOSURE: Expanded hemodialysis using a medium cut-off membrane combined with HA130 hemoadsorption versus postfilter hemodiafiltration.
OUTCOMES: Corrected reduction ratios of protein-bound uremic toxins (indoxyl sulfate, p-cresyl sulfate, carboxymethyllysine, and protein carbonyls) and middle molecules (β2-microglobulin, free light chains, prolactin, parathyroid hormone, soluble receptor for advanced glycation end-products).
ANALYTICAL APPROACH: Predialysis and postdialysis plasma concentrations were measured, and corrected reduction ratios were calculated after adjusting for hemoconcentration. Between-group comparisons were performed using nonparametric tests.
RESULTS: Corrected reduction ratios for key protein-bound uremic toxins were similar between medium cut-off dialysis with hemoadsorption and hemodiafiltration. Indoxyl sulfate corrected reduction ratios were 28.0% (IQR, 21.6-41.7) with medium cut-off dialysis with hemoadsorption and 26.0% (IQR, 22.5-37.9) with hemodiafiltration, while p-cresyl sulfate corrected reduction ratios were 31.8% (IQR, 23.9-37.4) versus 36.5% (IQR, 23.9-39.7), respectively (all P > 0.05). Carboxymethyllysine and protein carbonyl removal did not differ between modalities. In contrast, hemodiafiltration achieved higher corrected reduction ratios for conventional middle molecules, including β2-microglobulin and free light chains. Reduction of soluble receptor for advanced glycation end-products was modest and comparable across treatments.
LIMITATIONS: Small sample size, single-session design, and reliance on plasma reduction ratios without direct dialysate mass measurements.
CONCLUSIONS: In this exploratory study, medium cut-off dialysis with hemoadsorption achieved protein-bound uremic toxin removal similar to that of optimized postfilter hemodiafiltration, despite lower clearance of conventional middle molecules. Hybrid strategies integrating diffusion, convection, and adsorption may expand protein-bound uremic toxin removal options, particularly where hemodiafiltration is not feasible.
STUDY DESIGN: Prospective, single-center, parallel-group, single-session comparative study.
SETTING & PARTICIPANTS: Twenty anuric adult patients undergoing maintenance hemodialysis treated at a tertiary dialysis center were allocated to medium cut-off dialysis with hemoadsorption (n = 10) or postfilter hemodiafiltration (n = 10).
EXPOSURE: Expanded hemodialysis using a medium cut-off membrane combined with HA130 hemoadsorption versus postfilter hemodiafiltration.
OUTCOMES: Corrected reduction ratios of protein-bound uremic toxins (indoxyl sulfate, p-cresyl sulfate, carboxymethyllysine, and protein carbonyls) and middle molecules (β2-microglobulin, free light chains, prolactin, parathyroid hormone, soluble receptor for advanced glycation end-products).
ANALYTICAL APPROACH: Predialysis and postdialysis plasma concentrations were measured, and corrected reduction ratios were calculated after adjusting for hemoconcentration. Between-group comparisons were performed using nonparametric tests.
RESULTS: Corrected reduction ratios for key protein-bound uremic toxins were similar between medium cut-off dialysis with hemoadsorption and hemodiafiltration. Indoxyl sulfate corrected reduction ratios were 28.0% (IQR, 21.6-41.7) with medium cut-off dialysis with hemoadsorption and 26.0% (IQR, 22.5-37.9) with hemodiafiltration, while p-cresyl sulfate corrected reduction ratios were 31.8% (IQR, 23.9-37.4) versus 36.5% (IQR, 23.9-39.7), respectively (all P > 0.05). Carboxymethyllysine and protein carbonyl removal did not differ between modalities. In contrast, hemodiafiltration achieved higher corrected reduction ratios for conventional middle molecules, including β2-microglobulin and free light chains. Reduction of soluble receptor for advanced glycation end-products was modest and comparable across treatments.
LIMITATIONS: Small sample size, single-session design, and reliance on plasma reduction ratios without direct dialysate mass measurements.
CONCLUSIONS: In this exploratory study, medium cut-off dialysis with hemoadsorption achieved protein-bound uremic toxin removal similar to that of optimized postfilter hemodiafiltration, despite lower clearance of conventional middle molecules. Hybrid strategies integrating diffusion, convection, and adsorption may expand protein-bound uremic toxin removal options, particularly where hemodiafiltration is not feasible.