Middle molecule clearance with high cut-off dialyzer versus high-flux dialyzer using continuous veno-venous hemodialysis with regional citrate anticoagulation: A prospective randomized controlled trial

PLoS One. 2019 Apr 26;14(4):e0215823. doi: 10.1371/journal.pone.0215823. eCollection 2019.

Abstract

Background: Regional anticoagulation with citrate during renal replacement therapy (RRT) reduces the risk of bleeding, extends dialyzer lifespan and is cost-effective. Therefore, current guidelines recommend its use if patients are not anticoagulated for another reason and if there are no contraindications against citrate. RRT with regional citrate anticoagulation has been established in critically ill patients as continuous veno-venous hemodialysis (CVVHD) to reduce citrate load. However, CVVHD is inferior regarding middle molecule clearance compared to continuous veno-venous hemofiltration (CVVH). The use of a high cut-off dialyzer in CVVHD may thus present an option for middle molecule clearance similar to CVVH. This may allow combining the advantages of both techniques.

Methods: In this prospective, randomized, single-blinded single-center-trial, sixty patients with acute renal failure and established indication for renal replacement therapy were randomized 1:1 into two groups. The control group was put on CVVHD using regional citrate anticoagulation and a high-flux dialyzer, while the intervention group was on CVVHD using regional citrate anticoagulation and a high-cut-off dialyzer. The concentrations of urea, creatinine, β2-microglobulin, myoglobin, interleukin 6 and albumin were measured pre- and post-dialyzer 1, 6, 12, 24 and 48 hours after initiating CVVHD.

Results: Mean plasma clearance for β2-microglobulin was 19.6±5.8 ml/min in the intervention group vs. 12.2±3.6 ml/min in the control group (p<0.001). For myoglobin (8.0±4.5 ml/min vs. 0.2±3.6 ml/min, p<0.001) and IL-6 (1.5±4.3 vs. -2.5±3.5 ml/min, p = 0.002) a higher mean plasma clearance using high-cut-off dialyzer could be detected too, but no difference for urea, creatinine and albumin could be observed concerning this parameter between the two groups.

Conclusion: CVVHD using a high cut-off dialyzer results in more effective middle molecule clearance than that with high-flux dialyzer.

Trial registration: German Clinical Trials Register (DRKS00005254, registered 26th November 2013).

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anticoagulants / pharmacology*
  • Citric Acid / pharmacology*
  • Continuous Renal Replacement Therapy / instrumentation*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • beta 2-Microglobulin / blood

Substances

  • Anticoagulants
  • beta 2-Microglobulin
  • Citric Acid

Associated data

  • DRKS/DRKS00005254

Grants and funding

Laboratory analyses, medical disposables and additional costs of material were funded by Fresenius Medical Care Deutschland GmbH, Else-Kröner-Straße 1, D-61352 Bad Homburg v.d.H. This is an investigator initiated trial. Design of the study, collection, analysis and interpretation of data as well as writing the manuscript were not influenced by the funding body and are the work of the authors alone. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.