Neue Entwicklungen in der Dialysetechnik

Zusammenfassung

Die terminale Niereninsuffizienz geht mit einer Akkumulation von Urämietoxinen unterschiedlicher Größe, Hydrophilie und Proteinbindung einher. Lange Zeit waren Dialyseverfahren v. a. auf die Elimination niedermolekularer Urämietoxine mittels Diffusion ausgerichtet, während seit den 1980er-Jahren zunehmend die Konvektion mit einer verbesserten Elimination mittelmolekularer Moleküle in den Fokus rückte. Aktuelle Entwicklungen haben zum Ziel, diese historischen Dialyseprinzipien um elektromagnetische und adsorptive Mechanismen zu ergänzen und dabei Nebenwirkungen möglichst zu vermeiden. Neue nanotechnologische Verfahren bieten die Möglichkeit der Beschichtung von Dialysemembranen mit verschiedenen Substanzen und weitere Dialyseverfahren versuchen mittels hochkonzentrierter Natriumkonzentrationen die Elimination von proteingebundenen Substanzen zu verbessern. Neben diesen neuen Entwicklungen drängt sich aufgrund der unterschiedlichen, unspezifischen Adsorptionseigenschaften der bisher verwendeten Dialysematerialen die Frage auf, ob und – wenn ja – welche Dialysematerialien die Mortalität möglicherweise beeinflussen.

• Literatur

• 1 Depner TA, Vanholder R, Dhondt AM. et al. Is Kt/V urea a satisfactory measure for dosing the newer dialysis regimens?. Semin Dial 2001; 14: 8-21
• 2 Vanholder R, De Smet R, Lameire N. Protein-bound uremic solutes: the forgotten toxins. Kidney Int Suppl 2001; 78: S266-S270 doi:10.1046/j.1523–1755.2001.59780266.x
• 3 Eknoyan G, Beck GJ, Cheung AK. et al. Hemodialysis (HEMO) Study Group. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002; 347: 2010-2019 doi:10.1056/NEJMoa021583
• 4 Cheung AK, Rocco MV, Yan G. et al. Serum beta-2 microglobulin levels predict mortality in dialysis patients: results of the HEMO study. J Am Soc Nephrol 2006; 17: 546-555 doi:10.1681/ASN.2005020132
• 5 Ledebo I, Blankestijn PJ. Haemodiafiltration-optimal efficiency and safety. NDT Plus 2010; 3: 8-16 doi:10.1093/ndtplus/sfp149
• 6 Locatelli F, Martin-Malo A, Hannedouche T. et al. Membrane Permeability Outcome (MPO) Study Group. Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol 2009; 20: 645-654 doi:10.1681/ASN.2008060590
• 7 Maduell F, Moreso F, Pons M. et al. ESHOL Study Group. High-efficiency postdilution online hemodiafiltration reduces all-cause mortality in hemodialysis patients. J Am Soc Nephrol 2013; 24: 487-497 doi:10.1681/ASN.2012080875
• 8 Vanholder R, Schepers E, Pletinck A. et al. The uremic toxicity of indoxyl sulfate and p-cresyl sulfate: a systematic review. J Am Soc Nephrol 2014; 25: 1897-1907 doi:10.1681/ASN.2013101062
• 9 Schmidt S, Westhoff TH, Krauser P. et al. The uraemic toxin phenylacetic acid impairs macrophage function. Nephrol Dial Transplant 2008; 23: 3485-3493 doi:10.1093/ndt/gfn266
• 10 Scholze A, Jankowski V, Henning L. et al. Phenylacetic acid and arterial vascular properties in patients with chronic kidney disease stage 5 on hemodialysis therapy. Nephron Clin Pract 2007; 107: c1-c6 doi:10.1159/000105137
• 11 Vanholder R, Massy Z, Argiles A. et al. European Uremic Toxin Work Group. Chronic kidney disease as cause of cardiovascular morbidity and mortality. Nephrol Dial Transplant 2005; 20: 1048-1056 doi:10.1093/ndt/gfh813
• 12 Böhringer F, Jankowski V, Gajjala PR. et al. Release of uremic retention solutes from protein binding by hypertonic predilution hemodiafiltration. ASAIO J 2015; 61: 55-60 doi:10.1097/MAT.0000000000000166
• 13 Bergé-Lefranc D, Chaspoul F, Calaf R. et al. Binding of p-cresylsulfate and p-cresol to human serum albumin studied by microcalorimetry. J Phys Chem B 2010; 114: 1661-1665 doi:10.1021/jp9059517
• 14 Krieter DH, Devine E, Körner T. et al. Haemodiafiltration at increased plasma ionic strength for improved protein-bound toxin removal. Acta Physiol (Oxf) 2017; 219: 510-520 doi: 10.1111/apha.12730
• 15 Ronco C, Brendolan A, Winchester JF. et al. First clinical experience with an adjunctive hemoperfusion device designed specifically to remove beta 2-microglobulin in hemodialysis. Contrib Nephrol 2001; 133: 166-173
• 16 Pavlenko D, van Geffen E, van Steenbergen MJ. et al. New low-flux mixed matrix membranes that offer superior removal of protein-bound toxins from human plasma. Sci Rep 2016; 6: 34429 doi:10.1038/srep34429
• 17 Brettschneider F, Tölle M, van der Giet M. et al. Removal of protein-bound, hydrophobic uremic toxins by a combined fractionated plasma separation and adsorption technique. Artif Organs 2013; 37: 409-416 doi:10.1111/j.1525–1594.2012.01570.x
• 18 Böhringer F. Entwicklung klinischer Methoden zur vermehrten Abtrennung proteingebundener Urämie-Toxine im Rahmen einer extrakorporalen Therapie. Dissertation zur Erlangung des akademischen Grades des Doktors der Naturwissenschafteneingereicht im Fachbereich Biologie, Chemie, Pharmazie der Freien Universität Berlin 2013: 76 (Abb. 44)
• 19 Hakim RM. Influence of the dialysis membrane on outcome of ESRD patients. Am J Kidney Dis 1998; 32 (Suppl. 04) S71-S75
• 20 Krane V, Krieter DH, Olschewski M. et al. Dialyzer membrane characteristics and outcome of patients with type 2 diabetes on maintenance hemodialysis. Am J Kidney Dis 2007; 49: 267-275 doi:10.1053/j.ajkd.2006.11.026
• 21 Abe M, Hamano T, Wada A. et al. High-Performance Membrane Dialyzers and Mortality in Hemodialysis Patients: A 2-Year Cohort Study from the Annual Survey of the Japanese Renal Data Registry. Am J Nephrol 2017; 46: 82-92 doi:10.1159/000478032
• 22 Abe M, Kikuchi F, Kaizu K. et al. The influence of hemodialysis membranes on the plasma insulin level of diabetic patients on maintenance hemodialysis. Clin Nephrol 2008; 69: 354-360
• 23 Abe M, Okada K, Maruyama T. et al. Clinical evaluation of plasma insulin and C-peptide levels with 3 different high-flux dialyzers in diabetic patients on hemodialysis. Int J Artif Organs 2008; 31: 898-904
• 24 Zhang DL, Liu J, Cui WY. et al. Differences in bio-incompatibility among four biocompatible dialyzer membranes using in maintenance hemodialysis patients. Ren Fail 2011; 33: 682-691 doi:10.3109/0886022X.2011.589943
• 25 Locatelli F, Andrulli S, Viganò SM. et al. Evaluation of the Impact of a New Synthetic Vitamin E-Bonded Membrane on the Hypo-Responsiveness to the Erythropoietin Therapy in Hemodialysis Patients: A Multicenter Study. Blood Purif 2017; 43: 338-345 doi:10.1159/000453442
• 26 Huang J, Yi B, Li AM, Zhang H. Effects of vitamin E-coated dialysis membranes on anemia, nutrition and dyslipidemia status in hemodialysis patients: a meta-analysis. Ren Fail 2015; 37: 398-407 doi:10.3109/0886022X.2014.1001281
• 27 Laville M, Dorval M, Fort Ros J. et al. Results of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis. Kidney Int 2014; 86: 1260-1267 doi:10.1038/ki.2014.225
• 28 Meijers B, Metalidis C, Vanhove T. et al. A noninferiority trial comparing a heparin-grafted membrane plus citrate-containing dialysate versus regional citrate anticoagulation: results of the CiTED study. Nephrol Dial Transplant 2017; 32: 707-714 doi:10.1093/ndt/gfw461