title: On-line mixed hemodiafiltration with a feedback for ultrafiltration control: effect on middle-molecule removal.
abstract: BACKGROUND
  Increased middle-molecular uremic toxin removal seems to favorably influence survival in dialysis patients. The aim of this study was to verify if, in on-line mixed hemodiafiltration, solute removal by convection may be enhanced by forcing the ultrafiltration rate (QUF) and optimizing the infusion technique in order to achieve the highest possible filtration fraction (FF).
  
  
  METHODS
  Removal of beta2-microglobulin (beta2-m), urea, creatinine, and phosphate were compared in 20 patients randomly submitted to one dialysis session (A), one postdilution hemodiafiltration session (B), and three sessions of mixed hemodiafiltration (C, D, and E) at different infusion rates (QS). In mixed hemodiafiltration, a newly developed feedback system automatically maintained the transmembrane pressure (TMP) within its highest range of safety (250 to 300 mm Hg) at constant QUF, while ensuring the maximum FF by splitting infusion between pre- and postdilution.
  
  
  RESULTS
  A mean QS of 134 +/- 20 mL/min (mean FF = 0.65) was attained in post-HDF, and up to 307 +/- 41 mL/min (mean FF = 0.69) in mixed hemodiafiltration. The mean dialysate clearances (KDQ) for all tested solutes and urea eKt/V were significantly higher in all hemodiafiltration sessions than in dialysis. Only in the case of urea did the infusion mode have no significant effect. KDQ for beta2-m was maximal in session D and significantly higher than in session B (90.2 +/- 11 mL/min vs. 77.5 +/- 11 mL/min; P = 0.02). KDQ for beta2-m significantly correlated with QS and the plasma water flow rate (QPW). The highest KDQ for beta2-m was found at values of QS approximately QPW. Beyond this value KDQ decreased.
  
  
  CONCLUSIONS
  The mixed infusion mode in hemodiafiltration, controlled by the TMP-ultrafiltration feedback, seems to improve the efficiency of hemodiafiltration by fully exploiting the convective mechanism of solute removal. The feedback automatically adjusted the infusion rate and site to the maximum FF taking into account flow conditions, internal pressures, and hydraulic permeability of the dialyzer and their complex interactions.
authors.affiliation: Nephrology and Dialysis Department, Bolognini Hospital of Seriate, Bergamo, Italy. nefrologia.seriate@bolognini.bg.it
authors.forename: Luciano A
authors.initials: LA
authors.lastname: Pedrini
authors.forename: Vincenzo
authors.initials: V
authors.lastname: De Cristofaro
mesh_terms: D000368:Aged; D003404:Creatinine / Q000097:blood; D025461:Feedback, Physiological; D005260:Female; D017583:Hemodiafiltration / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D010710:Phosphates / Q000097:blood; D013813:Therapy, Computer-Assisted; D014508:Urea / Q000097:blood; D001613:beta 2-Microglobulin / Q000097:blood
chemical_list: D010710:Phosphates; D001613:beta 2-Microglobulin; D014508:Urea; D003404:Creatinine