**6. References**


Because albumin is a negative acute phase protein we can, in general, expect higher concentrations at lower inflammation (Panicchi et al., 2006; Kaysen et al., 1997). However, none-biocompatible membranes and partly low flux hemodialysis increases proinflammatory cytokines such as TNF-alpha. Ultrapure dialysis fluid is of relevant importance to prevent inflammation (Panicchi et al., 2008). On the other hand complement activation plays a role for inflammation during the dialysis sessions therefore biocompatible membranes are urgently necessary (Hakim et al., 1984). In the olHDF method as use in this study, both ultrapure dialysate and biocompatible membrane materials were used, enabling clear attenuation of procedure-associated inflammatory processes. This attenuation of inflammation to us seems the key factor for increased albumin production that even makes up for procedure-associated albumin losses. The nutritional situation (nPCR) has only a secondary influence (Savica et al., 2006; Stenvinkel, 2005). Hbvar also depends on inflammation and albumin concentration (Brimble et al., 2007). Hbvar in olHDF is lower

than in HD because of less inflammation and higher concentration of albumin.

In a retrospective, descriptive, multicentre study the influence of olHDF on Hb Level, ESA dosage and Hbvar was evaluated. 233 patients were included in the clinical analysis in three dialysis departments (D1 n=94; D2 n= 35, D3 n= 104). Mean dialysis efficacy expressed as spkt/V by Daugirdas was comparable in all dialysis units. We found differences in the frequency of olHDF in the dialysis departments followed by varying parameters of inflammation (CRP) and nutrition (albumin). It can be demonstrated that patients who underwent olHDF showed the highest serum albumin levels and the lowest signs of inflammation (CRP). This combination leads to significantly higher Hb concentrations and surprisingly lower ESA dosages to reach the target Hb in ol HDF vs HD. Due to the reduced inflammation Hbvar was improved in olHDF vs HD. There is a correlation between serum albumin concentration, Hb level and ESA dosage. OlHDF could be the gold standard for prevention of inflammation because of removal of proinflammatory substances and hydrophobic and protein bound uremic toxins. OlHDF influences positively inflammation, nutrition, Hb level, Hb variability and required ESA dosage in chronic renal replacement

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**5. Conclusions** 

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line sequential hemodiafiltration (HDF-OL-S): a new therapeutic option*. Nefrologia*.


Patients with chronic kidney disease and patients on renal replacement therapy, such as hemodialysis and peritoneal dialysis, have an increased susceptibility to infectious diseases compared with healthy subjects (Sarnak & Jaber 2000; Allon et al. 2003). Infection is also the second most common cause of morbidity and mortality in patients with end-stage renal

One contributing factor could be the chronic inflammatory activation seen in patients with chronic kidney disease and patients on dialysis, which causes a refractoriness of leukocytes

The immune system is designed to defend us from invading microorganisms, such as viruses and bacteria. The first response is called the innate immune response, mostly dependent on recruitment and activation of neutrophils (Parkin & Cohen 2001). Complement activation occurs on the bacterial cell surface, triggering a cascade of proteolytic reactions that are specific in so far as they act on microbial surfaces but not on host cells. Neutrophils have receptors both for common bacterial constituents and for complement. Neutrophils become activated through complement (C3b and C5a) but can also get activated directly by bacterial peptides, such as lipopolysaccharide, lipotechoic acid, mannans and fMLP (N-formylmethionyl leucyl phenylalanine) (Parkin & Cohen 2001). Activation of neutrophils occurs in several steps, comprising both priming and further activation, and is necessary for neutrophils to perform their specific actions at the inflammatory sites: phagocytosis and release of inflammatory mediators (Swain et al. 2002). Neutrophils are effector cells of great importance in the innate immune system. An impaired neutrophil function leads to several dysfunctions in the defense against invading microorganisms. Neutrophils have previously been regarded as wholly differentiated and static cells whose function is based on preformed receptors and soluble factors, and solely part of the innate immune system. This idea has been challenged by publications that show a high gene transcriptional activity following both activation and extravasation (Theilgaard-Monch et al. 2006). The transcriptional activation occurs at the inflammatory site and engages genes involved in multiple neutrophil functions, such as production of reactive oxygen species, hydrogen peroxide, cytokines and chemokines (Theilgaard-Monch et al. 2004; Coldren et al. 2006). Neutrophils direct both innate and adaptive immune responses,

disease (Bloembergen & Port 1996; Powe et al. 1999; Graff et al. 2002).

when confronted with invading microorganisms.

**1.1 The innate and adaptive immune responses** 

**1. Introduction** 

Jenny Olsson

*Sweden* 

*Department of Nephrology and Transplantation* 

*Skåne University Hospital, Malmö,* 

Yamashita, A.C. (2007). Mechanisms of solute and fluid removal in hemodiafiltration. *Contrib Nephrol*. Vol.158: 50- 56 **9** 
