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**6** 

*USA* 

Lee, Kyungsoo

**Pulse Push/Pull Hemodialysis:** 

*University of Michigan, Ann Arbor, and AnC Bio Inc.* 

**Convective Renal Replacement Therapy** 

The incidence of kidney disease is rapidly increasing worldwide, fueled by the increasing incidences of diabetes and obesity (Centers for Disease Control and Prevention, 2010), and thus, more patients with hypertension and diabetes develop end-stage renal disease (ESRD). Maintenance hemodialysis has become an established protocol for treating ESRD patients. This process is facilitated by two physical phenomena that facilitate mass transfer in purifying blood during maintenance hemodialysis. Diffusion caused by a concentration gradient between blood and dialysate contributes to the removal of uremic solutes, particularly small-size molecules. The removal of excess body water and mid-size molecules depends primarily on convective mass transfer, which results from hydraulic and osmotic

Remarkable improvements have been made in the technologies used for renal supportive dialysis treatment in ESRD patients. Polymeric membranes better prevent the transfer of pyrogenic substances into the blood stream and membrane biocompatibilities are much improved (Weber et al., 2004). The sharp molecular cut-offs of these membranes also prevent further loss of albumin during high-dose convective treatment (Ahrenholz et al., 2004). Narrow pore size distributions and improved hydraulic properties in the membrane field are matched by the evolution of various modalities for renal supportive treatment. Furthermore, better outcomes achieved by convective treatment have encouraged the use of synthetic membranes with high water permeability and sieving characteristics in clinical setups (Woods & Nandakumar, 2000), to the extent that hemodiafiltration (HDF) and volume-controlled highflux hemodialysis (HD) are now regarded as preferred forms of convective therapy, because the retention of middle to large-sized molecules by chronic renal failure patients is closely

Volume-controlled high-flux HD adequately clears mid-size solutes without sterile fluid infusion. Forward filtration exceeding desired volume removal is compensated for by backfiltration (Ofsthun & Leypoldt, 1995), and thus, this modality can provide a simpler form of dialysis treatment than other treatment methods. The convective dose delivered during high-flux HD has been shown to reduce mortality in patients at risk, as defined by a serum albumin level of <4 g/dl (Locatelli et al., 2009). However, overall patient survival remains comparable to that of low-flux HD (Eknoyan et al., 2002), which presumably is caused by the limited amount of internal filtration involved due to limitations imposed by

**1. Introduction** 

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