**Influence of Online Hemodiafiltration on Hemoglobin Level, ESA-Dosage and Serum Albumin – A Retrospective, Multicenter Analysis**

Roland E. Winkler, Peter Ahrenholz and Klaus Freivogel *Praxisverbund für Dialyse und Apherese, Rostock, BioArtProducts GmbH, Rostock, Analytica International GmbH, Lörrach,* 

*Germany* 

### **1. Introduction**

160 Progress in Hemodialysis – From Emergent Biotechnology to Clinical Practice

Vanholder, R., Laecke, S. V., Verbeke, F., Glorieux, G. & Biesen, W.V. (2008). Uraemic toxins

Vanholder, R. (2009). Effect of membrane permeability on survival of hemodialysis patients,

*Plus*, 1, pp. 2-10

*J Am Soc Nephrol*, 20, pp. 645–654

and cardiovascular disease: in vitro research versus clinical outcome studies, *NDT* 

In renal replacement therapy (RRT) a wide range of uremic toxins have to be removed (Vanholder et al., 2003; Vanholder et al., 2008). It is well known that the combination of diffusive and convective dialysis strategies (online hemodiafiltration, olHDF) improves the removal of uremic toxins, i.e. middle molecules, hydrophobic substances and protein (albumin) bound materials (Krieter et al., 2005; Ahrenholz et al., 2004; Ronco et al., 1999; Kim, 1994; Testa et al., 2006; Meyer et al., 2005; Mandolfo et al., 2006; Kanter et al., 2008). In the presence of ultrapure dialysis fluid which is ultrafiltrated by endotoxin restraint systems (Weber et al., 2000; Canaud et al., 2001; Minetti et al., 1985; Hakim et al., 1984) and biocompatible high flux dialysis membranes the convective diffusive treatment significantly prevents the complement activation (Braun et al., 1995; Savica et al., 2006; Jorres et al, 1999; Hörl et al., 1986) in the first minutes of olHDF session and removes proinflammatory substances (cytokines) too (Bellomo et al., 1991; Filiopoulos et al., 2008; Haas et al., 2007; Libetta et al., 2007; Mariano et al., 2005). The intra and interdialytic inflammations are reduced (Ramirez et al., 2007; Ramirez et al., 2007; Carracedo et al., 2006). The suppressed inflammatory process during olHDF leads to an increasing serum albumin concentration via an increased synthesis rate. In spite of a varying albumin removal caused by different dialysis membranes with/without adsorptive character and pore size (Pichaiwong et al., 2006; Yamashita, 2007; Tomo et al., 2008; Winchester et al.,2003; Winchester et al., 2004) the albumin synthesis rate increases by absent inflammation (Giordano et al., 2001). It is shown that in olHDF the ESA dosage needed to reach the hemoglobin goal is reduced (Vaslaki et al., 2006; Bonforte et al., 2002; Eiselt et al., 2000). The efficacy of dialysis measured by single pool Kt/V could be improved (Ahrenholz et al., 1997; Ding et al., 2002). There is evidence of longer survival of patients treated by olHDF versus hemodialysis (HD) independently of dialysis dosage (Canaud et al., 2008; Panicchi et al., 2008). The cycling of hemoglobin levels depends on inflammatory episodes and malnutrition (Del et al., 2005; Brimble et al., 2005). This retrospective, non randomized, multicentre, descriptive clinical evaluation examined the influence of olHDF on hemoglobin concentration (Hb), ESA dosage (ESA), Hb variability (Hbvar), albumin and CRP.

Influence of Online Hemodiafiltration on Hemoglobin Level,

Table 2. Mean weekly ESA dosage

**Total** 

**mmol/l** 

Table 3. Mean Hb concentrations

ESA-Dosage and Serum Albumin – A Retrospective, Multicenter Analysis 163

**All patients N** 94 35 104 233

**Patients with at least one ESA dosage N** 57 31 97 185

In nearly all patients (98.9%) an adjustment of ESA dosage was essential. Relevant changes in ESA dosages were defined as an elevation greater than two fold and lowering of a half of the ESA dosage, the end of ESA application or the start with more than 4200 U/week. The mean value of Hb (measured per patient over the whole study time) was 7.35 mmol/l (Table 3). In patients without ESA application during the 12 months study the mean value of Hb was larger (7.66 mmol/l) in comparison to patients with ESA dosage (7.27 mmol/l).

**Patients** <sup>37</sup> <sup>4</sup> 7 48 **without ESA Mean Hb N** 

**At least one ESA dosage Mean Hb N** 57 31 97 185

**Dialysis unit** 

**Mean** 3550 5934 9177 6420 **SD** 4443 5316 8487 7129 **Min** 0 0 0 0 **Median** 1577 5077 6500 4692 **Max** 18667 26769 46538 46538

**Mean** 5855 6700 9840 8086 **SD** 4365 5170 8409 7109 **Min** 231 167 308 167 **Median** 4714 5538 6769 6231 **Max** 18667 26769 46538 46538

**Dialysis unit** 

**Mean** 7.63 7.76 7.74 **7.66 SD** 0.46 0.61 0.63 0.49 **Min** 6.7 6.9 7.2 6.7 **Median** 7.5 8.0 7.5 7.5 **Max** 8.8 8.3 8.8 8.8

**Mean** 7.38 7.09 7.25 **7.27 SD** 0.41 0.52 0.53 0.50 **Min** 6.2 6.0 5.1 5.1 **Median** 7.5 7.2 7.4 7.4 **Max** 8.6 8.4 8.3 8.6

**Mean** 7.48 7.17 7.29 **7.35 SD** 0.44 0.57 0.55 0.52 **Min** 6.2 6.0 5.1 5.1 **Median** 7.5 7.2 7.4 7.4 **Max** 8.8 8.4 8.8 8.8

**Mean Hb N** 94 35 104 233

**1 2 3 Total** 

**1 2 3 Total** 
