The Effect of Hemodiafiltration on Inflammatory Biomarkers in Comparison to High Flux Dialyzers in Prevalent Hemodialysis Patients
Authors: Mady Gamal Elsayed , Bichari Walid Ahmed , Abdelgawad Mostafa Abdelnassier , Khedr Lina Essam , Rezk Khaled Mohamed , Attya Walid Abdalla 
Published: October 2021

Abstract

Introduction
Inflammation in patients with ESRD undergoing HD is an increasing concern for physicians and has been related to increase the rates of morbidity and mortality. Interestingly, patients with ESRD in conventional HD have frequent infections and a suboptimal response to vaccines; this is probably related to an immune inflammatory disorder associated either with uremia and/or nutritional status. In addition to CRP, which seems to be the most important marker for the identification and control of inflammation in clinical practice, many other markers are also available for the evaluation of inflammatory state. Decreased renal clearance clearly accounts for higher levels of circulating cytokines, although increased production has also been described. Hemodiafiltration has been shown to improve cardio-protection and the immunologic system and reduces infection and mortality compared with conventional HD. A recent study showed that hemodiafiltration compared with conventional HD reduced the risk of mortality in ESRD patients. Analysis of pooled individual participant data from randomized controlled trials has shown survival benefits of high volume-HDF on all-cause mortality and especially cardiovascular mortality rate. The mechanisms that lead to improved outcomes are not clear, but it is thought that HDF may reduce the production of inflammatory mediators through the use of biocompatible dialysers and ultrapure dialysate and also improve clearance of larger molecular weight substances, many of which are associated with oxidative stress, inflammation and endothelial dysfunction.

Objective
The aim of this study is to detect, prospectively, the effect of 3 months dialysis with Hemodiafiltration on inflammatory and nutritional biomarkers in comparison to conventional dialysis with high flux dialyzer in stable HD patients.

Patients and methods
30 adults aged 20-75 years who were selected from Dialysis Unit, Kobary El-Kobba Military Hospital. 30 male patients known to have chronic kidney disease and are on dialysis with high flux dialyzer more than 3 months were divided into 2 groups:15 Patients are shifted to be on dialysis with HDF and 15 Patients are continued to be on Regular Hemodialysis with high flux dialyzer. Full medical history and clinical examination. Anthropometric measurements and Laboratory investigations including Complete Blood Picture (WBCs, platelets, Hb), Coagulation profile PT, PTT&INR, Liver function tests (ALT, AST, T. Bilirubin and S. Albumin), Lipid profile (Triglycerides, total cholesterol, VLDL), S. creatinine, BUN, Na, K, Uric acid, Total Proteins, Serum Calcium, Serum Phosphorus, PTH, Serum ferritin, High sensitivity CRP (Enzyme- Linked Immunosorbent Assay (ELISA)) and IL6 (ELISA).

Results
The current study was conducted on 30 patients with chronic kidney disease on regular dialysis. The patients were divided into two groups A representing patients on hemodiafiltration (n = 15) and group B representing patients on dialysis with high flux dialyzer (n = 15). A high statistical significant difference (P &lt; 0.01) was found regarding K 4.3±0.6 meq/l in group A while it is 5.2±0.5 meq/l in group B, a high statistical significant difference (P &lt; 0.01) was found regarding phosphorus 4.6±1.0 mg/dl in group A while it is 6.1±0.9 mg/dl in group B and no statistical significant difference (P &gt; 0.05) was found as regard the uric acid. A statistical significant difference (P &lt; 0.05) was found regarding CRP 63.5±40.9 mg/dl in group A while it is 73.4±33.2 mg/dl in group B, a statistical significant difference (P &lt; 0.01) was found regarding IL6 85.3±37.6 mg/dl in group A while it is 156.7±151.9 mg/dl in group B after 3 months and no statistical significant difference (P &gt; 0.05) was found as regard those inflammatory markers before 3 months. A statistical significant difference (P &lt; 0.05) was found regarding CRP. A statistical significant difference (P &lt; 0.05) was found regarding IL6.

Conclusion
The present study revealed that there was no significant change in CRP and IL6 in patients on HDF compared to patients undergoing hemodialysis with high flux dialyzer before 3 months but there was a significant decrease in CRP and IL6 in patients on HDF compared to patients undergoing hemodialysis with high flux dialyzer after 3 months.