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Convective Therapies in the Treatment of CKD Stage 5 Patients: to Be or Not to Be Convincing (pp. 125-162) $100.00
Authors:  (José Carolino Divino-Filho and Ikuto Masakane)
Diffusion has been extensively applied for removal of uremic toxins since the
primordials of dialysis; this meaning that the clearance of an uremic toxin is inversely
correlated to its molecular weight. In contrast, convection mimics the natural filtration
process of the glomerulus, with solutes passing through the membrane, but within a range
given by the membrane properties, relatively independently of their molecular weight. In
the 60s, Belding Scribner made an observation that patients maintained on intermittent
peritoneal dialysis did remarkably well clinically, even though peritoneal dialysis was
much less efficient than hemodialysis at removing the commonly considered uremic toxins
of small molecular weight, such as urea. The longer treatment time (24 hours or longer)
presumably permitted the slowly diffusing middle molecular weight solutes to be
adequately removed. This “speculation” gave birth to the idea by Lee Hendersson and
Lewis W. Bluemle that convection would provide a superb tool to test the importance of
the “middle molecule” hypothesis, and possibly might offer a new treatment modality for
uremia. The first article on blood cleansing by convection (diafiltration) in uremic dog and
man was published in the USA in 1971 by L. Hendersson et al., whereas E. Quellhorst in
Germany published his in-depth clinical application of postdilution hemofiltration using
AN-69 membrane and fluid cycling equipment of his own design. The use of convective
therapies throughout the 70s, 80s, and early 90s was mostly limited by the costs and
complexity of the treatment and the lack of trials which could scientifically confirm the
efficiency and efficacy of the convective therapies. Only sterile and pyrogen-free solutions
can be used for convective transport therapies; delivering better efficiency as higher
replacement convective volumes are infused directly in the blood stream. Differently from
its predecessors and pioneers, the dialysis community nowadays relies mostly on the results
of randomized, controlled trials in order to accept new dialyisis options and especially
focuses on survival as most important outcome. Some studies have recently compared
online hemodiafiltration/hemofiltration to conventional hemodialysis and shown that the
therapy is safe, with good clinical results, and decreases overall and cardiovascular
mortality. New convective therapies delivery technology integrated into the hemodialysis
instruments, novel high-flux membranes, and the advent of online, membrane produced
intravenous quality solution have made the costs, efficiency, and safety of
hemodiafiltration and hemofiltration, at least, comparable to hemodialysis.
Hemodiafiltration is the most rapidly growing modality of chronic renal replacement
therapy in Europe today whereas in Japan, one-fourth of all patients in hemodialysis are
treated by convective therapies (about 75 thousand patients). The success of high-quality
dialysis in Japan is directly associated to providing a good individualized dialysis
prescription and by simply listening to the patient’s feelings. There is a need to better
understand how convective therapies can be utilized up to their full efficiency for each
individual patient, as well as to apply patient-centered outcome reports as an extremely
important tool in the prescription process and therapy success evaluation. It seems that the
need is to convince the dialysis medical community, and not the patients, about the positive
outcomes of the convective therapies. 

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Convective Therapies in the Treatment of CKD Stage 5 Patients: to Be or Not to Be Convincing (pp. 125-162)