The Application of Different Regimens of Online Hemodiafiltrationon Egyptian Children with Chronic Renal Failure on Regular Hemodialysis

Abstract

HDF is a new treatment modality for ESRD patients that expands the spectrum of uremic toxin removal from small-sized solutes to middle-sized and large molecular weight solutes by combining convective clearance. It has been proved superior to HD in many aspects, anemia correction, phosphorus clearance, suppression of inflammation and hemodynamic stability. However,its use is very limited in developing countries due to its high costs. Aim of this study was toevaluate the benefits versus costs of substitution of once or twice weekly HD sessions with HDF ones, in pediatric population In this sequential clinical follow up study, 34 pediatric patients with ESRD on regular hemodialysis in the Pediatric Dialysis Unit, Children's Hospital, Ain Shams University were followed up on 2 phases: initial phase (all patients on HD trice weekly for 3 months) and second phase, all patients were randomized into 2 groups, HDF group and HD group, the former was subdivided into once weekly HDF subgroup and twice weekly HDF subgroup. They were evaluated by clinical, laboratory, costs and cost benefit ratio at 0, 3, 9 and 18 months. On short term, the current study found that the HDF group, compared to HD group showed statistically difference in percentage change of weight SDS, height SDS, post dialysis fatigue frequency, Hb, P, PTH, IL-6, CRP, Kt/V, Epo dose/kg, Epo/Hct ratio, dialysis costs, non-dialysis costs and net costs. Also, on short term, the currentstudy found that the once subgroup, compared to twice subgroup showed statistically difference in percentage change of post dialysis fatigue frequency, Hb, PTH, IL-6, CRP, Kt/V, dialysis costs, non-dialysis costs and net costs. On long term, the current study found that the HDF group, compared to HD group showed statistically difference in percentage change of weight SDS, height SDS, post dialysis fatigue frequency, Hb, PTH, β2m, IL-6, hs-CRP, Kt/V,Epo dose/kg, Epo /Hct ratio, dialysis costs, non-dialysis costs and net costs. Also a statistically difference in benefit score category. Also, on short term, the current study found that the once subgroup, compared to twice subgroup showed statistically difference in percentage change of IL-6, hs-CRP, Kt/V, dialysis costs, non-dialysis costs and net costs. Also a statistically difference in cost benefit ratio. To conclude, the substitution of once or twice weekly HD sessions with OL-HDF sessions was beneficial in most of the clinical and laboratory parameters measured. Clinical are growth and dialysis related complication and laboratory are anemia, Ca-P metabolism, MM clearance and inflammatory profile.On long term, the twice weekly HDF sessions were statistically better than once in correction of inflammatory profile, elevation of Kt/V and more reduction in non-dialysis costs. Otherwise, no statistically significant difference was found between once and twice weekly HDF. The once weekly HDF has the least cost benefit ratio. We recommend the following: OL-HDF is has very promising results children with ESRD for whom transplantation is not feasible, if not possible to apply it because of financial causes, at least once weekly HDF is beneficial with minimal incremental costs.Every dialysis unit should have a full registry and records for costs of their patients’ treatment. This is to facilitate the economic evaluation (Cost effectiveness analysis) of any new modality of treatment.Further research on comparison between full HD mode (HD trice weekly) and partial HDF modes (once or twice weekly HDF) in children in developing countries where transplantation is not feasible for all patients, which include larger number of children from multicenter or preferably on national scale and for longer durations. Further research on Cost-effectiveness (which combines survival and QOL) of OL-HDF in children in developing countries where transplantation is not feasible for all patients, also should include larger number of children from multicenter or preferably on national scale and for longer durations.