Al-Azhar International Medical Journal

Volume 4 Issue 4 Article 24

2023
Section:

The Effect of Hemodiafiltration Versus Hemodialysis on Anemia in

Patients on regular hemodialysis
Emad Allam Mohamed
Department of Internal Medicine and Nephrology, Faculty of Medicine for boys, Al-Azhar University, Cairo, Egypt.

Ahmed Farag Abdelkader

Department of Internal Medicine and Nephrology, Faculty of Medicine for boys, Al-Azhar University, Cairo, Egypt.

Amr Ahmed Rizk

Department of Clinical pathology, Faculty of Medicine for boys, Al-Azhar University, Cairo, Egypt.

Ahmed Qayed Ibrahim Galhom

Department of Internal Medicine and Nephrology, Faculty of Medicine for boys, Al-Azhar University, Cairo, Egypt.,
[email protected]

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How to Cite This Article

Mohamed, Emad Allam; Abdelkader, Ahmed Farag; Rizk, Amr Ahmed; and Galhom, Ahmed Qayed Ibrahim (2023)
"The Effect of Hemodiafiltration Versus Hemodialysis on Anemia in Patients on regular hemodialysis," Al-Azhar
International Medical Journal: Vol. 4: Iss. 4, Article 24.
DOI: https://doi.org/10.58675/2682-339X.1735

This Original Article is brought to you for free and open access by Al-Azhar International Medical Journal. It has been
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ORIGINAL ARTICLE

The Effect of Hemodiafiltration Versus

Hemodialysis on Anemia in Patients on Regular
Hemodialysis

Emad Allam Mohamed a, Ahmed Farag Abdelkader a,

Amr Ahmed Rizk b, Ahmed Qayed Ibrahim Galhom a,*

a
Department of Internal Medicine and Nephrology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
b
Department of Clinical Pathology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt

Abstract

Background: Convective dialysis consists of hemodiafiltration, hemofiltration, and biofiltration devoid of acetate.
Hemodialysis (HD) eliminates solutes and water through diffusion over a semipermeable membrane. Hemofiltration (HF)
increases transmembrane pressure to increase solvent drag, whereas hemodiafiltration (HDF) combines HF and HD. More
than 90% of CKD studied cases with eGFRs below thirty mL/min developed renal anemia. Due to restricted red blood cell
transfusions, hemoglobin levels of approximately seven g/dL were clinically acceptable for cure of renal anemia. In
practice, there is substantial inter-patient variability, & subset of dialysis studied cases may need greater ESA dose.
Aim: To evaluate and compare between the role of Hemodiafiltration and Hemodialysis on Anemia in Patients on
regular hemodialysis.
Subject and methods: This prospective observational study, include 80 patients was selected from attendee of
nephrology dialysis units of National Institute of Nephrology and Urology and Al-Azhar hospitals.
Results: There was no statistically significant variation among groups in terms of dialysis characteristics. No statisti-
cally significant variation was found among groups in terms of cure doses.
Conclusion: Long-term HDF therapy for twelve months was linked to significant improvements in anaemia & nutri-
tional status.

Keywords: Anemia, Hemodiafiltration, Hemodialysis

1. Introduction has the potential to enhance how studied cases feel

& survive on dialysis.4 Hemodiafiltration, hemofil-

D ialysis or kidney transplant are used to elimi-

nate toxins & fluid from people who have
significant renal function loss. Dialysis eliminates
tration, & acetate free biofiltration are three kinds of
convective dialysis treatment.5
Diffusion, removal of solutes & water throughout
waste materials and fluid from the body by filtering semipermeable membrane down concentration
them over membrane in dialysis machine (for gradient, is used in standard hemodialysis. Hemo-
hemodialysis) (for peritoneal dialysis).1 Toxins that filtration, convection modality, uses enhanced trans-
accumulate in body when kidneys fail come in a membrane pressure to improve clearance across
variety of sizes, and bigger molecules are eliminated solvent drag, while hemodiafiltration combines HD &
less effectively by regular hemodialysis.2 HF.6
Newer dialysis types ‘push’ water through dialysis Erythropoiesis is controlled by erythropoietin,
membrane, allowing undesired molecules to be which is generated in stromal cells near kidney's
removed more efficiently.3 Greater molecules are proximal renal tubule. Renal anaemia is most com-
removed more effectively, & dialysis fluid has less mon complication in chronic kidney disease studied
contaminants, suggesting that convective dialysis cases & is caused by relative lack of endogenous

Accepted 19 September 2022.

Available online 30 December 2023

* Corresponding author.
E-mail addresses: [email protected], [email protected] (A.Q.I. Galhom).

https://doi.org/10.58675/2682-339X.1735
2682-339X/© 2023 The author. Published by Al-Azhar University, Faculty of Medicine. This is an open access article under the CC BY-SA 4.0 license
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 E.A. Mohamed et al. / Al-Azhar International Medical Journal 4 (2023)
1

erythropoietin secretion 1.7 Renal anaemia is

SPSS software was used for data entry & analysis
defined as estimated glomerular filtration rate is less
(SPSS 23.0 Version). The mean, proportion, & per-
than sixty mL/min; it has been confirmed that more
centage were computed. The c2 test was used to
than 90% of CKD studied cases with eGFRs less
establish association.
than thirty mL/min have renal anaemia.8
Because of limited supply of red blood cells for
transfusions, low haemoglobin levels of around 3. Results
seven g/dL were deemed clinically acceptable for Table 1.
treatment of renal anaemia to some extent.9 No statistically significant variation was found
Exogenous administration of erythropoiesis stim- among groups regarding years old, sex, primary
ulating agents is usually effective in treating anaemia renal pathology, duration of dialysis, and associated
in dialysis studied cases, however there is significant comorbidities Table 2.
inter-studied case variability in clinical practise, & No statistically significant variation was found
subset of dialysis studied cases may require greater among groups regarding characteristics of dialysis
than usual ESA dose to maintain recommended Table 3.
haemoglobin values among eleven & twelve g/dL. No statistically significant variation was showed
Numerous causes have been on turn advocated to among groups in terms of treatment doses. No statis-
explain this condition: Iron deficiency, vitamin B12 & tically significant variation was showed among
folic acid deficiency, severe secondary hyperpara- groups regarding baseline anemia parameters. High
thyroidism, hemodialysis-related chronic inflam- statisti- cally significant variation was showed
mation & oxidative stress, or insufficient dialysis.10 among groups regarding anemia parameters after 12
Goal of this research was to evaluate and compare months Table 4. No statistically significant variation
between roles of Hemodiafiltration & Hemodialysis was found among groups in terms of baseline
on Anemia in studied cases on regular hemodialysis. laboratory measurements. After 12 months, the
HDF group was related to significantly higher levels
2. Patients and methods of albumin,
calcium, phosphorus, & intact PTH.
This was prospective observational research,
include 80 patients selected from attendee of 4. Discussion
nephrology dialysis units of National Institute of
Nephrology and Urology and Al-Azhar hospitals, Global prevalence & incidence of maintenance
Samples were collected by the systematic random dialysis are growing.11,12 According to World Bank
method. All Males and females aging 30e50 years & World Health Organization data, 2.16 million
and had Dialysis for at least three months were Asians will require renal replacement therapy by
contained within the research. Exclusion criteria 2030, 223% rise.13
was chronic infection, malignancy, acute illness,
Table 1. Patient characteristics (N ¼ 80).
malnutrition, & chronic blood disease. Research HDF HD P value
protocol was approved by Local Ethics Committee & (N ¼ 40) (N ¼ 40)
written informed consents were obtained. Age (years) 0.446a
All included studied cases were separated into Mean ± SD 39.5 ± 6.5 38.5 ± 6.1
two groups: Group (A): 40 HDF studied cases with Range 30e50 30e49
Sex 0.496b
anemia Hb < 10 g%. Group (B): 40 HD patients with Female 15 (37.5%) 18 (45%)
anemia Hb < 10 g%. Both groups were on matched Male 25 (62.5%) 22 (55%)
dose of ESA and I.V Iron. Both groups on regular Primary Renal Pathology 0.900b
HD for 3 months. All studied cases were subjected Diabetic Nephropathy 19 (47.5%) 18 (45%)
Hypertensive Nephropathy 11 (27.5%) 11 (27.5%)
to: Complete history taking, Complete physical Glomerulonephritis 8 (20%) 10 (25%)
test: General test: Vital signs (Blood pressure, ADPKD 2 (5%) 1 (2.5%)
Temperature, Heart rate, Respiratory rate) & Signs Duration of Dialysis (months) 0.206a
of (Pallor, Cyanosis, Jaundice, & Lymph node Mean ± SD 5.9 ± 1.8 6.5 ± 1.9
enlargement). Lab investigations including (CBC, Range 3e9 3e9
Associated Comorbidities
LFT, KFT). Values for Urea Reduction Ratio, creati-
Diabetes Mellitus 19 (47.5%) 18 (45%) 0.823b
nine, phosphorus, calcium, blood urea nitrogen, Cardiac Disease 7 (17.5%) 9 (22.5%) 0.576b
parathyroid hormone, hemoglobin, ferritin, trans- Cerebrovascular Disease 6 (15%) 7 (17.5%) 0.762b
ferrin saturation, serum iron, TIBC and erythropoi- a
Independent sample t-test.
etin dose were assessed. b
c2 test.
 E.A. Mohamed et al. / Al-Azhar International Medical Journal 4 (2023)
1

Table 2. Dialysis characteristics (N ¼ 80).

Hemodialysis on Anemia in studied cases on regu-
HDF HD P value a
lar hemodialysis.
(N ¼ 40) (N ¼ 40) This prospective observational study was con-
Session Length (hours) 0.978 ducted in nephrology dialysis units of National
Mean ± SD 3.7 ± 0.4 3.7 ± 0.3 Institute of Nephrology and Urology and Al-Azhar
Range 3e4.5 2.9e4.6 hospitals. This research was conducted on 80 ESRD
Urea Reduction Ratio 0.994
Mean ± SD 72.5 ± 4.7 72.6 ± 4.6
studied cases in Hemodialysis. All studied cases
Range 65e80 65e80 were separated into two groups: group A: 40 HDF
Kt/V 0.969 studied cases with anemia Hb < 10 g% and group B:
Mean ± SD 1.5 ± 0.3 1.4 ± 0.2 40 HD patients with anemia Hb < 10 g%.
Range 1e1.9 0.9e2.0 Regarding demographic data of tested groups, we
Blood Flow Rate (ml/min) 0.776
Mean ± SD 266 ± 9.6 267 ± 10.7 showed that there was no statistically significant
Range 250e280 246e284 variation among HD & HDF groups regarding years
Predilution 5 (12.5) old, sex, primary renal pathology, duration of dial-
Convection Volume (L) ysis, and associated comorbidities.
Mean ± SD 20.3 ± 6.2
As regard Primary Renal Pathology, we found that
Range 10e30
in HDF group, 19 (47.5%) patients had diabetic
a
Independent sample t-test. nephropathy, 11 (27.5%) had hypertensive ne-
phropathy, 8 (20%) had GN, and two (5%) had
ADPKD. In HD group, 18 (45%) patients had dia-
Between modalities of RRT, maintenance hemo- betic nephropathy, 11 (27.5%) had hypertensive
dialysis has been major technique worldwide for nephropathy, 10 (25%) had GN, and one (2.5%)
studied cases with end-stage renal disease.12,14 had ADPKD. No statistically significant variation
According to US Renal Data System report, in 2016, was shown among groups regarding primary renal
87.3% of incident ESRD studied case in US used HD pathology (c2 test, P 0.900).
¼
for RRT.15 Also, as regard Associated Comorbidities, we found
Hemodiafiltration is newer dialysis method that, that in HDF group, 19 (47.5%) patients were diabetic,
unlike conventional hemodialysis, achieves clear- 7 (17.5%) had cardiac disease, and 6 (15%) had
ance of middle & large molecular weight solutes. cere- brovascular disease. In HD group, 18 (45%)
HD is based on diffusive transport of solutes along patients were diabetic, 9 (22.5%) had cardiac
semipermeable membrane & is only effective in disease, and 7 (17.5%) had cerebrovascular disease.
removing small solutes, whilst HDF involves pre- or No statistically significant variation was shown
post-filter infusion of sterile, pyrogen-free fluid, among groups regarding primary renal pathology (c2
allowing clearance by convection in addition to test, P > 0.05). In line with the present study
diffusion.16 Kashgary et al.,17 who enrolled 164 studied cases
The main goal of this research was to evaluate in HD group & 77 studied cases in HDF group, this
and compare between roles of Hemodiafiltration & study reported that there were no statistically
significant variations

Table 4. Laboratory measurements (N ¼ 80).

Table 3. Management of anemia (N ¼ 80).
HDF HD P valuea
HDF HD P value a (N ¼ 40) (N ¼ 40)
(N ¼ 40) (N ¼ 40)
Mean SD Mean SD
Mean SD Mean SD Albumin (g/dl)
ESA Dose (IU/kg/week) 187 75.4 186 75.4 0.994 Baseline 3.6 0.2 3.5 0.4 0.438
IV Iron Dose (mg/day) 5.4 2.3 5.3 2.5 0.982 After 12 months 4.0 0.3 3.4 0.2 0.000
Hemoglobin (g/dl) Calcium (mg/dl)
Baseline 8.4 0.7 8.2 1.0 0.550 Baseline 8.1 0.4 8.2 0.4 0.429
After 12 months 11.1 0.6 10.4 0.2 0.000 After 12 months 8.3 0.4 7.9 0.5 0.002
Ferritin (ng/ml) Phosphorus (mg/dl)
Baseline 9.6 3.3 9.5 3.2 0.925 Baseline 4.9 0.3 5.1 0.4 0.137
After 12 months 37.8 8.1 29.7 8.1 0.000 After 12 months 6.2 0.4 5.9 0.4 0.009
TSAT (%) Intact PTH (pg/ml)
Baseline 11.2 4.4 11.0 4.4 0.994 Baseline 309 130 308 130 0.987
After 12 months 32.3 7.1 23.6 7.2 0.000 After 12 months 442 154 350 183 0.018
a
Independent sample t-test. a Independent sample t-test.
 E.A. Mohamed et al. / Al-Azhar International Medical Journal 4 (2023)
1

among HD & HDF groups regarding age, gender,

In current research, in HDF group, the baseline
primary renal pathology, duration of dialysis,
values were 8.4 ± 0.7 g/dl, 9.6 ± 3.3 ng/ml and
and associated comorbidities. The most common
11.2 ± 4.4% for hemoglobin, ferritin and TSAT,
comorbidities were hypertension followed by
respectively. In the HD group, the baseline values
diabetes.
were 8.2 ± 1.0 g/dl, 9.5 ± 3.2 ng/ml, and 11.0 ±
As well, Ibrahem et al.,18 compared twenty stud-
4.4% for hemoglobin, ferritin, and TSAT,
ied cases on low flux dialyzer, twenty studied cases respectively. No statistically significant variation was
on high flux dialyzer, and 20 patients on hemodia- shown among groups regarding baseline anemia
filtration. The study reported that the studied parameters (Independent sample t-test, P > 0.05).
groups were similar as regard demographic data After 12 months, the anemia parameters were
and baseline characteristics. About 33.3% were significantly different between groups in favor for
hypertensive (HTN), 21.7% had chronic glomerulo- HDF (Independent sample t-test, P < 0.05). The
nephritis, 20% were of unknown cause, 13.3% had mean Hgb was 11.1 ± 0.6 g/dl in HDF group, &
obstructive uropathy and 11.7% had polycystic 10.4 ± 0.2 g/dl in HD group. Mean ferritin has been
kidney disease and no history of diabetes. 37.8 ± 8.1 ng/ml in HDF group, & 29.7 ± 8.1 ng/ml in
As regard the characteristics of the dialysis pro- HD group. Mean TSAT was 32.3 ± 7.1% in HDF
cess between groups. The mean session length was group, & 23.6 ± 7.2% in the HD group.
3.7 ± 0.4 h in HDF group and 3.7 ± 0.3 h in HD
Furthermore, Ibrahem et al.,18 revealed that statis-
group. Mean URR was 72.5 ± 4.7 in HDF group &
tically significant increase in hemoglobin level,
72.6 ± 4.6 in HD group. Mean Kt/V was 1.5 ± 0.3 in platelets number and serum albumin level and highly
HDF group & 1.4 ± 0.2 in HD group. Mean blood significant increase in HDL (High density lipopro-
flow rate was 266 ± 9.6 ml/min in HDF group & tein) in hemodiafiltration group when compared to
267 ± 10.7 ml/min in HD group. No statistically high flux and low flux dialysis groups.
significant variation was shown among groups Also, Georgatzakou et al.,20 described that mean
regarding characteristics of dialysis (Independent Hb was non significantly increased after therapy in
sample t-test, P > 0.05). In the HDF group, pre- HD group, however it was significantly increased
dilution was performed in five (12.5%) patients. The in HDF group after treatment.
mean convection volume was 20.3 ± 6.2 L, ranging As well, Hamzagi´c et al.,21 revealed that HDF
between 10 and 30 L. have significantly higher positive impact on anemia
In agreement with our study Kashgary et al.,17
parameters when compared to HD treatment.
discovered that there was statistically significant However, Kashgary et al.,17 described that there
variation among tested groups as regard character- was no significant variation in post treatment anemia
istics of dialysis (including Session Length, Urea parameters, the same results were reported by Smith
Reduction Ratio, Kt/V and Dialysis Access).
et al.,19 in adults and Galal & Hesham,22 in pediatrics.
Furthermore, Smith et al.,19 enrolled 50 studied This was in disagreement with our results may be due
cases in HD group & 50 studied cases in HDF group, to the differences in sample size and inclusion criteria
study described that there was statistically significant as well as the differences in study settings.
variation between the tested groups as regard char- In the current study, at baseline, the albumin was
acteristics of dialysis (including Session Length, Urea 3.6 ± 0.2 and 3.5 ± 0.4 g/dl in HDF & HD groups.
Reduction Ratio, Kt/V and Blood Flow Rate. In the
Mean baseline serum calcium was 8.1 ± 0.4 &
HDF group, predilution was performed in 4 (9.1%)
8.2 ± 0.4 mg/dl in HDF & HD groups. Mean baseline
patients. mean convection volume was 20.6 ± 4.6 L.
serum phosphorus was 4.9 ± 0.3 and 5.1 ± 0.4
Regarding the anemia treatment doses in both
mg/dl in HDF & HD groups, respectively. Mean
groups and anemia lab parameters, we found that
baseline intact PTH was 309 ± 130 and 308 ± 130
the mean ESA dose was 187 ± 75.4 IU/kg/week in
pg/ml in HDF & HD groups, respectively. No
HDF group, and 186 ± 75.4 IU/kg/week in HD statistically significant variation was found among
group. mean IV iron dose was 5.4 ± 2.4 mg/day in groups in terms of baseline laboratory measurements
the HDF and 5.3 ± 2.5 mg/day in the HD groups. No (Inde- pendent sample t-test, P > 0.05).
statistically significant variation was shown among After 12 months post-treatment, the HDF group
groups in terms of treatment doses (Independent was related to significantly greater levels of albu-
sample t-test, P > 0.05). min, calcium, phosphorus, & intact PTH (Indepen-
In agreement with the current study Lee et al.,15 dent sample t-test, P < 0.05). The mean albumin
revealed that there was no statistically significant level increased to 4 ± 0.3 and 3.4 ± 0.2 mg/dl in HDF
variation among groups in terms of anemia treat- & HD groups, respectively. Mean calcium level
ment doses. increased to 8.3 ± 0.4 & 7.9 ± 0.5 mg/dl in HDF &
 E.A. Mohamed et al. / Al-Azhar International Medical Journal 4 (2023)
1

HD groups, respectively. Mean phosphorus level

Authorship
increased to 6.2 ± 0.4 and 5.9 ± 0.4 mg/dl in HDF &
HD groups, respectively. Mean intact PTH All authors have a substantial contribution to the
increased to 442 ± 154 and 350 ± 183 pg/ml in article.
HDF
& HD groups, respectively.
Similarly, current study Ibrahem et al.,18 reported Conflicts of interest
that the HDF group was related to significantly
greater levels of albumin, calcium, phosphorus, & There are no conflicts of interest.
intact PTH (Independent sample t-test, P < 0.05).
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