Seminars in Dialysis
Volume 19 Page 115 - March 2006
doi:10.1111/j.1525-139X.2006.00136.x
Volume 19 Issue 2
UNRESOLVED ISSUES IN DIALYSIS
Ultrapure Dialysate: Facts and Myths
Juergen Bommer* and Bertrand L. Jaber†‡
ABSTRACT
During hemodialysis, blood comes in contact with a large volume of dialysate. Since the purity of dialysate has been linked to acute and long-term complications in hemodialysis patients, the limit of bacterial and endotoxin contamination has been reduced in recent years. Questions have been raised as to whether ultrapure dialysate is required to prevent such complications; in particular, the chronic inflammatory status frequently found in chronically hemodialyzed patients. In vivo and in vitro data suggest that cytokine stimulation in the blood depends on the concentration of bacteria or endotoxin in the dialysate and on the endotoxin permeability of the dialysis membrane. It is not proven whether ultrapure dialysate reduces significantly proinflammatory cytokine generation compared with standard dialysate within the limits of recent recommendations, if rather impermeable dialysis membranes are used. Cuprophane membranes are more permeable to cytokine-inducing substances compared with synthetic membranes such as polysulfone and polyamide. Clinical reports have also attempted to link several acute and chronic complications of hemodialysis to dialysate purity. To date, however, there is no large randomized clinical trial demonstrating that ultrapure dialysate significantly reduces biomarkers of inflammation and other consequential putative complications, including dialysis-related amyloidosis, erythropoietin requirement, and cardiovascular morbidity and mortality. In conclusion, based on the existing clinical data, ultrapure dialysate is recommended in the setting of suboptimal bacteriologic quality of standard dialysate and the use of permeable dialysis membranes.
I’ve been doing dialysis for over 15 years, I have some neuropathy but that is the only consequence of long term dialysis that I can point to and it is getting better.
I’d say my neuropathy peaked in the summer of 2003 and has declined, as measured by how long I have to be on my feet before they “fall asleep”. This is not a widely reported experience except among those who dialyze more frequently and even among this subset of dialysis consumers outcomes vary. I don’t know how to assign credit for my improving outcomes – is all the credit due to more frequent treatments? How much credit should go to the immune system compatibility of the Aksys? How much credit should other, non-treatment, factors receive?
And then just in the category of the PHD’s immune system compatibility how much credit should go to the ultra pure dialysate and how much credit should go to the biocompatibility of the PHD’s blood tubing and the reused F-80?
I take a high natural hemoglobin as an unambiguous sign of optimal dialysis. I’m off EPO and my last hemoglobin was 14.something. Again I don’t know how to assign credit. Sure detailed studies would be great but I have to believe that continually and needlessly stimulating the immune system is worse than not stimulating the immune system. If you have a choice I’d go with biocompatibility, I’d go with ultra pure dialysate.
I’d say my neuropathy peaked in the summer of 2003 and has declined, as measured by how long I have to be on my feet before they “fall asleep”. This is not a widely reported experience except among those who dialyze more frequently and even among this subset of dialysis consumers outcomes vary. I don’t know how to assign credit for my improving outcomes – is all the credit due to more frequent treatments? How much credit should go to the immune system compatibility of the Aksys? How much credit should other, non-treatment, factors receive?
It is great that your neuropathy has improved and very curious as to the precise reason. Are you diabetic or is neuropathy another effect of longer years on dialysis…how many? How many hours can you be on your feet before the numbness sets in… is it just numbness or pain as well?
Neuropathy is a common consequence of not just dialysis but CKD (I’m not diabetic). I was first diagnosed with CKD over 20 years ago.
It’s the pins and needles feeling – like the feet (it’s bilateral) have fallen asleep. At its worst it would start up about half way through my morning walk, so after 15 minutes. Now I can complete the walk before the symptoms start.
After about 45 minutes to an hour it’ll start up if I’m walking – about 90 minutes if I’m just standing (at work I mostly stand when I’m producing graphics).