An alternate dialysis adequacy marker in excessive flux hemodialysis

Results from the Dialysis Outcomes and Practice Patterns Study
November 30, 2020 0 Comments

Indian J Nephrol. 2015 Could-Jun; 25(3): 143–145.


The traditional, low flux (LF) dialyzer permits the removing of small molecular solutes like urea and creatinine. Excessive flux (HF) dialyzers enable the efficient removing of center molecules (MM) as properly, and are related to decreased hemodialysis-related morbidity and mortality. Cystatin C has engaging traits as a consultant MM. The purpose of this research was to find out cystatin C discount ratio (CysCRR) in each LF and HF teams and to check it with different markers of dialysis adequacy. Thirty-seven sufferers have been subjected to each LF and HF hemodialysis 2 weeks aside. Serum urea, creatinine and cystatin C have been measured pre- and post-dialysis. Cystatin C was measured by latex-enhanced immunoturbidimetry. Urea and creatinine discount ratios have been 72.3 ± 14.7% and 62.5 ± 13%, respectively within the LF group. The CysCRR was −9.7 ± 6.7% and 29.2 ± 11% in LF and HF hemodialysis, respectively. The statistically vital lower in CysCRR within the HF group exhibits the efficient clearance of MM by HF dialyzers. Therefore, CysCRR may very well be utilized to measure the MM clearance in HF hemodialysis. This research highlights the importance of cystatin C as an vital dialysis adequacy marker changing the traditional markers similar to urea and creatinine in HF hemodialysis. Among the many center molecules cystatin C scores over beta-2 microglobulin.

Key phrases: Cystatin C, excessive flux dialysis, center molecules


The uremic syndrome is attributable to the progressive retention of a lot of compounds referred to as uremic retention solutes or uremic toxins. They embrace not solely small plasma solutes, but additionally protein-bound solutes and center molecules (MM)[1](molecular weight between 500 and 60,000 Da).

The traditional low flux (LF) dialyzer permits efficient small solute clearance, however its clearance of MM is comparatively decrease. Excessive flux (HF) dialyzer permits extra environment friendly removing of small water-soluble uremic compounds in addition to MM and ensures improved dialysis high quality and reduces the short- and long-term hemodialysis-related issues. Dialysis with HF membranes end in a discount in erythropoietin resistance, delay in lack of residual renal operate, improved lipid profiles, particularly elevated high-density lipoproteins ldl cholesterol, lowered triglyceride ranges and removing of superior glycosylation finish merchandise, which have been implicated within the pathogenesis of atherosclerosis and dialysis-related amyloidosis.[2]

Serum creatinine is probably the most generally used marker for assessing kidney operate in sufferers with power kidney illness (CKD). The usage of serum urea is really useful by the Kidney Illness Final result High quality Enchancment medical follow guideline to evaluate dialysis clearance.[3] The urea and creatinine discount ratios (CRR) which might be generally used can assess the removing of solely small solutes by typical hemodialysis.

Cystatin C is a single nonglycosylated polypeptide chain consisting of 120 amino acid residues with a molecular mass of 13 kD, which is within the MM vary.[4] It’s produced by all nucleated cells,[5] freely filtered on the glomerulus and nearly totally reabsorbed and metabolized by proximal tubular cells.[6,7,8,9] A number of research have prompt that cystatin C is beneficial as a marker of hemodialysis toxin removing, because it has the engaging options as a consultant MM.[10,11]

Although HF dialyzers with improved MM clearance are extensively used, urea and CRR are used to evaluate the dialysis adequacy. This research goals to evaluate whether or not cystatin C discount ratio (CysCRR) can be utilized instead indicator of MM clearance in HF hemodialysis.

Topics and Strategies

The research was authorized by the human ethics committee of Sri Ramachandra Medical School and Analysis Institute (SRMC), Chennai, India, and written consent was obtained from all of the individuals. A complete set of 37 sufferers of each sexes >18 years outdated was chosen. All of the sufferers have been initially subjected to LF hemodialysis after which to HF hemodialysis 2 weeks later. The dialyzers used have been F6HPS for LF and F60S for HF (Fresenius Medical Care).

All sufferers present process upkeep hemodialysis at SRMC, 3 instances/week have been included. The residual renal operate of the sufferers was not identified. Sufferers with thyroid dysfunction, malignancies, steroid remedy and HIV an infection and pregnant girls have been excluded from the research. All of the blood samples have been collected earlier than and after the second HD session of the week, in keeping with the rules for HD adequacy.[12] Blood samples have been collected and serum was saved at −70°C till assayed. Urea nitrogen was measured utilizing urease–glutamate dehydrogenase technique on the BioLis premium 24i analyzer manufactured by Tokyo Boeki Medical System, Japan. Serum creatinine was measured by the modified Jaffe’s assay and serum cystatin C was measured by latex-enhanced immunoturbidimetry on the identical analyzer.

The efficacy of dialysis was then assessed by calculating the discount ratio for serum creatinine as proven under: CRR = 100 × (1-Ci/Co) the place Ci and Co characterize post-dialysis and pre-dialysis serum creatinine ranges. The identical method is used for the calculation of urea and CysCRR.

SPSS 10 statistical software program developed by IBM Company, United States was used for the evaluation of the outcomes. Pupil’s t-test was used for the evaluation of the pre- and post-dialysis samples of urea, creatinine and cystatin C. Pupil’s t-test was additionally used to check urea, creatinine and CysCRR between LF and HF hemodialysis teams.


There’s a statistically vital enhance within the imply values of cystatin C from the pre-dialysis to the post-dialysis within the LF group []. There’s a statistically vital lower within the imply values of cystatin C from the pre-dialysis to the post-dialysis [] within the HF group.

Desk 1

Urea, creatinine and cystatin C ranges in sufferers present process low flux hemodialysis

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Desk 2

Urea, creatinine and cystatin C ranges in sufferers present process excessive flux hemodialysis

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As proven in , the distinction within the imply values of CysCRR between the LF (−9.78 ± 6.705) and the HF (29.27 ± 11.129) dialysis is statistically vital.

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Comparability of urea, creatinine and cystatin C discount ratios between low flux and excessive flux hemodialysis


Krishnamurthy et al., has proven statistically vital enhance within the imply values of cystatin C with a CysCRR of −38% within the LF group. This enhance in cystatin C values within the post-dialysis (LF) pattern is because of the pore dimension of the LF membrane (1.5 nm), which doesn’t enable the removing of MM like cystatin C. The electrostatic interplay between the microproteins and different plasma proteins adsorbed onto the dialyzer membrane hinders the filtration of those molecules. The rise in cystatin C is because of the hemoconcentration that happens throughout dialysis.[13] Cystatin C serves as a surrogate marker of the insufficient clearance of MM by LF membranes.

The efficient clearance of cystatin C by HF dialyzers is because of the distinction within the ultrafiltration charges. Cystatin C is eliminated successfully by the HF membranes because the pore dimension of the membranes is between 1.5 and 1.7 nm.[14] Huang et al., discovered no correlation between CysCRR and the small solute clearance (urea discount ratio and CRR). That is because of the distinction of their intra-dialytic kinetic conduct.[15] Cystatin C, a MM that’s distributed primarily extracellularly is minimally protein sure with presumed gradual redistribution between the intravascular and the extravascular areas due to its dimension. In contrast, serum urea and creatinine are distributed in extracellular (each intravascular and extravascular) and intracellular areas, with presumed fast equilibration between all three compartments throughout hemodialysis. CysCRR is affected by a mixture of diffusive and convective clearance.

As cystatin C is strictly distributed in extracellular fluid, varied kinetic fashions usually are not required to explain its kinetics throughout HD. Its manufacturing price is comparatively fixed or minimally variable; cystatin C circulates freely in unbounded type and its elimination from the circulation is sort of solely by way of glomerular filtration.

Cystatin C has been proven to correlate with mortality in sufferers with coronary coronary heart illness. In sufferers with stage III or IV CKD, the cystatin C stage was related to all trigger and heart problems mortality.[16] It was concluded that if cystatin C ranges correlate with medical final result within the dialysis inhabitants whatever the residual renal operate, it could turn out to be an vital dialysis adequacy parameter.


This research highlights the significance of cystatin C because the dialysis adequacy marker for the clearance of MM in HF dialysis, thus changing the traditional dialysis adequacy markers of urea and creatinine utilized in LF dialyzers.

Additional research with bigger pattern sizes are required to determine the goal of a passable cystatin C stage after dialysis that’s wanted to enhance the medical outcomes in HF dialysis.


Supply of Assist: Nil

Battle of Curiosity: None declared.


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