Combination of Medium Cut-off Dialyzer Membrane and Diet Modification to Alleviate Residual Uremic Syndrome of Dialysis Patients

End Stage Renal Disease Clinical Trial

Official title:

Combination of Medium Cut-off Dialyzer Membrane and Diet Modification to Alleviate Residual Uremic Syndrome of Dialysis Patients

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT04247867
• Other study ID #: RIIDTOXINS
• Status: Recruiting
• Phase: N/A
• Start date: August 31, 2020
• Est. completion date: October 31, 2022

Study information

• Verified date: May 2022
• Source: University Medical Centre Ljubljana
• Contact: Jernej Pajek, MD, PhD
• Phone: +38615228124
• Email: jernej.pajek[@]mf.uni-lj.si
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The study will compare achieved levels of protein-bound uremic toxins with dialysis using a medium cut-off membrane compared to the treatment by online haemodiafiltration with a high-flux dialysis membrane. In the second phase of the study dietary fiber and short-chain fatty acid intake will be increased to verify a possible additional reduction in the levels of protein bound uremic toxins.

Description:

The investigators will carry out a prospective interventional randomised study to compare achieved serum concentrations of selected protein bound uremic toxins by dialysis with a medium cut-off membrane (Theranova, Baxter AG, USA) and online hemodiafiltration with a standard "high-flux" dialysis membrane. In the second phase, both dialysis purification methods will be supplemented by a change in the diet with increase of the daily intake of dietary fiber to 30g and addition of a short-chain fatty acid propionate in the dose of 1 g daily.

The main outcome of the study is the serum concentration of p-cresol sulphate. Secondary outcome is the serum concentration of indoxyl-sulphate and trimethylamine-N-oxide (TMAO). Serum albumin concentration and lean body weight of patients represent safety outcomes for this study.

This investigator-initiated research project has been entirely planned and will be conducted by the clinical researchers in a tertiary University Medical Center Ljubljana.

The study will include 50 chronic prevalent stable dialysis patients in the following periods:

• 2 weeks of wash-in period with standard bicarbonate haemodialysis and standard high-flux dialysis membrane,

• then the patients will be randomized in a 1:1 ratio to either one of the two study arms:

• (interventional study arm) 4 weeks of dialysis with medium cut-off (Theranova) membrane (first phase), then dialysis for 4 weeks with the same membrane and increased fiber intake (second phase),

• (control study arm) 4 weeks of dialysis with a high-flux membrane using on-line haemodiafiltration (first phase) and 4 weeks of high-flux membrane haemodiafiltration and increased fiber intake (second phase),

• finally, all patients will undergo a 4 week wash-out period with a standard bicarbonate haemodialysis using standard high-flux dialysis membrane identical to wash-in period.

Measurement of the study end-points will be carried out at the end of 2-week wash-in period, each 4-week period and at the end of 4 week wash-out period.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 50
• Est. completion date: October 31, 2022
• Est. primary completion date: August 30, 2022
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• patient on chronic hemodialysis or hemodiafiltration for at least 12 weeks,

• age 18 years old or more,

• a functioning arteriovenous fistula or graft as a permanent dialysis vascular access,

• being able to give an informed consent to participate in the survey;

Exclusion Criteria:

• planned kidney transplantation, transition to peritoneal dialysis or to another dialysis center within 12 weeks of the start of the study,

• active chronic inflammation (e.g., an active autoimmune disease or an open wound), chronic ongoing infection or cancer in last 4 weeks,

• acute febrile illness in last 4 weeks,

• new cardiovascular or neurovascular event in last 4 weeks,

• a need for hospitalization in the last 4 weeks,

• clinically evident malnutrition and/or body mass index of 19 kg/m2 and/or loss of body weight for 5% in last 3 months,

• immunosuppressive treatment,

• expected survival of less than 1 year,

• pregnancy or breast-feeding,

• indication for dietary supplements to increase calorie and / or protein intake,

• specific indication for carrying out hemodiafiltration instead of hemodialysis as per attending physician,

• serum albumin concentration <32 g/l at screening to enter the study,

• inability to follow the study diet or test procedures,

• rapid reduction of residual renal function in the period prior to entry into the study,

• intolerant of on-line haemodiafiltration (infusion intolerance);

Related Conditions & MeSH terms

• Diet, Healthy
• End Stage Renal Disease
• Haemodialysis
• Kidney Diseases
• Kidney Failure, Chronic

Intervention

Device:
• medium cut-off (MCO) dialysis membrane
Medium cut-off dialysis (MCO) membrane is a dialysis membrane with a higher molecular weight retention onset and similar cut-off as standard high-flux dialysis membranes. It is capable of providing increased clearance of medium sized uremic toxins and some plasma proteins (cytokines, inflammatory mediators).

Dietary Supplement:
• Dietary fiber mixture (Plantago Psyllium and Inulin)
Dietary fiber (Psyllium 69% and Inulin 30% mixture) added to the meals in the dose of 5g BID for 4 weeks in the second phase of the study.
• Sodium propionate
Sodium propionate (a short-chain fatty acid) added to the meals in the dose of 500 mg BID in the second phase in the study.

Locations

Country	Name	City	State
Slovenia	University Medical Center ljubljana	Ljubljana

Sponsors (2)

Lead Sponsor	Collaborator
University Medical Centre Ljubljana	University of Ljubljana

Country where clinical trial is conducted

Slovenia, 

References & Publications (18)

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Borges NA, Barros AF, Nakao LS, Dolenga CJ, Fouque D, Mafra D. Protein-Bound Uremic Toxins from Gut Microbiota and Inflammatory Markers in Chronic Kidney Disease. J Ren Nutr. 2016 Nov;26(6):396-400. doi: 10.1053/j.jrn.2016.07.005. — View Citation

Chapdelaine I, de Roij van Zuijdewijn CL, Mostovaya IM, Lévesque R, Davenport A, Blankestijn PJ, Wanner C, Nubé MJ, Grooteman MP; EUDIAL Group, Blankestijn PJ, Davenport A, Basile C, Locatelli F, Maduell F, Mitra S, Ronco C, Shroff R, Tattersall J, Wanner C. Optimization of the convection volume in online post-dilution haemodiafiltration: practical and technical issues. Clin Kidney J. 2015 Apr;8(2):191-8. doi: 10.1093/ckj/sfv003. Epub 2015 Feb 16. — View Citation

Claro LM, Moreno-Amaral AN, Gadotti AC, Dolenga CJ, Nakao LS, Azevedo MLV, de Noronha L, Olandoski M, de Moraes TP, Stinghen AEM, Pécoits-Filho R. The Impact of Uremic Toxicity Induced Inflammatory Response on the Cardiovascular Burden in Chronic Kidney Disease. Toxins (Basel). 2018 Sep 23;10(10). pii: E384. doi: 10.3390/toxins10100384. — View Citation

Depner TA. Uremic toxicity: urea and beyond. Semin Dial. 2001 Jul-Aug;14(4):246-51. Review. — View Citation

Dobre M, Meyer TW, Hostetter TH. Searching for uremic toxins. Clin J Am Soc Nephrol. 2013 Feb;8(2):322-7. doi: 10.2215/CJN.04260412. Epub 2012 Sep 27. Review. — View Citation

Eloot S, Van Biesen W, Glorieux G, Neirynck N, Dhondt A, Vanholder R. Does the adequacy parameter Kt/V(urea) reflect uremic toxin concentrations in hemodialysis patients? PLoS One. 2013 Nov 13;8(11):e76838. doi: 10.1371/journal.pone.0076838. eCollection 2013. — View Citation

Kirsch AH, Lyko R, Nilsson LG, Beck W, Amdahl M, Lechner P, Schneider A, Wanner C, Rosenkranz AR, Krieter DH. Performance of hemodialysis with novel medium cut-off dialyzers. Nephrol Dial Transplant. 2017 Jan 1;32(1):165-172. doi: 10.1093/ndt/gfw310. Erratum in: Nephrol Dial Transplant. 2021 Jul 23;36(8):1555-1556. — View Citation

Krishnasamy R, Hawley CM, Jardine MJ, Roberts MA, Cho YJ, Wong MG, Heath A, Nelson CL, Sen S, Mount PF, Pascoe EM, Darssan D, Vergara LA, Paul-Brent PA, Toussaint ND, Johnson DW, Hutchison CA. Design and methods of the REMOVAL-HD study: a tRial Evaluating Mid cut-Off Value membrane clearance of Albumin and Light chains in HaemoDialysis patients. BMC Nephrol. 2018 Apr 17;19(1):89. doi: 10.1186/s12882-018-0883-8. — View Citation

Marzocco S, Fazeli G, Di Micco L, Autore G, Adesso S, Dal Piaz F, Heidland A, Di Iorio B. Supplementation of Short-Chain Fatty Acid, Sodium Propionate, in Patients on Maintenance Hemodialysis: Beneficial Effects on Inflammatory Parameters and Gut-Derived Uremic Toxins, A Pilot Study (PLAN Study). J Clin Med. 2018 Sep 30;7(10). pii: E315. doi: 10.3390/jcm7100315. — View Citation

Moe SM, Zidehsarai MP, Chambers MA, Jackman LA, Radcliffe JS, Trevino LL, Donahue SE, Asplin JR. Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease. Clin J Am Soc Nephrol. 2011 Feb;6(2):257-64. doi: 10.2215/CJN.05040610. Epub 2010 Dec 23. — View Citation

Montemurno E, Cosola C, Dalfino G, Daidone G, De Angelis M, Gobbetti M, Gesualdo L. What would you like to eat, Mr CKD Microbiota? A Mediterranean Diet, please! Kidney Blood Press Res. 2014;39(2-3):114-23. doi: 10.1159/000355785. Epub 2014 Jul 29. Review. — View Citation

Mostovaya IM, Blankestijn PJ, Bots ML, Covic A, Davenport A, Grooteman MP, Hegbrant J, Locatelli F, Vanholder R, Nubé MJ; EUDIAL1 - an official ERA-EDTA Working Group. Clinical evidence on hemodiafiltration: a systematic review and a meta-analysis. Semin Dial. 2014 Mar;27(2):119-27. Review. — View Citation

Pajek J, Kveder R, Bren A, Gucek A, Ihan A, Osredkar J, Lindholm B. Short-term effects of a new bicarbonate/lactate-buffered and conventional peritoneal dialysis fluid on peritoneal and systemic inflammation in CAPD patients: a randomized controlled study. Perit Dial Int. 2008 Jan-Feb;28(1):44-52. — View Citation

Sirich TL. Dietary protein and fiber in end stage renal disease. Semin Dial. 2015 Jan-Feb;28(1):75-80. doi: 10.1111/sdi.12315. Epub 2014 Oct 16. — View Citation

Wang AY, Ninomiya T, Al-Kahwa A, Perkovic V, Gallagher MP, Hawley C, Jardine MJ. Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: a systematic review and meta-analysis of randomized trials. Am J Kidney Dis. 2014 Jun;63(6):968-78. doi: 10.1053/j.ajkd.2014.01.435. Epub 2014 Mar 28. Review. — View Citation

Zickler D, Schindler R, Willy K, Martus P, Pawlak M, Storr M, Hulko M, Boehler T, Glomb MA, Liehr K, Henning C, Templin M, Trojanowicz B, Ulrich C, Werner K, Fiedler R, Girndt M. Medium Cut-Off (MCO) Membranes Reduce Inflammation in Chronic Dialysis Patients-A Randomized Controlled Clinical Trial. PLoS One. 2017 Jan 13;12(1):e0169024. doi: 10.1371/journal.pone.0169024. eCollection 2017. — View Citation

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* Note: There are 18 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Serum concentration of uremic toxin trimethylamine N-oxide (TMAO)	Blood for the laboratory measurements of serum TMAO concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Serum concentration of beta2-microglobulin	Blood for the laboratory measurements of serum beta2-microglobulin concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Serum concentration of phosphate	Blood for the laboratory measurements of serum phosphate concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Serum urea concentration	Blood for the laboratory measurements of serum urea concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Serum albumin concentration	Blood for the laboratory measurements of serum albumin concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Dialysis symptom index questionnaire score	A validated questionnaire of 30 questions regarding the dialysis symptoms experienced during the last week. Unabbreviated scale title: Dialysis symptom index. Each of 30 items (symptoms) is ranked on a 5-point Likert scale. Minimal score: 0. Maximum score: 150. Higher scores mean worse outcomes (worse symptom burden).	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Time to finish 10 repetition sit to stand test	This validated test measures lower limb strength. Participants are required to stand up and sit down 10 times from an armless chair as quickly as possible, the outcome is the time needed to perform the test.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Other	Physical activity level as measured by accelerometry	Number of accelerometer counts in 7 days.	At the end of wash-in period (basal sample-baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Primary	Serum concentration of uremic toxin p-cresol sulphate	Blood for the laboratory measurements of serum total p-cresol sulphate concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).
Secondary	Serum concentration of uremic toxins indoxyl sulfate	Blood for the laboratory measurements of serum total indoxyl sulfate concentration will be taken from the arterial line before the start of midweek hemodialysis procedure.	At the end of wash-in period (basal sample-baseline), at the end of first phase (4 weeks after baseline), at the end of second phase (8 weeks after baseline), at the end of wash-out period (12 weeks after baseline).