Dialysis – Transplantation
Kidney International (2005) 68, 867–877; doi:10.1111/j.1523-1755.2005.00469.x
The clearance of protein-bound solutes by hemofiltration and hemodiafiltration
TIMOTHY W MEYER, JASONL WALTHER, MARIA ENRICA PAGTALUNAN, ANDRESW MARTINEZ, ALI TORKAMANI, PATRICKD FONG, NATALIES RECHT, CHANNINGR ROBERTSON and THOMASH HOSTETTER
- Department of Medicine, VA Palo Alto Health Care Science, Palo Alto, California
- Department of Medicine, Stanford University, Palo Alto, California
- Department of Chemical Engineering, Stanford University, Stanford, California
- Department of Medicine, University of Minnesota, Minneapolis, Minneapolis
- and the NIDDK, Bethesda, Maryland
Correspondence: Timothy W. Meyer, Nephrology 111R, Palo Alto VAHCS, 3801 Miranda Ave., Palo Alto, CA 94303. E-Mail: twmeyer@stanford.edu
Received 21 December 2004; Revised 8 March 2005; Accepted 22 March 2005.
Abstract
The clearance of protein-bound solutes by hemofiltration and hemodiafiltration.
Background
Hemofiltration in the form of continuous venovenous hemofiltration (CVVH) is increasingly used to treat acute renal failure. Compared to hemodialysis, hemofiltration provides high clearances for large solutes but its effect on protein-bound solutes has been largely ignored.
Methods
Standard clinical systems were used to remove test solutes from a reservoir containing artificial plasma. Clearances of the protein-bound solutes phenol red (CPR) and indican (CIN) were compared to clearances of urea (CUREA) during hemofiltration and hemodiafiltration. A mathematical model was developed to predict clearances from values for plasma flow Qp, dialysate flow Qd, ultrafiltration rate Qf, filter size and the extent of solute binding to albumin.
Results
When hemofiltration was performed with Qp 150 mL/min and Qf 17 mL/min, clearance values were CPR 1.0 
0.1 mL/min; CIN 3.7 0.5 mL/min; and CUREA 14 1 mL/min. The clearance of the protein-bound solutes was approximately equal to the solute-free fraction multiplied by the ultrafiltration rate corrected for the effect of predilution. Addition of Qd 42 mL/min to provide HDF while Qp remained 150 mL/min resulted in proportional increases in the clearance of protein-bound solutes and urea. In contrast, the clearance of protein-bound solutes relative to urea increased when hemodiafiltration was performed using a larger filter and increasing Qd to 300 mL/min while Qp was lowered to 50 mL/min. The pattern of observed results was accurately predicted by mathematical modeling.
Conclusion
In vitro measurements and mathematical modeling indicate that CVVH provides very limited clearance of protein-bound solutes. Continuous venous hemodiafiltration (CVVHDF) increases the clearance of protein-bound solutes relative to urea only when dialysate flow rate and filter size are increased above values now commonly employed.
Keywords:
hemofiltration, hemodiafiltration, CVVH, protein binding
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