Expanded Hemodialysis: A New Therapy for a New Class of Membranes

A wide spectrum of molecules is retained in end-stage kidney disease, normally defined as uremic toxins. These solutes have different molecular weights and radii. Current dialysis membranes and techniques only remove solutes in the range of 50-15,000 Da, with limited or no capability to remove solutes in the middle to high molecular weight range (up to 50,000 Da). Improved removal has been obtained with high cut-off (HCO) membranes, with albumin loss representing a limitation to their practical application. Hemodiafiltration (HDF) at high volumes (>23 L/session) has produced some results on middle molecules and clinical outcomes, although complex hardware and high blood flows are required. A new class of membrane has been recently developed with a cut off (MWCO) close to the molecular weight of albumin. While presenting negligible albumin loss, these membranes have a very high retention onset (MWRO), allowing high clearances of solutes in a wide spectrum of molecular weights. These membranes originally defined (medium cut off) are probably better classified as high retention onset. The introduction of such membranes in the clinical routine has allowed the development of a new concept therapy called "expanded hemodialysis" (HDx). The new therapy is based on a special hollow fiber and dialyzer design. Its simple set-up and application offer the possibility to use it even in patients with suboptimal vascular access or even with an indwelling catheter. The system does not require a particular hardware or unusual nursing skill. The quality of dialysis fluid is, however, mandatory to ensure a safe conduction of the dialysis session. This new therapy is likely to modify the outcome of end-stage kidney disease patients, thanks to the enhanced removal of molecules traditionally retained by current dialysis techniques.