Effect of ultrapure dialysate on markers of inflammation, oxidative stress, nutrition and anemia parameters

a meta-analysis

Susantitaphong, Paweena
Riella, Cristian
Jaber, Bertrand L.

¹Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St Elizabeth's Medical Center, Boston, MA, USA
²Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
³Extracorporeal Multiorgan Support Dialysis Center, Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Correspondence and offprint requests to: Bertrand L. Jaber; E-mail: [email protected]

Received July 21, 2012

Accepted September 24, 2012

Nephrology Dialysis Transplantation 28(2):p 438-446, February 2013. | DOI: 10.1093/ndt/gfs514

Background

Markers of inflammation are linked to malnutrition and confer an increased mortality risk in hemodialysis patients. Ultrapure dialysate might have a beneficial effect on markers of inflammation. We conducted a meta-analysis that examined the effect of ultrapure versus standard dialysate on markers of inflammation, oxidative stress, nutrition and anemia parameters.

Methods

We performed a literature search using MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and scientific abstracts. Single-arm studies, nonrandomized and randomized controlled trials were included. We conducted random effects model meta-analyses to assess changes in the aforementioned outcomes.

Results

We identified 16 single-arm studies, 2 crossover and 3 parallel-arm nonrandomized controlled trials and 5 crossover and 5 parallel-arm randomized controlled trials. In an analysis of 23 study arms or cohorts (n = 2221), ultrapure dialysate resulted in a significant decrease in C-reactive protein (−3.2 mg/L; 95% CI −4.6, −1.8; P < 0.001). Other markers of inflammation and oxidative stress displayed similar significant improvements. Ultrapure dialysate also resulted in a significant increase in serum albumin (0.11 g/dL; 95% CI 0.02, 0.19; P = 0.011) and hemoglobin (0.40 g/dL; 95% CI 0.06, 0.75; P = 0.022), and a decrease in the weekly erythropoietin dose (−273 units; 95% CI −420, −126; P < 0.001). The results remained significant in analyses restricted to controlled trials.

Conclusions

Use of ultrapure dialysate in hemodialysis patients results in a decrease in markers of inflammation and oxidative stress, an increase in serum albumin and hemoglobin and a decrease in erythropoietin requirement. Although improvement in these surrogate endpoints might confer a cardiovascular benefit, a large trial with hard clinical endpoints is required.