A time for rediscovery: chronic hemofiltration for end-stage renal disease

Provision of maintenance renal replacement therapy (MRRT) is becoming increasingly challenging. The number of patients requiring MRRT is growing rapidly, while the number of nephrologists, nurses, and other staff available to provide therapy is not increasing at a similar rate. Patients are now older and have more comorbid conditions, which magnifies the complexity of their RRT and makes it increasingly difficult to maintain the quality of care within the limitations of constrained economic resources. The two most commonly used MRRTs are hemodialysis (HD) and peritoneal dialysis (PD). A third modality of MRRT, hemofiltration, is not currently in widespread use in North America. In hemofiltration, plasma is filtered through a highly permeable, biocompatible synthetic membrane and waste products are removed by convection and solvent drag as the filtrate moves across the membrane. Hemofiltration equipment constantly monitors the rate of plasma removal and administers a sterile, nonpyrogenic replacement solution at an appropriate rate to replace the waste-laden ultrafiltrate and avoid vdume depletion in the patient. Hemofiltration may offer some potential clinical advantages to the MRRT patient, including better hemodynamic and cardiovascular stability, enhanced removal of middle molecular weight toxins, increased comfort, and therapy preference. Some reports indicate possible reduced morbidity and mortality and reduced risk of bacterial contamination and inflammation as a result of the use of sterile, ultrapure replacement fluids. Chronic hemofiltration is a relatively simple MRRT option that may offer significant benefits for many patients who have end-stage renal disease (ESRD) and deserves closer consideration for these patients.