Enhanced cognitive outcomes with triple-mode dialysis in kidney failure: role of protein-bound toxin clearance

This study aimed to investigate the effects of different dialysis modalities on cognitive function in patients with end stage renal disease and to explore their association with the clearance of protein bound uremic toxins. A total of 135 patients undergoing maintenance hemodialysis were enrolled and randomly assigned to one of three treatment groups hemodialysis HD hemodialysis combined with hemodiafiltration HD + HDF and hemodialysis combined with hemodiafiltration plus hemoperfusion HD + HDF + HP. Cognitive function was evaluated using the Mini Mental State Examination MMSE and the Montreal Cognitive Assessment MoCA which assess multiple domains including memory attention executive function and orientation. Plasma levels of homocysteine Hcy and indoxyl sulfate IS were measured before and after dialysis sessions. Statistical analysis included comparisons among groups Spearman correlation multiple linear and logistic regression and receiver operating characteristic ROC curve analysis. Cognitive scores improved progressively across the three groups with the greatest improvement observed in the HD + HDF + HP group. Toxin levels decreased accordingly and were lowest in the HD + HDF + HP group. Multivariate analysis identified Hcy and IS as independent risk factors for cognitive impairment. ROC analysis demonstrated that both toxins had strong predictive value for cognitive decline. The results indicate that combined HDF and HP enhances removal of protein bound toxins and is associated with better preservation of cognitive function. These findings suggest that triple modality dialysis may provide a promising strategy to reduce cognitive decline and improve neurological outcomes in patients undergoing maintenance hemodialysis.