Engineering perspective on the evolution of push/pull-based dialysis treatments

Abstract

The incidence of kidney disease is rapidly increasing worldwide, and techniques and devices for treating end-stage renal disease (ESRD) patients have been evolving. Better outcomes achieved by convective treatment have encouraged the use of synthetic membranes with high water permeability in clinical setups, and high-flux hemodialysis (HD) and hemodiafiltration (HDF) are now preferred forms of convective therapy in ESRD patients. Push/pull-based dialysis strategies have also been examined to increase convective mass transfer in ESRD patients. The push/pull technique uses the entire membrane as a forward filtration domain for a period of time. However, backfiltration must accompany the forward filtration to compensate for the fluid depletion resulting from the forward filtration, making it necessary to switch the membranes to a backfiltration domain. This paper attempts to describe the advancement of push/pull-based renal supportive treatments in terms of their technical description, hemodialytic efficacy including fluid management accuracy and applicability for clinical use. How the optimization of push and pull actions could translate into better convective efficiency will also be discussed in depth.

Keywords::

• backfiltration
• convection
• hemodiafiltration
• hemodialysis
• push/pull
• ultrafiltration

Financial & competing interests disclosure

The author serves as a principal research investigator for AnC Bio, Inc. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Push/pull techniques rely on the cyclic repetition of forward and backward filtration during dialysis treatments.

• • Repetitive ultrafiltration contributes to the increase in the total filtration volume and convective mass transfer.

• • Repetitive backfiltration compensates for the fluid depletion which occurred during filtration phases, and allows membrane hydraulic capabilities to be optimally maintained.

• • Pulse push/pull hemodialysis is the push/pull strategy which uses a pulsatile flow.

• • The most advanced pulse push/pull hemodialysis unit combined with the dual piston pump has been found to offer the maximal permissible level of convective volume exchange, while ensuring unmatched fluid balancing accuracy.

• • Push/pull dialysis modality equipped by features that simplify overall dialysis treatment can provide treatment alternatives beyond the current thrice-weekly dialysis practice, presumably allowing even more frequent home-based dialysis treatments for patients with kidney malfunction.

Notes