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Impact of contaminated dialysate on long‐term haemodialysis‐related complications: is it really that important?

2001; Oxford University Press; Volume: 16; Issue: 10 Linguagem: Inglês

10.1093/ndt/16.10.1986

1460-2385

Menso J. Nubé, Muriel P.C. Grooteman,

Central Venous Catheters and Hemodialysis

Recently, in haemodialysis (HD) concern has been raised about the long-term consequences of non-sterile dialysate and the concomitant use of dialysers with large pore size, usually high-flux devices w1,2x. According to current opinion, monocytes are activated by the repeated transfer of bacteria-derived substances from the dialysate compartment to the circulation of the patient, resulting in the secretion of a variety of proinflammatory cytokines, such as interleukin-1b (IL-1b), interleukin-6 (IL-6) and tumour necrosis factor alpha (TNFa). Due to the recurrent character of the stimulus, a chronic inflammatory state is induced, leading to a number of long-term HD-related complications, such as infections, malnutrition, dialysis-related amyloidosis (DRA), accelerated atherosclerosis and increased mortality w3x. However, the cause and nature of HD-induced monocyte activation is a controversial issue. Various provoking factors have been recognized, including complement activation w4x, coagulation w5x, mechanical stress and shear forces w6x and direct contact between blood cells and the membrane of the dialyser w7x. In addition, dialysate factors, such as the presence of acetate w8x and the backtransfer of contaminated dialysate may induce cell activation as well. In the following section we will discuss the arguments supporting backtransport of endotoxins (ETX), which are mainly indirect. Thereafter, we will review the available evidence with reference to backtransport of contaminated dialysate in clinical practice, as measured by antibodies against ETX, the appearance of limulus amoebocyte lysate (LAL) activity in the blood during HD, and recent clinical intraand peri-dialytical data relating to this topic. Finally, we shall review a number of relevant clinical follow-up studies with respect to the occurrence of long-term complications during HD with different types of dialysers.