Introduction and Aims: Pain is a major health problem in hemodialysis patients. Cause of pain related to the several complications such as osteitis fibrosa cystica, dialysis related amyloidosis (DRA), osteomalacia. Especially pain related to DRA might affect on the activities of daily life (ADL) due to nocturnal awakening. We had been reported the β2microglobulin (MG) adsorption column (Lixelle) reduced the radiolucency of bone cysts in the wrist joints, and improves clinical symptoms associated with DRA (Blood Purif. 2011;32(4):317-22). On the other hand, high volume online hemodiafiltration (HDF) also can remove β2MG efficiently. In this study, we evaluated the effect of combination therapy with β2MG adsorption column and online HDF on the DRA related symptoms.
Methods: 42 patients who had the history of hemodialysis for more than 20 years and had the operation for carpal tunnel syndrome were recruited. Sever pain in the upper (shoulder, elbow, wrist, and finger) and lower (hip, knee, and foot) joints related with DRA were treated with high volume (40 L/session) online HDF for 4 month (1st HDF period). After 1st online HDF period, these patients had been treated withβ2MG adsorption column (Lixelle) and/or online HDF for next 4months (Lixelle period). In last 4 month patients treated with only online HDF (2st HDF period) (Figure). Blood levels ofβ2MG, high sensitive C reactive protein (hCRP), matrix metalloproteinase (MMP)-3, Kt/V, and pain score (Face Scale or VAS score) were evaluated before and after each period.
Results: Among three periods in this study, there were no significant differences in Kt/V (1.5±0.2 vs. 1.5±0.2 vs. 1.5±0.3 respectively), β2MG (26.9 ±6.1 vs. 25.5±6.4 vs. 26.5 ± 5.9 mg/L respectively), hCRP (0.08±0.10 vs. 0.08±0.12 vs. 0.08±0.09 mg/dL respectively), IL-6 (5.53 ±4.84 vs. 4.78±5.95 vs. 4.5 ±5.10 pg/mL respectively), and MMP-3 (268±254 vs. 269±280 vs. 277±301 ng/mL respectively) levels. Although 8 patients improved the pain score in 1st HDF session, the addition of Lixelle to online HDF induced further improved of pain score (from 22.0 ± 11.9 to 13.0 ± 11.0 (p=0.014)) in 6 patients. Furthermore, among 5 patients without improvement of pain score in 1st HDF session, 3 patients had significant improvement of pain score (from 28±10.2 to 21±11.5 (p=0.005)) in the Lixelle period.
Conclusions: There were no significant differences in dialysis efficiency and inflammatory index between online HDF and Lixelle period. Although 19% of patients significantly improved pain score by online HDF, further improvement of pain score was observed in 14% of patients by the addition of Lixelle therapy. Furthermore, combination therapy of Lixelle and online HDF reduced pain score in the 15% of patients without improvement of pain score in the period of online HDF. Thus, it has a possibility that combination therapy of Lixelle and online HDF could reduce DRA related pain, which online HDF failed to reduce.
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