Contribution of Residual Function to Removal of Protein-Bound Solutes in Hemodialysis

Background and objectives This study evaluated the contribution of residual function to the removal of solutes for which protein binding limits clearance by hemdialysis. Design, setting, participants, & measurements Solute concentrations were measured in 25 hemodialysis patients with residual urea clearances ranging from 0.1 to 6.2 ml/min per 1.73 m(2). Mathematical modeling assessed the effect of residual function on time-averaged solute concentrations. Results Dialytic clearances of the protein-bound solutes p-cresol sulfate, indoxyl sulfate, and hippurate were reduced in proportion to the avidity of binding and averaged 8 +/- 2, 10 +/- 3, and 44 +/- 13% of the dialytic urea clearance. For each bound solute, the residual clearance was larger in relation to the residual urea clearance. Residual kidney function therefore removed a larger portion of each of the bound solutes than of urea. Increasing residual function was associated with lower plasma levels of p-cresol sulfate and hippurate but not indoxyl sulfate. Wide variation in solute generation tended to obscure the dependence of plasma solute levels on residual function. Mathematical modeling that corrected for this variation indicated that increasing residual function will reduce the plasma level of each of the bound solutes more than the plasma level of urea. Conclusions In comparison to urea, solutes than bind to plasma proteins can be more effectively cleared by residual function than by hemodialysis. Levels of such solutes will be lower in patients with residual function than in patients without residual function even if the dialysis dose is reduced based on measurement of residual urea clearance in accord with current guidelines. Clin JAm Soc Nephrol 6: 290-296, 2011. doi: 10.2215/CJN.06100710