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Clin J Am Soc Nephrol. 2018 May 7;13(5):805-814. doi: 10.2215/CJN.10110917. Epub 2018 Mar 5.

Exploring the Clinical Relevance of Providing Increased Removal of Large Middle Molecules.

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Department of Renal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.
Department of Renal Medicine, Concord Repatriation General Hospital and University of Sydney, Sydney, New South Wales, Australia; and.
Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia;
Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand.


Dialysis technologies have continued to advance over recent decades; however, these advancements have not always been met with improved patient outcomes. In part, the high morbidity and mortality associated with dialysis have been attributed to a group of uremic toxins, which are described as "difficult to remove." With a new generation of hemodialysis membranes now making meaningful clearance of these molecules possible, it is an apt time to review the clinical relevance of these middle molecules. Our review describes the developments in membrane technology that enable the removal of large middle molecules (molecular mass >15 kD) that is limited with high-flux dialysis membranes. Of the known 58 middle molecules, a literature search identified 27 that have molecular mass >15 kD. This group contains cytokines, adipokines, hormones, and other proteins. These molecules are implicated in chronic inflammation, atherosclerosis, structural heart disease, and secondary immunodeficiency in the literature. Single-center safety and efficacy studies have identified that use of these membranes in maintenance dialysis populations is associated with limited loss of albumin and increased clearance of large middle molecules. Larger, robustly conducted, multicenter studies are now evaluating these findings. After completion of these safety and efficacy studies, the perceived clinical benefits of providing clearance of large middle molecules must be assessed in rigorously conducted, randomized clinical studies.


Adipokines; Albumins; Artificial; Atherosclerosis; Chronic inflammation; Heart Diseases; Inflammation; Kidneys; Molecular Weight; cardiovascular disease; chronic dialysis; cytokines; hemodialysis; immune deficiency; malnutrition; renal dialysis; uremia

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