Hemodiafiltration improves on cardiovascular, overall survival vs. high-flux hemodialysis
Key takeaways:
- Hemodiafiltration may allow more effective toxin removal vs. high-flux hemodialysis.
- Hemodiafiltration was associated with better outcomes than high-flux hemodialysis.
Hemodiafiltration may be associated with better cardiovascular and overall survival vs. high-flux hemodialysis for patients on dialysis, according to a European Renal Association consensus statement.
“Further [randomized controlled trials] RCTs are required to overcome the significant bias in existing studies and better clarify the impact of high-volume [hemodiafiltration] HDF on survival, clinical and biochemical outcomes, [health-related quality of life] HrQoL and cost-effectiveness,” Yuri Battaglia, MD, PhD, associate professor in the department of medicine at the University of Verona, and head of the nephrology and dialysis unit at Pederzoli Hospital in Italy, and colleagues wrote.
A consensus statement from the European Dialysis Working Group of the European Renal Association addressed survival, HrQoL and biochemical endpoints of low- and high-volume hemodiafiltration vs. high-flux hemodialysis (HD) for children and adults with kidney failure.
Researchers searched five large electronic databases to identify parallel or crossover RCTs that assessed relevant measures. Using a mini-Delphi method, investigators outlined 22 key points that combined meta-analyses and clinical experience.
Main outcomes were categorized into three groups: mortality, including all-cause mortality, CV mortality, sudden cardiac death, intradialytic hypotension, hospital admissions and infection rates; QoL measures, such as sleep, physical activity, uremic pruritus and the clearing of uremic toxins; and biomarkers of nutrition, inflammation, anemia and mineral bone disorders.
Hemodiafiltration was associated with better mortality outcomes than high-flux HD, according to the analysis, when high convection volumes were achieved.
Further, researchers agreed on the following key consensus points:
Convection volume
- A convection volume greater than 23 L/session in hemodiafiltration may lower overall and CV mortality vs. high-flux HD.
- Optimal vascular access through an arteriovenous fistula may help achieve high convection volume more effectively than a central venous catheter or graft.
All-cause mortality
- Hemodiafiltration may lower all-cause mortality depending on patient health and convection volume.
CV events
- Hemodiafiltration may reduce CV mortality but not sudden cardiac death or intradialytic hypotensive episodes.
Infections and hospitalizations
- There are similar risks for all-cause and infection-related hospitalizations between hemodiafiltration and high-flux HD.
- Hemodiafiltration could lower infection-related mortality.
QoL
- Hemodiafiltration may better preserve physical symptoms, cognitive function and physical activity.
- Sleep quality and uremic pruritus outcomes are similar in both therapies.
Biomechanical outcomes
- Hemodiafiltration may effectively remove middle-molecular-weight uremic toxins
- There are similar pre-dialysis serum beta 2-microglobulin levels, nutritional markers, inflammation and anemia control in both therapies.
Pediatric section
- Hemodiafiltration is considered as safe and well-tolerated as high-flux HD in children.
Research suggests hemodiafiltration may reduce CV damage, improve blood pressure, growth and overall quality of life. “[Hemodiafiltration] therapy provides promise for the growing dialysis populations worldwide, who have amongst the highest mortality and the lowest quality of life reported in patients with chronic diseases,” Battaglia and colleagues wrote in the statement.
Importantly, “RCTs do not represent the ‘real world’ situation seen in dialysis clinics; the RCTs generally include younger population, with a lower prevalence of diabetes and CVD, and a higher prevalence of AVF use, which are therefore more likely to achieve higher blood flows and the desired convection volume that are associated with superior outcomes.”
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