Hemodiafiltration May Improve Survival Compared with Hemodialysis

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Trials comparing hemodiafiltration and hemodialysis have yielded inconclusive results but have had significant limitations. In The New England Journal of Medicine study, a recent meta-analysis of patient-level data suggested a survival benefit of hemodiafiltration when a convection volume was delivered at a high dose. This trial assessed survival in patients with kidney failure receiving high-dose hemodiafiltration versus conventional, high-flux hemodialysis.

The pragmatic, randomized trial included 1360 patients with kidney failure and at least 3 months on high-flux hemodialysis, enrolled at 61 European centers. All were considered candidates for a convection volume of at least 23 L per session in post-dilution mode. Patients were assigned to open-label treatment with high-dose hemodiafiltration or continued conventional, high-flux hemodialysis. All-cause mortality was assessed at a median follow-up of 30 months, along with secondary outcomes.

In the hemodiafiltration group, the mean convection volume was 25.3 L per session. All-cause mortality was 17.3% in patients assigned to hemodiafiltration versus 21.9% in the hemodialysis group. The survival benefit of hemodiafiltration was greater for patients without a baseline history of cardiovascular disease or diabetes: hazard ratios, 0.58 and 0.65, respectively. Risks of death from cardiovascular causes and a composite of fatal or nonfatal cardiovascular outcomes were similar between groups.

This clinical trial finds a survival benefit of high-dose hemodiafiltration compared with conventional, high-flux hemodialysis in patients with kidney failure. The effects on survival may vary according to comorbidity and other patient characteristics [Blankestijn PJ, et al. Effect of hemodiafiltration or hemodialysis on mortality in kidney failure. N Engl J Med, published online ahead of print June 16, 2023. doi: 10.1056/NEJMoa2304820; https://www.nejm.org/doi/10.1056/NEJMoa2304820].