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Nephrol Dial Transplant. 2017 Oct 11. doi: 10.1093/ndt/gfx277. [Epub ahead of print]

Mortality risk in patients on hemodiafiltration versus hemodialysis: a 'real-world' comparison from the DOPPS.

Author information

1
Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy.
2
Arbor Research Collaborative for Health, Ann Arbor, MI, USA.
3
Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
4
Nephrology Department, University Hospital Vall d'Hebron, Barcelona, Spain.
5
Department of Nephrology, University Hospital, Ghent, Belgium.
6
Heart of England NHS Foundation Trust, Birmingham, UK.
7
MVZ DaVita Rhein-Ruhr, Dusseldorf, Germany.
8
Department of Nephrology, Heinrich-Heine-University, Dusseldorf, Germany.
9
Division of Nephrology, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden.
10
Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
11
Vanderbilt University, Nashville, TN, USA.

Abstract

Background:

With its convective component, hemodiafiltration (HDF) provides better middle molecule clearance compared with hemodialysis (HD) and is postulated to improve survival. A previous analysis of Dialysis Outcomes and Practice Patterns Study (DOPPS) data in 1998-2001 found lower mortality rates for high replacement fluid volume HDF versus HD. Randomized controlled trials have not shown uniform survival advantage for HDF; in secondary (non-randomized) analyses, better outcomes were observed in patients receiving the highest convection volumes.

Methods:

In a 'real-world' setting, we analyzed patients on dialysis >90 days from seven European countries in DOPPS Phases 4 and 5 (2009-15). Adjusted Cox regression was used to study HDF (versus HD) and mortality, overall and by replacement fluid volume.

Results:

Among 8567 eligible patients, 2012 (23%) were on HDF, ranging from 42% in Sweden to 12% in Germany. Median follow-up was 1.5 years during which 1988 patients died. The adjusted mortality hazard ratio (95% confidence interval) was 1.14 (1.00-1.29) for any HDF versus HD and 1.08 (0.92-1.28) for HDF >20 L replacement fluid volume versus HD. Similar results were found for cardiovascular and infection-related mortality. In an additional analysis aiming to avoid treatment-by-indication bias, we did not observe lower mortality rates in facilities using more HDF (versus HD).

Conclusions:

Our results do not support the notion that HDF provides superior patient survival. Further trials designed to test the effect of high-volume HDF (versus lower volume HDF versus HD) on clinical outcomes are needed to adequately inform clinical practices.

KEYWORDS:

anemia; chronic kidney disease; dialysis; hemodiafiltration; high-flux dialysis

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