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BMC Nephrol. 2019 Feb 1;20(1):34. doi: 10.1186/s12882-019-1219-z.

Outcomes and practice patterns with hemodiafiltration in Shanghai: a longitudinal cohort study.

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Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
Department of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China.
Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
Division of Nephrology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
Department of Nephrology, 85 Hospital of People's Liberation Army, Shanghai, 200052, China.
Department of Nephrology, 455 Hospital of People's Liberation Army, Shanghai, 200052, China.
Department of Nephrology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, China.
Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 202150, China.
Department of Nephrology, Changhai Hospital, Second Military Medical University, Shanghai, Shanghai, 200433, China.
Department of Nephrology, Tongji Hospital, Tongji University, Shanghai, 200092, China.
Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
Baxter China Investment Co Ltd, Medical Affairs, Shanghai, 200031, China.
Baxter Healthcare (Asia) Pte Ltd, Medical Affairs, Singapore, 189673, Singapore.
School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1142, New Zealand.
Department of Renal Medicine, Counties Manukau Health, Auckland, 1640, New Zealand.
Department of Renal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, 4029, Australia.
School of Medicine, University of Queensland, Brisbane, Queensland, 4072, Australia.



Globally, there is increased clinical interest and uptake of hemodiafiltration (HDF) for increased removal of uremic toxins. To date, there has been no epidemiological analysis of HDF in China. We present HDF practice patterns and associated mortality risk in Shanghai.


This is an observational, prospectively collected, retrospective analysis of 9351 Chinese patients initiating hemodialysis in Shanghai from 2007 to 2014. The primary exposure was hemodialysis sub-modality at inception, classified into hemodiafiltration (HDF) and hemodialysis (HD), with adjustment for concommitant hemoperfusion. The primary outcome was patient mortality. We used Cox proportional hazards regression and Fine and Gray's proportional subhazards regression, with multiple imputation of missing co-variates by the chained equation method, adjusting for demographic and clinical variables.


Overall, patients in the cohort were younger, with a more males, and with a lower body mass index when compared to corresponding non-Asian cohorts. Mortality rate was low although it doubled over the period of observation. HDF utilization increased from 7% of patients in 2007 to 42% of patients in 2014. The majority of patients received HDF once a week. The adjusted hazard ratio of death (95% confidence intervals) for HDF versus HD was 0.85 (0.71-1.03), and corresponding sub-hazard ratio 0.86 (0.71-1.03). There was strong effect modification by age. In those aged 40-60 years, the hazard ratio (95% confidence intervals) was 0.65 (0.45-0.94), and sub-hazard ratio also 0.65 (0.45-0.95).


Our study has certain limitations resulting from the limited number of co-variates available for modelling, missing data for some co-variates, and the lack of verification of data against source documentation. Notwithstanding, there is evidence of clinical benefit from HDF in China, and potential to improve patient outcomes through the greater removal of middle and larger uremic solutes.


China; Epidemiology; Hemodiafiltration; Hemodialysis; Mortality

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