Large cohort studies suggest that high convective volumes associated with online hemodiafiltration may reduce the risk of mortality/morbidity compared to optimal high-flux hemodialysis. By contrast, intradialytic tolerance is not well studied. The aim of the FRENCHIE (French Convective versus Hemodialysis in Elderly) study was to compare high-flux hemodialysis and online hemodiafiltration in terms of intradialytic tolerance. In this prospective, open-label randomized controlled trial, 381 elderly chronic hemodialysis patients (over age 65) were randomly assigned in a one-to-one ratio to either high-flux hemodialysis or online hemodiafiltration. The primary outcome was intradialytic tolerance (day 30-day 120). Secondary outcomes included health-related quality of life, cardiovascular risk biomarkers, morbidity, and mortality. During the observational period for intradialytic tolerance, 85% and 84% of patients in high-flux hemodialysis and online hemodiafiltration arms, respectively, experienced at least one adverse event without significant difference between groups. As exploratory analysis, intradialytic tolerance was also studied, considering the sessions as a statistical unit according to treatment actually received. Over a total of 11,981 sessions, 2,935 were complicated by the occurrence of at least one adverse event, with a significantly lower occurrence in online hemodiafiltration with fewer episodes of intradialytic symptomatic hypotension and muscle cramps. By contrast, health-related quality of life, morbidity, and mortality were not different in both groups. An improvement in the control of metabolic bone disease biomarkers and β2-microglobulin level without change in serum albumin concentration was observed with online hemodiafiltration. Thus, overall outcomes favor online hemodiafiltration over high-flux hemodialysis in the elderly.

While the effect of early referral to a nephrologist on QoL appeared centre dependent, a smooth transition onto dialysis was associated with significantly better early QoL, independent of other variables.

P roteinuria is a major risk factor for progression to ESRD in both diabetic and nondiabetic nephropathies (1,2). Angiotensin II is a key player in the development of renal failure, either directly by promoting tissue fibrosis or indirectly through its action on glomerular hemodynamic and proteinuria (1,3-5). Therefore, inhibition of the renin-angiotensin system (RAS), through either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB), may have a positive impact on proteinuria and renal failure progression (2). ACEI significantly slow down renal failure progression in type 1 diabetes (6), as well as in nondiabetic nephropathies (7)(8)(9)(10)(11)(12). ARB demonstrated a similar nephroprotective effect in type 2 diabetes (13,14). However, despite treatment with ACEI or ARB, many patients present residual proteinuria and progress to ESRD.ACEI and ARB antagonize the RAS at different levels, suggesting that their combination may be beneficial (15). Several studies have shown that dual blockade of RAS by ACEI and ARB can decrease proteinuria more than ACEI and ARB alone in IgA nephropathy (16,17), type 1 (18) and 2 (19) diabetes, and mixed primary nephropathies (20 -24). This dual blockade of the RAS is also more effective at preventing renal failure progression than each form of monotherapy (25). However, only one study has shown that combined half doses of ACEI and ARB decrease proteinuria better than optimal doses of ACEI or ARB, demonstrating a true synergistic antiproteinuric activity (26). This latter study included only nondiabetic patients who had well-equilibrated BP and were taking fewer than two antihypertensive drugs and no RAS blocking agent before their inclusion in the study. However, most patients with severe proteinuria and renal failure do not reach the targeted BP in the absence of multiple drug regimens including a RAS blocking agent (7,8), particularly in the case of diabetes (13,14). Furthermore, the antiproteinuric effect of ACEI may be blunted by high salt intake and can subsequently be restored by diuretics (27). The aim of this study was to determine (1) whether the synergistic effect of ACEI and ARB on proteinuria is general to patients with renal failure of various causes, including diabetes, irrespective of their baseline BP, and (2) whether the antiproteinuric effect of combined ACEI and ARB can be increased by raising diuretic dosage.