High-Efficiency Postdilution Online Hemodiafiltration Reduces All-Cause Mortality in Hemodialysis Patients

Abstract

Retrospective studies suggest that online hemodiafiltration (OL-HDF) may reduce the risk of mortality compared with standard hemodialysis in patients with ESRD. We conducted a multicenter, open-label, randomized controlled trial in which we assigned 906 chronic hemodialysis patients either to continue hemodialysis (n=450) or to switch to high-efficiency postdilution OL-HDF (n=456). The primary outcome was all-cause mortality, and secondary outcomes included cardiovascular mortality, all-cause hospitalization, treatment tolerability, and laboratory data. Compared with patients who continued on hemodialysis, those assigned to OL-HDF had a 30% lower risk of all-cause mortality (hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.53-0.92; P=0.01), a 33% lower risk of cardiovascular mortality (HR, 0.67; 95% CI, 0.44-1.02; P=0.06), and a 55% lower risk of infection-related mortality (HR, 0.45; 95% CI, 0.21-0.96; P=0.03). The estimated number needed to treat suggested that switching eight patients from hemodialysis to OL-HDF may prevent one annual death. The incidence rates of dialysis sessions complicated by hypotension and of all-cause hospitalization were lower in patients assigned to OL-HDF. In conclusion, high-efficiency postdilution OL-HDF reduces all-cause mortality compared with conventional hemodialysis.

Intradialytic Cardiac Magnetic Resonance Imaging to Assess Cardiovascular Responses in a Short-Term Trial of Hemodiafiltration and Hemodialysis

“…The Turkish HDF and CONTRAST studies found no difference in mortality or cardiovascular events [15,16] whereas the ESHOL study reported a large (30%) reduction in all-cause mortality [17]. This evidence base is further complicated by the divergent results of four meta-analyses, all of which showed reductions in IDH with HDF but only one suggested improved patient outcomes [11][12][13][14].…”

“…On-line haemodiafiltration (HDF) is a modified haemodialysis (HD) modality incorporating increased convective clearance, which has long been reported to reduce intradialytic hypotension (IDH) [11][12][13][14]. However, despite three randomised controlled trials and several meta-analyses, opinion remains conflicted as to whether HDF improves patient outcomes and the mechanisms by which HDF may do so are not well elucidated [11][12][13][14][15][16][17][18].…”

Nocturnal intermittent hemodialysis

“…However, patients, who received a convective volume of >15 l (CONTRAST) or 17.4 l (Turkish online hemodiafiltration study), had a significantly lower mortality rate. This result was confirmed in the ESHOL study, where patients on online HDF had a 30 % lower risk of all-cause mortality [17]. However, a review of the β2-MG levels in these studies (CONTRAST: decrease, Turkish online: unchanged, ESHOL: increase) suggests that it is unlikely that the effect of online HDF on mortality is attributable to the removal of middle molecules only.…”

Effects of Expanded Hemodialysis Therapy on Clinical Outcomes

“…On further analysis, the convective volumes used in the ESHOL study were found to be significantly higher compared with the other 2 studies, and a post-hoc analysis of all 3 studies suggests a benefit from HDF over HFHD when higher convective volumes are used. In the case of ESHOL, this was both in the 23.1-25.5 L/treatment cohort and in the >25.4 L/treatment cohort [7] . In CON-TRAST, benefit was seen in the >21.95 L/treatment cohort [8] and in the Turkish study >19.5 L/treatment [9] .…”