medwireNews: Compared with conventional hemodialysis, online hemodiafiltration is associated with significantly better survival rates among people with chronic kidney disease (CKD), show the results of a meta-analysis published in The Lancet.
Not only was the primary endpoint of all-cause mortality found to be reduced by a significant 16% with hemodiafiltration versus hemodialysis, but cardiovascular mortality was also significantly reduced by 22%, over a median follow-up of 30 months.
The analysis, “provides compelling evidence” and “strengthens the notion that haemodiafiltration can be considered as a superior alternative to the present standard (ie, haemodialysis),” for people with renal failure, say Robin Vernooij (University Medical Center Utrecht, the Netherlands) and fellow researchers.
They say that their results address some important questions that were left outstanding after the results of the CONVINCE trial were published last year, notably whether there were particular subgroups of people with CKD who might benefit more than others, or if higher than lower convection volumes were better for improving patient survival.
To address these questions, the researchers searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Clinical trials and identified five randomized clinical trials (RCTs) that compared hemodiafiltration and hemodialysis, and also had data on mortality outcomes.
Altogether the trials included 4153 individuals, 2083 who received hemodiafiltration and 2070 given hemodialysis.
The median age of the included trial participants was 65.5 years, 62.7% were men, just under one third (31.5%) had diabetes, and 39.5% had a history of cardiovascular disease. On average, people had been on dialysis for 33 months before entry into their respective trials. The median convection hemodiafiltration volume achieved was 23 L, which is the volume believed to confer a benefit in CKD, the researchers explain.
All-cause mortality occurred in 23.3% of individuals in the hemodiafiltration group and in 27.3% of those in the hemodialysis group. The respective event rates per 100 patient–years were 9.37 and 11.18, and the hazard ratio (HR) was a significant 0.84 in favor of hemodiafiltration.
A total of 362 deaths were attributed to cardiovascular disease, occurring in 8.1% of the hemodiafiltration group and 9.8% of the hemodialysis group, again giving a significant difference favoring hemodiafiltration (HR=0.78).
All-cause mortality and cardiovascular mortality were similarly reduced more with hemodiafiltration than hemodialysis across subgroups based on age, gender, diabetes, prior cardiovascular disease, dialysis vintage, vascular access, and serum albumin concentration.
Plus, in a multivariate analysis, all-cause mortality was 37% lower and cardiovascular mortality was 42% lower in people who received hemodiafiltration convection volumes greater than 23 L versus those who had hemodialysis after adjusting for age, sex, creatinine, and history of cardiovascular disease or diabetes.
And, using convection volume as a continuous variable, the researchers found “the higher the convection volume, the greater the benefit.”
Bruno Ranchin (Hospices Civils de Lyon Pediatric Nephrology Unit, Bron, France) and Rukshana Shroff (University College London, UK) comment on the findings in a related editorial.
They observe that this “is the largest and most rigorous analysis available to date. Yet, individual patient data analysis can only be as good as the individual trial data input into it.”
The editorialists point out that RCTs “do not represent the real-world situation seen in dialysis clinics.” RCTs tend to include younger populations, who are less likely to have diabetes and cardiovascular disease, and more likely to have an arteriovenous fistula. Trial populations are thus “more likely to achieve higher blood flows and the desired convection volume that are associated with superior outcomes.”
Ranchin and Shroff observe that the data reinforce “the superior survival outcomes seen with haemodiafiltration compared with conventional haemodialysis that have been reported in some RCTs.” They conclude that hemodiafiltration “provides hope for the growing dialysis populations worldwide who have among the highest mortality and the lowest quality of life reported in patients with chronic diseases.”
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