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Comparative Study
. 2018 Apr 1;33(4):683-689.
doi: 10.1093/ndt/gfx277.

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

Francesco Locatelli  1 , Angelo Karaboyas  2 , Ronald L Pisoni  2 , Bruce M Robinson  2   3 , Joan Fort  4 , Raymond Vanholder  5 , Hugh C Rayner  6 , Werner Kleophas  7   8 , Stefan H Jacobson  9 , Christian Combe  10 , Friedrich K Port  2 , Francesca Tentori  2   11
Affiliations
Comparative Study

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

Francesco Locatelli et al. Nephrol Dial Transplant. .

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.

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Figures

FIGURE 1
FIGURE 1
Dialysis facility use of HDF, by country and DOPPS phase. DOPPS Phase 4: 2009–11; DOPPS Phase 5: 2012–15. Data suppressed from five facilities with sparse data (five or fewer eligible patients).
FIGURE 2
FIGURE 2
HDF replacement fluid volume, by country and DOPPS phase. DOPPS Phase 4: 2009–11; DOPPS Phase 5: 2012–15.
See this image and copyright information in PMC

References

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