Mortality risk for patients receiving hemodiafiltration versus hemodialysis: European results from the DOPPS

Abstract

Hemodiafiltration (HDF) is used sporadically for renal replacement therapy in Europe but not in the US. Characteristics and outcomes were compared for patients receiving HDF versus hemodialysis (HD) in five European countries in the Dialysis Outcomes and Practice Patterns Study. The study followed 2165 patients from 1998 to 2001, stratified into four groups: low- and high-flux HD, and low- and high-efficiency HDF. Patient characteristics including age, sex, 14 comorbid conditions, and time on dialysis were compared between each group using multivariate logistic regression. Cox proportional hazards regression assessed adjusted differences in mortality risk. Prevalence of HDF ranged from 1.8% in Spain to 20.1% in Italy. Compared to low-flux HD, patients receiving low-efficiency HDF had significantly longer average duration of end-stage renal disease (7.0 versus 4.7 years), more history of cancer (15.4 versus 8.7%), and lower phosphorus (5.3 versus 5.6 mg/dl); patients receiving high-efficiency HDF had significantly more lung disease (15.5 versus 10.2%) and received a higher single-pool Kt/V (1.44 versus 1.35). High-efficiency HDF patients had lower crude mortality rates than low-flux HD patients. After adjustment, high-efficiency HDF patients had a significant 35% lower mortality risk than those receiving low-flux HD (relative risk=0.65, P=0.01). These observational results suggest that HDF may improve patient survival independently of its higher dialysis dose. Owing to possible selection bias, the potential benefits of HDF must be tested by controlled clinical trials before recommendations can be made for clinical practice.

Role of Residual Kidney Function and Convective Volume on Change in β2-Microglobulin Levels in Hemodiafiltration Patients

“…Actually, lower predialysis ␤2M levels have been reported after 3 to 12 mo treatment with HDF, as compared with low-flux or high-flux HD (10)(11)(12)(13)(14)(15). It has been proposed that the improved survival of HDF patients, as reported in few observational studies (16)(17)(18), can be partly attributed to increased removal of ␤2M and other MMW uremic toxins by convective transport.…”

Nocturnal intermittent hemodialysis

“…In this study, the risk of mortality was significantly reduced when the duration of the dialysis session exceeded 4 h; each 30 min extension of dialysis reduced the mortality risk by about 7 % [18].…”

Implementation and Management of Strategies to Set and to Achieve Clinical Targets

“…In addition, DOPPS has also shown that overall clinical practices at the facility level were essential for improving patient outcomes [21]. In other words, dialysis facilities achieving optimal targets for a core of selected quality control items in the majority of patients were extending life expectancy to each patient individually [ 21 ]). In this new perspective, it is then necessary to implement complementary items of quality control probing the degree of compliance of dialysis facilities with best clinical practices [22,23].…”

“…Among the main findings of DOPPS it must be stressed that less use of central venous catheter [10,11], longer duration of dialysis with reduced ultrafiltration rate [12], adequate dialysis schedule [13], higher dialysis dose delivered [14], better control of fluid overload and blood pressure control [15], prevention of metabolic bone disease [16,17], better control of anaemia with lower erythropoiesis-stimulating agent dose require-ment [18,19], enhanced convective dose [20] are all beneficial to patient outcomes. In addition, DOPPS has also shown that overall clinical practices at the facility level were essential for improving patient outcomes [21]. In other words, dialysis facilities achieving optimal targets for a core of selected quality control items in the majority of patients were extending life expectancy to each patient individually [ 21 ]).…”