Why and how high volume hemodiafiltration may reduce cardiovascular mortality in stage 5 chronic kidney disease dialysis patients? A comprehensive literature review on mechanisms involved

Abstract

Online hemodiafiltration (HDF) is an established renal replacement modality for patients with end stage chronic kidney disease that is now gaining rapid clinical acceptance worldwide. Currently, there is a growing body of evidence indicating that treatment with HDF is associated with better outcomes and reduced cardiovascular mortality for dialysis patients. In this comprehensive review, we provide an update on the potential mechanisms which may improve survival in HDF treated patients.

Switching from high‐flux dialysis to hemodiafiltration: Cost‐consequences for patients, providers, and payers

“…However, by achieving better patient outcomes at the same or lower costs, OL‐HDF meets the core prerequisites of patients, providers, and payers alike. There are certainly areas requiring further refinement through the acquisition of more evidence, but the current data and clinical experience with HDF are sufficiently strong to suggest its superiority over conventional HD (including high‐flux HD) based upon clinical endpoints derived from RCTs and real‐world evidence 26 . Several millions of OL‐HDF treatment sessions are carried out safely annually without increased procedure‐specific incidences.…”

“…A body of clinical evidence indicates that HDF, particularly at high substitution volumes (> 21 L per treatment) provides survival benefits for patients; this has given rise to the concept of convective dose which considers the total ultrafiltration volume (volume due to substitution and weight loss 21–25 . To our knowledge to date, no studies have shown any inferiority or detrimental effects attributed to OL‐HDF 26 . Further, previous studies that were unable to demonstrate any superiority of OL‐HDF (over HF‐HD) probably applied substitution volumes below 21 L per treatment, as the convective dose concept only became evident subsequently after the initial set of clinical studies on OL‐HDF 26 …”

“…The transition from Hf‐HD to HDF has gained pace in recent years as there is a conviction of its clinical and economic advantages as well as it being safe and as simple a modality to implement as regular HD 26 …”

Hemodiafiltration outcomes in special situations

“…In a PSM study of 1012 incident patients in Spanish Fresenius units utilizing HDF with CV > 21 L/session, all-cause and cardiovascular mortality were significantly less in the HDF-treated subjects. 33 The apparent advantage of higher CVs was explored further using PSM of two HDF populations with different CV (<4.6 and >64.8 L/wk). 16 Cardiovascular disease within the Charlson index was not specifically reported.…”

The rationale and clinical potential of on‐line hemodiafiltration as renal replacement therapy

“…Today, the maximal convection dose remains unknown 43,63,64 . Mechanisms supporting clinical benefits of online HDF have been summarized in a recent review 65 Future perspectives may be envisaged with online modalities.…”