International Urology and Nephrology

, Volume 44, Issue 5, pp 1435–1440

Hemodiafiltration and survival of end-stage renal disease patients: the long journey goes on

Nephrology - Review


Survival of end-stage renal disease (ESRD) patients remains unacceptably poor. The excessive mortality of hemodialysis (HD) patients may result, at least in part, from the insufficient removal of medium or high molecular weight uremic toxins and from the systemic inflammatory response induced by the bioincompatibility of HD systems. Hemodiafiltration (HDF) combines diffusion and convection in a single modality, and it appears to be a promising method to improve ESRD patient outcomes. Emerging evidence suggests that this technique may be superior to classic diffusive HD in terms of patient morbidity. Despite the more widespread use of online HDF, evidence for survival benefits of HDF over other treatment modalities is scarce. Results of observational studies suggest lower mortality of HDF patients as compared to HD patients. Recent prospective randomized trials, however, failed to demonstrate any improvement in survival. Subanalyses of these trials, however, showed a significant survival benefit of HDF patients receiving high substitution volumes (17 L per session and more) compared to HD patients and to HDF patients receiving lower volumes. The explanation for this volume-dependent effect remains elusive. There is an urgent need for further randomized controlled trials to confirm previous findings and to identify those ESRD patients that are likely to benefit mostly from HDF.


Hemodiafiltration Survival End-stage renal disease Hemodialysis 


  1. 1.
    US Renal Data System (2011), USRDS 2011 Annual Report, Atlas chronic kidney disease and end-stage renal disease, National Institute of Health, National Institutes of Diabetes and Digestion and Kidney Disease, Bethesda, MDGoogle Scholar
  2. 2.
    Vanholder R, Glorieux G (2003) European Uremic Toxin Work Group. Uraemic toxins and cardiovascular disease. Nephrol Dial Transplant 18(3):463–466PubMedCrossRefGoogle Scholar
  3. 3.
    Depner TA (2001) Uremic toxicity: urea and beyond. Semin Dial 14(4):246–251PubMedCrossRefGoogle Scholar
  4. 4.
    Blankestijn PJ, Ledebo I, Canaud B (2010) Hemodiafiltration: clinical evidence and remaining questions. Kidney Int 77(7):581–587PubMedCrossRefGoogle Scholar
  5. 5.
    Kerr PG (2011) International differences in hemodialysis delivery and their influence on outcomes. Am J Kidney Dis 58(3):461–470PubMedCrossRefGoogle Scholar
  6. 6.
    Henderson LW, Silverstein ME, Ford CA, Lysaght MJ (1975) Clinical response to maintenance hemodiafiltration. Kidney Int Suppl 2:58–63PubMedGoogle Scholar
  7. 7.
    Granger Vallée A, Canaud B (2011) Updating online haemodiafiltration in the renal replacement therapy of chronic kidney disease patients. European Nephrol 5:143–147Google Scholar
  8. 8.
    Ronco C (2011) Hemodiafiltration: evolution of a technique towards better dialysis care. Contrib Nephrol 168:19–27PubMedCrossRefGoogle Scholar
  9. 9.
    Hyodo T, Koutoku N (2011) Preservation of residual renal function with HDF. Contrib Nephrol 168:204–212PubMedCrossRefGoogle Scholar
  10. 10.
    Ohtake T, Oka M, Ishioka K, Honda K, Mochida Y, Maesato K, Moriya H, Hidaka S, Kobayashi S (2012) Cardiovascular protective effects of on-line hemodiafiltration: comparison with conventional hemodialysis. Ther Apher Dial 16(2):181–188PubMedCrossRefGoogle Scholar
  11. 11.
    Nakai S, Iseki K, Tabei K, Kubo K, Masakane I, Fushimi K, Kikuchi K, Shinzato T, Sanaka T, Akiba T (2001) Outcomes of hemodiafiltration based on Japanese dialysis patient registry. Am J Kidney Dis 38(4 Suppl 1):S212–S216PubMedCrossRefGoogle Scholar
  12. 12.
    Pedrini LA, De Cristofaro V, Comelli M, Casino FG, Prencipe M, Baroni A, Campolo G, Manzoni C, Colì L, Ruggiero P, Acquistapace I, Auriemma L (2011) Long-term effects of high-efficiency on-line haemodiafiltration on uraemic toxicity. A multicentre prospective randomized study. Nephrol Dial Transplant 26(8):2617–2624PubMedCrossRefGoogle Scholar
  13. 13.
    Davenport A, Gardner C (2010) Pan Thames Renal Audit Group. The effect of dialysis modality on phosphate control: haemodialysis compared to haemodiafiltration. The Pan Thames Renal Audit. Nephrol Dial Transplant 25(3):897–901PubMedCrossRefGoogle Scholar
  14. 14.
    Panichi V, Scatena A, Paoletti S, Migliori M (2011) Impact of dialysis technique on renal anemia. Contrib Nephrol 171:261–265PubMedCrossRefGoogle Scholar
  15. 15.
    Tiranathanagul K, Praditpornsilpa K, Katavetin P, Srisawat N, Townamchai N, Susantitaphong P, Tungsanga K, Eiam-Ong S (2009) On-line hemodiafiltration in Southeast Asia: a 3 year prospective study of a single center. Ther Apher Dial 13(1):56–62PubMedCrossRefGoogle Scholar
  16. 16.
    Locatelli F, Altieri P, Andrulli S, Bolasco P, Sau G, Pedrini LA, Basile C, David S, Feriani M, Montagna G, Di Iorio BR, Memoli B, Cravero R, Battaglia G, Zoccali C (2010) Hemofiltration and hemodiafiltration reduce intradialytic hypotension in ESRD. J Am Soc Nephrol 21(10):1798–1807PubMedCrossRefGoogle Scholar
  17. 17.
    Schiffl H (2007) Prospective randomized cross-over long-term comparison of online haemodiafiltration and ultrapure high-flux haemodialysis. Eur J Med Res 12(1):26–33PubMedGoogle Scholar
  18. 18.
    Rabindranath KS, Strippoli GF, Daly C, Roderick PJ, Wallace S, MacLeod AM (2006) Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev (4): CD006258Google Scholar
  19. 19.
    Canaud B, Bragg-Gresham JL, Marshall MR, Desmeules S, Gillespie BW, Depner T, Klassen P, Port FK (2006) Mortality risk for patients receiving hemodiafiltration versus hemodialysis: European results from the DOPPS. Kidney Int 69(11):2087–2093PubMedCrossRefGoogle Scholar
  20. 20.
    Jirka T, Cesare S, Di Benedetto A, Perera Chang M, Ponce P, Richards N, Tetta C, Vaslaky L (2006) Mortality risk for patients receiving hemodiafiltration versus hemodialysis. Kidney Int 70(8):1524PubMedCrossRefGoogle Scholar
  21. 21.
    Panichi V, Rizza GM, Paoletti S, Bigazzi R, Aloisi M, Barsotti G, Rindi P, Donati G, Antonelli A, Panicucci E, Tripepi G, Tetta C (2008) RISCAVID Study Group. Chronic inflammation and mortality in haemodialysis: effect of different renal replacement therapies. Results from the RISCAVID study. Nephrol Dial Transplant 23(7):2337–2343PubMedCrossRefGoogle Scholar
  22. 22.
    Vinhas J, Vaz A, Barreeto C, Assuncao J (2007) Survival advantage of patients on hemodiafiltration is independent of dialysis dose and patient characteristics: data from a single centre. Port J Nephrol Hypert 21:287–292Google Scholar
  23. 23.
    Vilar E, Fry AC, Wellsted D, Tattersall JE, Greenwood RN, Farrington K (2009) Long-term outcomes in online hemodiafiltration and high-flux hemodialysis: a comparative analysis. Clin J Am Soc Nephrol 4(12):1944–1953PubMedCrossRefGoogle Scholar
  24. 24.
    Maduell F, Moreso F, Pons M, Ramos R, Mora-Macià J, Foraster A, Soler J, Galceran JM (2011) Online Hemodiafiltration Study Group from the Catalonian Society of Nephrology. Design and patient characteristics of ESHOL study, a Catalonian prospective randomized study. J Nephrol 24(2):196–202PubMedCrossRefGoogle Scholar
  25. 25.
    Ok E, Asci G, Ok ES, Kircelli F, Yilmaz M, Hur E, Demirci MS, Ozdogan O, Demirci C, Sertoz OO, Duman S, Ozkahya M, Kayikcioglu M, Elbi H, Basci A, Toz H (2011) Comparison of postdilution on-line hemodiafiltration and hemodialysis (Turkish HDF study). Late breaking clinical trials NDT Plus 4 (Suppl 2) abstract 2Google Scholar
  26. 26.
    Grooteman MP, van den Dorpel MA, Bots ML, Penne EL, van der Weerd NC, Mazairac AH, den Hoedt CH, van der Tweel I, Lévesque R, Nubé MJ, Ter Wee PM, Blankestijn PJ; for the CONTRAST Investigators (2012) Effect of Online Hemodiafiltration on All-Cause Mortality and Cardiovascular Outcomes. J Am Soc Nephrol 23(6):1087–1096Google Scholar
  27. 27.
    Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW, Allon M, Bailey J, Delmez JA, Depner TA, Dwyer JT, Levey AS, Levin NW, Milford E, Ornt DB, Rocco MV, Schulman G, Schwab SJ, Teehan BP (2002) Hemodialysis (HEMO) Study Group. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 347(25):2010–2019PubMedCrossRefGoogle Scholar
  28. 28.
    Locatelli F, Martin-Malo A, Hannedouche T, Loureiro A, Papadimitriou M, Wizemann V, Jacobson SH, Czekalski S, Ronco C (2009) Membrane Permeability Outcome (MPO) Study Group. Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol 20(3):645–654PubMedCrossRefGoogle Scholar
  29. 29.
    Delmez JA, Yan G, Bailey J, Beck GJ, Beddhu S, Cheung AK, Kaysen GA, Levey AS, Sarnak MJ (2006) Hemodialysis (HEMO) Study Group. Cerebrovascular disease in maintenance hemodialysis patients: results of the HEMO Study. Am J Kidney Dis 47(1):131–138PubMedCrossRefGoogle Scholar
  30. 30.
    Tattersall J, Canaud B, Heimburger O, Pedrini L, Schneditz D (2010) European Renal Best Practice advisory Board. High-flux or low-flux dialysis: a position statement following publication of the Membrane Permeability Outcome study. Nephrol Dial Transplant 25(4):1230–1232PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, B.V. 2012

Authors and Affiliations

  1. 1.Department of Internal Medicine IV-Campus InnenstadtUniversity of MunichMunichGermany
  2. 2.KFH Renal Centre Munich-WestMunichGermany

Personalised recommendations