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Why Is High Volume Online Post-dilution Hemodiafiltration Associated with Improved Survival?

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Hemodiafiltration

Abstract

Retention of middle molecular weight (MMW) uremic toxins has been related to mortality in patients with end-stage kidney disease (ESKD). Therefore, interest has shifted from pure diffusive dialysis techniques, such as low-flux hemodialysis (HD), which remove only small water solutes, towards convective therapies, such as hemodiafiltration (HDF), which remove larger compounds as well. Controversy exists, however, as to whether the positive effect of HDF on MMW solutes translates in a superior clinical outcome. Here, we describe the results of three recent large randomized controlled trials (RCT), comparing online post-dilution HDF with HD, and four systematic reviews on convective therapy, and discuss the discrepancies between these studies. Actually, it appears that the concept of ‘convective therapy’ is confusing, as it is not strictly defined and differently interpreted. When convection volumes >21 L/session are applied, especially cardiovascular (CV) mortality is markedly reduced, while the incidence non-CV death due to infections or malignancies, remains unaltered. Echocardiographic analysis suggests that left ventricular (LV) function and structure worsen in HD and remain stable in HDF. Moreover, intradialytic hemodynamic stability appears better preserved during HDF. Currently, there is no convincing evidence that HDF lowers CV mortality by improvements in inflammation, nutrition, CKD-mineral and bone disease, dyslipidemia and anemia control.

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  1. Department of Nephrology, VU University Medical Center, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands

    Menso J. Nubé MD, PhD

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  1. Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands

    Menso J. Nubé

  2. Department of Nephrology, VU University Medical Center, Amsterdam, The Netherlands

    Muriel P.C. Grooteman

  3. Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands

    Peter J. Blankestijn

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Nubé, M.J. (2016). Why Is High Volume Online Post-dilution Hemodiafiltration Associated with Improved Survival?. In: Nubé, M., Grooteman, M., Blankestijn, P. (eds) Hemodiafiltration. Springer, Cham. https://doi.org/10.1007/978-3-319-23332-1_19

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