Did 20 years of technological innovations in hemodialysis contribute to better patient outcomes?

During the past two decades, impressive technological innovations have been introduced in the field of hemodialysis. This review analyzes whether these have been translated into better patient survival. The potential impacts of an increase in dialysis dosage, the preference of high-flux versus low-flux membranes, the choice between convection and diffusion as dialysis strategy, the chemical composition and biologic purity of dialysate, the effect of sodium, potassium, volume profiling, and the intradialytic volume monitoring aiming at improving hemodynamic stability are explored. Studies in which the dialysis dosage was increased were not associated with increased patient survival, whereas the superiority of high-flux over low-flux membranes is not convincingly demonstrated. Although strict evidence is lacking, observational data suggest an advantage of convective over pure diffusive strategies. Longer duration of the dialysis sessions and/or higher frequency of dialysis is probably beneficial, but the results of powerful randomized, controlled trials should be awaited. Sodium profiling has more disadvantages than advantages, whereas potassium profiling mainly in arrhythmia-prone patients with ventricular hypertrophy should be considered. Intradialytic blood volume monitoring has reduced intradialytic hypotension episodes, but hard evidence for improving patient survival is lacking. Overall, the major technological advances in dialysis have not yet been translated into longer patient survival. Optimal predialysis care in preventing the cardiovascular damage that accumulates before the start of dialysis and timely creation of an arteriovenous fistula as vascular access is a more effective and more economic strategy in the long-term outcome of the dialysis patient.