Ionut Nistor1, Suetonia C Palmer2, Jonathan C Craig3, Valeria Saglimbene4, Mariacristina Vecchio5, Adrian Covic6, Giovanni F M Strippoli7. 1. Department of Nephrology, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania; European Renal Best Practice Methods Support Team, Ghent University Hospital, Ghent, Belgium. 2. Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand. 3. School of Public Health, University of Sydney, Sydney, New South Wales, Australia. 4. Diaverum Medical Scientific Office, Lund, Sweden. 5. Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy. 6. Department of Nephrology, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania. 7. School of Public Health, University of Sydney, Sydney, New South Wales, Australia; Diaverum Medical Scientific Office, Lund, Sweden; Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy. Electronic address: strippoli@negrisud.it.
Abstract
BACKGROUND: Convective dialysis therapies (hemofiltration or hemodiafiltration) are associated with lower mortality compared to hemodialysis in observational studies. A previous meta-analysis of randomized trials comparing convective modalities with hemodialysis in 2006 was inconclusive due to insufficient data. Additional randomized trials recently have reported conflicting results. STUDY DESIGN: Systematic review and meta-analysis of randomized trials to February 27, 2013. SETTING & POPULATION: Patients with chronic kidney failure treated by hemodialysis, hemodiafiltration, hemofiltration, or biofiltration. SELECTION CRITERIA FOR STUDIES: Randomized controlled trials. INTERVENTION: Convective therapies (hemodiafiltration, hemofiltration, and acetate-free biofiltration) compared with hemodialysis. OUTCOMES: All-cause and cardiovascular mortality, nonfatal cardiovascular events, hospitalization, change in dialysis modality, health-related quality of life, adverse events, blood pressure, and clearances of urea and β2-microglobulin. RESULTS: 35 trials (4,039 participants) were included. In low-quality evidence, convective dialysis had little or no effect on all-cause mortality (relative risk [RR], 0.87; 95% CI, 0.70-1.07) and may reduce cardiovascular mortality (RR, 0.75; 95% CI, 0.58-0.97) and hypotension (RR, 0.72; 95% CI, 0.66-0.80) during dialysis, but had uncertain effects on nonfatal cardiovascular events (RR, 1.14; 95% CI, 0.85-1.52) and hospitalization (RR, 1.21; 95% CI, 0.12-12.05). Adverse events were not reported systematically and health-related quality-of-life outcomes were sparse. Convective therapies reduced predialysis levels of β2-microglobulin (mean difference, -5.77 [95% CI, -10.97 to -0.56]mg/dL) and increased dialysis dose (Kt/Vurea mean difference, 0.10; 95% CI, 0.02-0.19), but these effects were very heterogeneous. Sensitivity analyses limited to trials comparing hemodiafiltration with hemodialysis showed similar results. LIMITATIONS: Studies had important risks of bias leading to low confidence in the summary estimates and generally were limited to patients who had adequate dialysis vascular access. CONCLUSIONS: Treatment effects of convective dialysis are unreliable due to limitations in trial methods and reporting. Convective dialysis may reduce cardiovascular but not all-cause mortality, and effects on nonfatal cardiovascular events and hospitalization are inconclusive.
BACKGROUND: Convective dialysis therapies (hemofiltration or hemodiafiltration) are associated with lower mortality compared to hemodialysis in observational studies. A previous meta-analysis of randomized trials comparing convective modalities with hemodialysis in 2006 was inconclusive due to insufficient data. Additional randomized trials recently have reported conflicting results. STUDY DESIGN: Systematic review and meta-analysis of randomized trials to February 27, 2013. SETTING & POPULATION: Patients with chronic kidney failure treated by hemodialysis, hemodiafiltration, hemofiltration, or biofiltration. SELECTION CRITERIA FOR STUDIES: Randomized controlled trials. INTERVENTION: Convective therapies (hemodiafiltration, hemofiltration, and acetate-free biofiltration) compared with hemodialysis. OUTCOMES: All-cause and cardiovascular mortality, nonfatal cardiovascular events, hospitalization, change in dialysis modality, health-related quality of life, adverse events, blood pressure, and clearances of urea and β2-microglobulin. RESULTS: 35 trials (4,039 participants) were included. In low-quality evidence, convective dialysis had little or no effect on all-cause mortality (relative risk [RR], 0.87; 95% CI, 0.70-1.07) and may reduce cardiovascular mortality (RR, 0.75; 95% CI, 0.58-0.97) and hypotension (RR, 0.72; 95% CI, 0.66-0.80) during dialysis, but had uncertain effects on nonfatal cardiovascular events (RR, 1.14; 95% CI, 0.85-1.52) and hospitalization (RR, 1.21; 95% CI, 0.12-12.05). Adverse events were not reported systematically and health-related quality-of-life outcomes were sparse. Convective therapies reduced predialysis levels of β2-microglobulin (mean difference, -5.77 [95% CI, -10.97 to -0.56]mg/dL) and increased dialysis dose (Kt/Vurea mean difference, 0.10; 95% CI, 0.02-0.19), but these effects were very heterogeneous. Sensitivity analyses limited to trials comparing hemodiafiltration with hemodialysis showed similar results. LIMITATIONS: Studies had important risks of bias leading to low confidence in the summary estimates and generally were limited to patients who had adequate dialysis vascular access. CONCLUSIONS: Treatment effects of convective dialysis are unreliable due to limitations in trial methods and reporting. Convective dialysis may reduce cardiovascular but not all-cause mortality, and effects on nonfatal cardiovascular events and hospitalization are inconclusive.
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Authors: Ira M Mostovaya; Muriel P C Grooteman; Carlo Basile; Andrew Davenport; Camiel L M de Roij van Zuijdewijn; Christoph Wanner; Menso J Nubé; Peter J Blankestijn Journal: Clin Kidney J Date: 2015-06-10