Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: A systematic review and meta-analysis of randomized trials

Amanda Y. Wang, Toshiharu Ninomiya, Anas Al-Kahwa, Vlado Perkovic, Martin P. Gallagher, Carmel Hawley, Meg J. Jardine

Research output: Contribution to journalArticle

58 Citations (Scopus)

Abstract

Background Whether convective modalities of dialysis, including hemofiltration (HF) and hemodiafiltration (HDF), improve cardiovascular outcomes and mortality is unclear. Study Design Systematic review and meta-analysis. Setting & Population Patients receiving HDF, HF, or standard hemodialysis (HD). Selection Criteria for Studies Randomized controlled trials. Intervention Convective modalities of dialysis (HDF and HF) versus standard HD. Outcomes The primary outcome was clinical cardiovascular outcomes. Secondary outcomes were all-cause mortality, episodes of symptomatic hypotension, dialysis adequacy, and β2-microglobulin level. Relative risks (RRs) or weighted mean differences with 95% CIs for individual trials were pooled using random-effects models. Results The search yielded 16 trials including 3,220 patients. Therapies assessed were convective modalities (HDF or HF) compared with standard HD. Compared with HD, convective modalities did not significantly reduce the risk of cardiovascular events (RR, 0.85; 95% CI, 0.66-1.10) or all-cause mortality (RR, 0.83; 95% CI, 0.65-1.05). Convective modalities reduced symptomatic hypotension (RR, 0.49; 95% CI, 0.30-0.81) and improved serum β2- microglobulin levels (-5.95 mg/L; 95% CI, -10.27 to -1.64), but had no impact on small-molecule clearance (weighted mean difference in Kt/V, 0.04; 95% CI, -0.04 to 0.12). There was a nonsignificant trend to a greater likelihood of receiving a kidney transplant for participants allocated to filtration therapies (RR, 1.19; 95% CI, 0.99-1.42). Limitations The trials were predominantly of suboptimal quality and underpowered, with imbalance in some prognostic variables at baseline. Intention-to-treat analysis was not used in some trials. Our analysis was limited to published outcomes. Conclusions The potential benefits of convective modalities over standard HD for cardiovascular outcomes and mortality remain unproved. Further high-quality randomized trials are needed to define the impact of these modalities on clinically important outcomes.

Original languageEnglish
Pages (from-to)968-978
Number of pages11
JournalAmerican Journal of Kidney Diseases
Volume63
Issue number6
DOIs
Publication statusPublished - Jun 2014

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Hemodiafiltration
Hemofiltration
Chronic Kidney Failure
Renal Dialysis
Meta-Analysis
Cardiovascular Diseases
Mortality
Dialysis
Hypotension
Intention to Treat Analysis
Patient Selection
Randomized Controlled Trials
Transplants
Kidney
Therapeutics
Serum
Population

All Science Journal Classification (ASJC) codes

  • Nephrology

Cite this

Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure : A systematic review and meta-analysis of randomized trials. / Wang, Amanda Y.; Ninomiya, Toshiharu; Al-Kahwa, Anas; Perkovic, Vlado; Gallagher, Martin P.; Hawley, Carmel; Jardine, Meg J.

In: American Journal of Kidney Diseases, Vol. 63, No. 6, 06.2014, p. 968-978.

Research output: Contribution to journalArticle

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abstract = "Background Whether convective modalities of dialysis, including hemofiltration (HF) and hemodiafiltration (HDF), improve cardiovascular outcomes and mortality is unclear. Study Design Systematic review and meta-analysis. Setting & Population Patients receiving HDF, HF, or standard hemodialysis (HD). Selection Criteria for Studies Randomized controlled trials. Intervention Convective modalities of dialysis (HDF and HF) versus standard HD. Outcomes The primary outcome was clinical cardiovascular outcomes. Secondary outcomes were all-cause mortality, episodes of symptomatic hypotension, dialysis adequacy, and β2-microglobulin level. Relative risks (RRs) or weighted mean differences with 95{\%} CIs for individual trials were pooled using random-effects models. Results The search yielded 16 trials including 3,220 patients. Therapies assessed were convective modalities (HDF or HF) compared with standard HD. Compared with HD, convective modalities did not significantly reduce the risk of cardiovascular events (RR, 0.85; 95{\%} CI, 0.66-1.10) or all-cause mortality (RR, 0.83; 95{\%} CI, 0.65-1.05). Convective modalities reduced symptomatic hypotension (RR, 0.49; 95{\%} CI, 0.30-0.81) and improved serum β2- microglobulin levels (-5.95 mg/L; 95{\%} CI, -10.27 to -1.64), but had no impact on small-molecule clearance (weighted mean difference in Kt/V, 0.04; 95{\%} CI, -0.04 to 0.12). There was a nonsignificant trend to a greater likelihood of receiving a kidney transplant for participants allocated to filtration therapies (RR, 1.19; 95{\%} CI, 0.99-1.42). Limitations The trials were predominantly of suboptimal quality and underpowered, with imbalance in some prognostic variables at baseline. Intention-to-treat analysis was not used in some trials. Our analysis was limited to published outcomes. Conclusions The potential benefits of convective modalities over standard HD for cardiovascular outcomes and mortality remain unproved. Further high-quality randomized trials are needed to define the impact of these modalities on clinically important outcomes.",
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T2 - A systematic review and meta-analysis of randomized trials

AU - Wang, Amanda Y.

AU - Ninomiya, Toshiharu

AU - Al-Kahwa, Anas

AU - Perkovic, Vlado

AU - Gallagher, Martin P.

AU - Hawley, Carmel

AU - Jardine, Meg J.

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N2 - Background Whether convective modalities of dialysis, including hemofiltration (HF) and hemodiafiltration (HDF), improve cardiovascular outcomes and mortality is unclear. Study Design Systematic review and meta-analysis. Setting & Population Patients receiving HDF, HF, or standard hemodialysis (HD). Selection Criteria for Studies Randomized controlled trials. Intervention Convective modalities of dialysis (HDF and HF) versus standard HD. Outcomes The primary outcome was clinical cardiovascular outcomes. Secondary outcomes were all-cause mortality, episodes of symptomatic hypotension, dialysis adequacy, and β2-microglobulin level. Relative risks (RRs) or weighted mean differences with 95% CIs for individual trials were pooled using random-effects models. Results The search yielded 16 trials including 3,220 patients. Therapies assessed were convective modalities (HDF or HF) compared with standard HD. Compared with HD, convective modalities did not significantly reduce the risk of cardiovascular events (RR, 0.85; 95% CI, 0.66-1.10) or all-cause mortality (RR, 0.83; 95% CI, 0.65-1.05). Convective modalities reduced symptomatic hypotension (RR, 0.49; 95% CI, 0.30-0.81) and improved serum β2- microglobulin levels (-5.95 mg/L; 95% CI, -10.27 to -1.64), but had no impact on small-molecule clearance (weighted mean difference in Kt/V, 0.04; 95% CI, -0.04 to 0.12). There was a nonsignificant trend to a greater likelihood of receiving a kidney transplant for participants allocated to filtration therapies (RR, 1.19; 95% CI, 0.99-1.42). Limitations The trials were predominantly of suboptimal quality and underpowered, with imbalance in some prognostic variables at baseline. Intention-to-treat analysis was not used in some trials. Our analysis was limited to published outcomes. Conclusions The potential benefits of convective modalities over standard HD for cardiovascular outcomes and mortality remain unproved. Further high-quality randomized trials are needed to define the impact of these modalities on clinically important outcomes.

AB - Background Whether convective modalities of dialysis, including hemofiltration (HF) and hemodiafiltration (HDF), improve cardiovascular outcomes and mortality is unclear. Study Design Systematic review and meta-analysis. Setting & Population Patients receiving HDF, HF, or standard hemodialysis (HD). Selection Criteria for Studies Randomized controlled trials. Intervention Convective modalities of dialysis (HDF and HF) versus standard HD. Outcomes The primary outcome was clinical cardiovascular outcomes. Secondary outcomes were all-cause mortality, episodes of symptomatic hypotension, dialysis adequacy, and β2-microglobulin level. Relative risks (RRs) or weighted mean differences with 95% CIs for individual trials were pooled using random-effects models. Results The search yielded 16 trials including 3,220 patients. Therapies assessed were convective modalities (HDF or HF) compared with standard HD. Compared with HD, convective modalities did not significantly reduce the risk of cardiovascular events (RR, 0.85; 95% CI, 0.66-1.10) or all-cause mortality (RR, 0.83; 95% CI, 0.65-1.05). Convective modalities reduced symptomatic hypotension (RR, 0.49; 95% CI, 0.30-0.81) and improved serum β2- microglobulin levels (-5.95 mg/L; 95% CI, -10.27 to -1.64), but had no impact on small-molecule clearance (weighted mean difference in Kt/V, 0.04; 95% CI, -0.04 to 0.12). There was a nonsignificant trend to a greater likelihood of receiving a kidney transplant for participants allocated to filtration therapies (RR, 1.19; 95% CI, 0.99-1.42). Limitations The trials were predominantly of suboptimal quality and underpowered, with imbalance in some prognostic variables at baseline. Intention-to-treat analysis was not used in some trials. Our analysis was limited to published outcomes. Conclusions The potential benefits of convective modalities over standard HD for cardiovascular outcomes and mortality remain unproved. Further high-quality randomized trials are needed to define the impact of these modalities on clinically important outcomes.

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