Haemodiafiltration, haemofiltration and haemodialysis for end‐stage kidney disease
Abstract
Background
Renal replacement therapy (RRT) for end‐stage kidney disease (ESKD) can be achieved by several interventions including haemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation. HD, haemofiltration (HF), haemodiafiltration (HDF) and acetate‐free biofiltration (AFB) are extracorporeal RRT methods. It has been suggested that HF and HDF may reduce the frequency and severity of intradialytic and post‐dialytic adverse symptoms and may be more effective than HD in the removal of high molecular weight molecules.
Objectives
To compare convective modes of extracorporeal RRT (HF, HDF or AFB) with HD and to establish if any of these techniques is superior to each other in patients with ESKD.
Search methods
We searched MEDLINE (1966‐2006), EMBASE (1980‐2006), Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library issue 2, 2006) and CINAHL (1872‐2006). Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.
Selection criteria
RCTs comparing HF, HDF, AFB and HD for ESKD were included. Trials enrolling any patient undergoing RRT for ESKD were included.
Data collection and analysis
Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). Heterogeneity was measured using the Chi‐square (χ²) and I² statistic.
Main results
Twenty studies (657 patients) were included. Seventeen studies compared HF, HDF or AFB with HD, two compared HDF with AFB and one compared HF with HDF. The studies were generally small with suboptimal quality. Convective modalities (HF, HDF, AFB) did not differ significantly from HD for mortality (RR 1.68, 95% CI 0.23 to 12.13; χ² = 2.58, P = 0.11, I² = 61.2%), number of hospital admissions/year (MD 0.20, 95% CI ‐0.07 to 0.47) and dialysis adequacy (Kt/V: MD 0.09, 95% CI 0.02 to 0.17; χ² = 3.73, P = 0.29, I² = 19.6%). No study assessed number of dialysis treatments associated with "any adverse symptoms", sessions that were stopped early, change of dialysis modality or dialysis‐related amyloidosis.
Authors' conclusions
We were unable to demonstrate whether convective modalities (either HF, HDF or AFB) have significant advantages over HD with regard to clinically important outcomes of mortality, dialysis‐related hypotension and hospitalisation. More adequately‐powered good quality RCTs assessing clinically important outcomes (mortality, hospitalisation, quality of life) are needed.
PICOs
Plain language summary
Haemodiafiltration, haemofiltration and haemodialysis for end‐stage kidney disease
Haemodialysis (HD), haemofiltration (HF), haemodiafiltration (HDF) and acetate‐free biofiltration (AFB) are renal replacement therapy (RRT) methods where impurities are removed from the blood extracorporeally, i.e. outside the body using a dialysis machine. It has been suggested that convective methods (either HF, HDF or AFB) may reduce the frequency and severity of adverse symptoms that may occur during and after a dialysis session, and may be more effective than HD in the removal of high molecular weight molecules. We identified 20 studies (657 patients) which compared HF, HDF or AFB with HD (n = 17), HDF with AFB (n = 2) or HF with HDF (n = 1). Our review did not find any evidence for improvement of clinically important outcomes such as mortality, dialysis‐associated hypotension and dialysis‐related amyloidosis with convective modalities when compared to HD.
