Haemodiafiltration, haemofiltration and haemodialysis for end‐stage kidney disease

Ionut Nistor; Suetonia C Palmer; Jonathan C Craig; Valeria Saglimbene; Mariacristina Vecchio; Adrian Covic; Giovanni FM Strippoli

doi:10.1002/14651858.CD006258.pub2

Cochrane Database of Systematic Reviews

Hemodiafiltración, hemofiltración y hemodiálisis para la enfermedad renal terminal

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DOI:

https://doi.org/10.1002/14651858.CD006258.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

20 mayo 2015see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Riñón y trasplante

Copyright:

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Ionut Nistor

Nephrology Department, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania

European Renal Best Practice Methods Support Team, Ghent University Hospital, Ghent, Belgium
Suetonia C Palmer

Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
Jonathan C Craig

Sydney School of Public Health, The University of Sydney, Sydney, Australia

Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
Valeria Saglimbene

Clinical Pharmacology and Epidemiology, Mario Negri Sud Consortium, Santa Maria Imbaro, Italy
Mariacristina Vecchio

Department of Clinical Pharmacology and Epidemiology, Mario Negri Sud Consortium, Santa Maria Imbaro, Italy
Adrian Covic

Nephrology Department, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
Giovanni FM Strippoli

Correspondencia a: Cochrane Renal Group, Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia

[email protected]

[email protected]

Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy

Diaverum Medical Scientific Office, Lund, Sweden

Diaverum Academy, Bari, Italy

Contributions of authors

Original review (2006)

Giovanni FM Strippoli: Design, conduct, data‐analysis, writing review
Alison M MacLeod: Design and writing the review
Conal Daly: Designing, screening search results, selecting relevant studies and writing the review
Paul Roderick: Design and writing the review.
Sheila Wallace: Develop search strategy
Kannaiyan S Rabindranath: Develop search strategy, screen search titles, select studies, data extraction and analysis, writing review

Updated review (2015)

Ionut Nistor: Screening and identification of additional studies for inclusion, development of database, data extraction, completion of tables and figures, drafting of first version of updated manuscript
Suetonia Palmer: Data checking and analysis, revision of first and subsequent drafts, generation of additional tables
Valeria Saglimbene: Screening and identification of additional studies for inclusion, data extraction and checking
Jonathan C. Craig: Data analysis and revision of first and subsequent drafts
Giovanni FM Strippoli: Screening and identification of additional studies for inclusion, data analysis and revision of first and subsequent drafts

Sources of support

Internal sources

University of Sydney School of Public Health, non‐established PhD scholarship, Australia.

External sources

National Kidney Research Fund, UK.
European Renal Best Practice and ERA‐EDTA, Other.

Ionut Nistor was the recipient of a grant from European Renal Best Practice (ERBP) and the European Renal Association‐ European Dialysis Transplantation Association (ERA‐EDTA).

Declarations of interest

The 2006 review was funded by the National Kidney Research Fund (UK).

Acknowledgements

2006 review

The 2006 version of this review was funded by the National Kidney Research Fund (UK). We thank Drs C Basile, J Eiselt, LW Henderson, W Lornoy, E Moville, M Noris, H Schiffl, and V Wizemann for supplying data relating to their studies on request. Dr Strippoli was part‐funded through a University of Sydney School of Public Health, non‐established PhD scholarship.

2015 review

Drs Rabindranath, Daly, Roderick, Wallace and MacLeod were authors on the first version of this review. We thank Drs Alvestrand (PROFIL Study 2011), Asci (TURKISH HDF 2013), Coll (Coll 2009), Grooteman (CONTRAST (Dutch) Study 2005), Locatelli (Bolasco 2003), Mancini (Santoro 2005a), Mandolfo (Mandolfo 2008), Mostovaya (CONTRAST (Dutch) Study 2005), Ok (TURKISH HDF 2013), Pedrini (Pedrini 2011a), Righetti (Righetti 2010), Santoro (Santoro 2005a; Santoro 1999), Selby (Selby 2006a), Stefansson (Stefansson 2012), Tessitore (Santoro 1999), Vaslaki (Vaslaki 2006),and Vernaglione (Cristofano 2004) for supplying data for their studies on request.

Dr Nistor is a fellow of the Methods Support Team of European Renal Best Practice (ERBP), supported by a grant of the European Renal Association‐European Dialysis Transplantation Association (ERA‐EDTA).

Version history

Published

Title

Stage

Authors

Version

2015 May 20

Haemodiafiltration, haemofiltration and haemodialysis for end‐stage kidney disease

Review

Ionut Nistor, Suetonia C Palmer, Jonathan C Craig, Valeria Saglimbene, Mariacristina Vecchio, Adrian Covic, Giovanni FM Strippoli

https://doi.org/10.1002/14651858.CD006258.pub2

2006 Oct 18

Haemodiafiltration, haemofiltration and haemodialysis for end‐stage kidney disease

Review

Kannaiyan S Rabindranath, Giovanni FM Strippoli, Conal Daly, Paul J Roderick, Sheila A Wallace, Alison M MacLeod

https://doi.org/10.1002/14651858.CD006258

Differences between protocol and review

Risk of bias assessment tool has replaced the quality assessment checklist (Rabindranath 2005).

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Female; Humans; Male;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 4

Funnel plot of comparison: 1 Convection (haemofiltration/HDF/acetate‐free biofiltration) versus haemodialysis, outcome: 1.1 All‐cause mortality.

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Figure 5

Funnel plot of comparison: 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, outcome: 1.2 Cardiovascular mortality.

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Figure 6

Funnel plot of comparison: 1 Convection (haemofiltration/HDF/acetate‐free biofiltration) versus haemodialysis, outcome: 1.6 Change of dialysis modality.

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Analysis 1.1

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 1 All‐cause mortality.

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Analysis 1.2

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 2 Cardiovascular mortality.

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Analysis 1.3

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 3 Nonfatal cardiovascular event (rate/person‐years follow‐up).

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Analysis 1.4

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 4 Hospitalisation.

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Analysis 1.5

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 5 Hospitalisation (rate/person‐years follow‐up).

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Analysis 1.6

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 6 Change of dialysis modality.

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Study	Treatment effect	No. of participants
ESHOL Study 2011	In this study which reporting the number of hypotensive events/person‐years follow‐up, convective dialysis reduced the rate of hypotension during dialysis (906 participants: RR 0.72, 95% CI 0.66 to 0.80)	906

Analysis 1.7

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 7 Hypotension during dialysis (rate/person‐years follow‐up).

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Analysis 1.8

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 8 Dialysis sessions with hypotension.

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Analysis 1.9

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 9 Predialysis blood pressure.

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Analysis 1.10

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 10 Maximal drop in blood pressure during dialysis.

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Analysis 1.11

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 11 Kidney diseases questionnaire and well‐being scores.

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Analysis 1.12

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 12 Kt/V.

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Analysis 1.13

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 13 Urea reduction ratio.

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Analysis 1.14

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 14 Predialysis serum B₂ microglobulin.

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Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 15 B2 microglobulin clearance.

Analysis 1.15

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 15 B₂ microglobulin clearance.

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Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 16 Dialysate B2 microglobulin level.

Analysis 1.16

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 16 Dialysate B₂ microglobulin level.

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Study	Convective therapy	Diffusive therapy	P value from paper
Hospitalisation
Verzetti 1998	8	17	Not reported
Patients experiencing hypotension
Fox 1993	1/9	0/9	Not reported
Karamperis 2005	0/12	0/12	Not significant
Pedrini 2011a	2/62	5/62	Not reported
Teo 1987	0/10	0/10	Not reported
Intradialytic hypotensive events
Selby 2006a	23	37	Not significant
Stefansson 2012	32 dialysis sessions with hypotension from a total of 520 sessions	28 dialysis sessions with hypotension from a total of 520 sessions	Not significant
Symptomatic intradialytic hypotensive events
Selby 2006a	2	2	Not significant
Predialysis systolic blood pressure (mm Hg)
Karamperis 2005	12 patients Mean (± SE): 145.0 (7)	12 patients Mean (± SE): 144.0 (6)	Not significant
Noris 1998	5 patients Mean (± SE): 136.3 (2.7)	5 patients Mean (± SE): 128.3 (3.6)	P > 0.05
Pedrini 2011a	62 patients Mean (± SE): 140 (22)	62 patients Mean (± SE): 147 (22)	P = 0.014
Stefansson 2012	20 patients Mean (± SE): 161.2 (29.9)	20 patients Mean (± SE): 157.5 (26.1)	Not reported
Todeschini 2002	9 patients Mean (± SE): 153 (8)	9 patients Mean (± SE): 153 (6)	P > 0.05
Predialysis diastolic blood pressure (mm Hg)
Karamperis 2005	12 patients Mean (± SE): 81.0 (3)	12 patients Mean (± SE): 83.0 (3)	Not significant
Noris 1998	5 patients Mean (± SE): 78.0 (2.7)	5 patients Mean (± SE): 75.3 (3.4)	P > 0.05
Pedrini 2011a	62 patients Mean (± SE): 75.0 (13)	62 patients Mean (± SE): 80.0 (13)	P = 0.05
Stefansson 2012	20 patients Mean (± SE): 88.9 (12.6)	20 patients Mean (± SE): 86.4 (10.8)	Not reported
Todeschini 2002	9 patients Mean (± SE): 83 (2)	9 Mean (± SE): 88 (2)	P > 0.05
Predialysis mean arterial pressure (mm Hg)
Karamperis 2005	12 patients Mean (± SE): 103.0 (4)	12 patients Mean (± SE): 104.0 (4)	Not significant
Teo 1987	10 patients Mean (± SEM): 94.4 (6.7)	10 patients Mean (± SEM): 94.7 (6.1)	"Statistically insignificant"
Postdialysis systolic blood pressure (mm Hg)
Karamperis 2005	12 patients Mean (± SE): 128.0 (8)	12 patients Mean (± SE): 129.0 (5)	Not significant
Noris 1998	5 patients Mean (± SE): 136.3 (4.2)	5 patients Mean (± SE): 127.1 (3.6)	P > 0.05
Pedrini 2011a	62 patients Mean (± SE): 138 (25)	62 patients Mean (± SE): 138 (21)	"not differ significantly"
Stefansson 2012	20 patients Mean (± SE): 161.6 (25.1)	20 patients Mean (± SE): 157.1 (22.8)	Not reported
Todeschini 2002	9 patients Mean (± SE): 114 (4)	9 patients Mean (± SE): 121 (3)	P > 0.05
Postdialysis diastolic blood pressure (mm Hg)
Karamperis 2005	12 patients Mean (± SE): 73.0 (4)	12 patients Mean (± SE): 77.0 (4)	Not significant
Pedrini 2011a	62 patients Mean (± SE): 77.0 (14)	62 patients Mean (± SE): 76.0 (13)	"not differ significantly"
Stefansson 2012	20 patients Mean (± SE): 86.8 (12.8)	20 patients Mean (± SE): 85.3 (10.3)	Not reported
Postdialysis fall in systolic blood pressure (mm Hg)
Todeschini 2002	9 patients Mean (± SE): ‐39 (8)	9 patients Mean (± SE): ‐32 (6)	P > 0.05
Postdialysis mean arterial pressure (mm Hg)
Karamperis 2005	12 patients Mean (± SE): 91.0 (5)	12 patients Mean (± SE): 94.0 (3)	Not significant
Teo 1987	10 patients Mean (± SEM): 90.7 (3.8)	10 patients Mean (± SEM): 96.3 (5.9)	"Statistically insignificant"
Difference between pre‐ and postdialysis systolic blood pressure (mm Hg)
Noris 1998	5 patients Mean (± SE): 0 (4.8)	5 patients Mean (± SE): ‐0.3 (4.6)	P > 0.05
Difference between pre‐ and postdialysis diastolic blood pressure (mm Hg)
Noris 1998	5 patients Mean (± SE): ‐1.4 (2.7)	5 patients Mean (± SE): ‐3.1 (2.8)	P > 0.05
Todeschini 2002	9 patients Mean (± SE): ‐8 (6)	9 patients Mean (± SE): ‐13 (3)	P > 0.05
Intradialysis mean systolic blood pressure (mm Hg)
Selby 2006a	12 patients Mean (± SEM): 137.8 (5.3)	12 patients Mean (± SEM): 145.5 (8.0)	P < 0.0001
Intradialysis mean diastolic blood pressure (mm Hg)
Selby 2006a	12 patients Mean (± SEM): 79.2 (1.9)	12 patients Mean (± SEM): 80.8 (3.5)	P = 0.005
Intradialysis mean arterial pressure (mm Hg)
Selby 2006a	12 patients Mean (± SEM): 104.1(5.2)	12 patients Mean (± SEM): 100.5 (2.9)	P < 0.0001
Teo 1987	10 patients Mean (± SEM): 89.5 (5.6)	10 patients Mean (± SEM): 95.3 (5.5)	"statistically insignificant decrease"
Kt/V
Basile 2001	10 patients Mean (± SD): .28 (0.05)	10 patients Mean (± SD): 1.30 (0.05)	No significant difference
Kantartzi 2013	48 patients Mean (± SD): 1.45 (0.16)	48 patients Mean (± SD): 1.42 (0.02)	P = 0.33
Karamperis 2005	12 patients Mean (± SD): 1.8 (0.20)	12 patients Mean (± SD): 1.70 (0.00)	No significant difference
Noris 1998	5 patients Mean (± SE) = 1.28 (0.08)	5 patients Mean (± SE): 1.16 (0.11)	P > 0.05
Pedrini 2011a	62 patients Mean (± SE): 1.60 (0.31)	62 patients Mean (± SE): 1.44 (0.26)	P < 0.0001
Righetti 2010	24 patients Mean (± SE): 1.6 (0.02)	24 patients Mean (± SE): 1.51 (0.02)	P < 0.01
Selby 2006a	12 patients Mean (± SE): 1.37 (0.28)	12 patients Mean (± SE): 1.38 (0.32)	P = 0.91
Stefansson 2012	20 patients Mean (± SE): 1.51 (0.2)	20 patients Mean (± SE): 1.47 (0.24)	Not reported
Todeschini 2002	9 patients Mean (± SE): 1.54 (0.09)	9 patients Mean (± SE): 1.46 (0.05)	P > 0.05
Tuccillo 2002	12 patients Mean (± SD): 1.49 (0.20)	12 patients Mean (± SD): 1.41 (0.24)	P > 0.05
Urea reduction ratio
Righetti 2010	24 patients Mean (± SE): 73.1 (0.5)	24 patients Mean (± SE): 70.9 (0.5)	P < 0.01
Predialysis serum B₂ microglobulin level (mg/L)
Kantartzi 2013	48 patients Mean (± SE): 31.9 (7.64)	48 patients Mean (± SE): 47.36 (12.21)	P < 0.01
Pedrini 2011a	62 patients Mean (± SE): 22.2 (7.8)	62 patients Mean (± SE): 33.5 (11.8)	P < 0.0001
Righetti 2010	24 patients Mean (± SE): 26.0 (0.5)	24 patients Mean (± SE): 30.9 (0.6)	P < 0.01
Stefansson 2012	20 patients Mean (± SE): 23.7 (8.1)	20 patients Mean (± SE): 34.6 (17)	Not reported

Analysis 1.17

Comparison 1 Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis, Outcome 17 Data from cross‐over studies.

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Analysis 2.1

Comparison 2 Convection versus convection (haemofiltration versus haemodiafiltration), Outcome 1 All‐cause mortality.

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Analysis 2.2

Comparison 2 Convection versus convection (haemofiltration versus haemodiafiltration), Outcome 2 Predialysis blood pressure.

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Analysis 2.3

Comparison 2 Convection versus convection (haemofiltration versus haemodiafiltration), Outcome 3 Kt/V.

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Study	Haemodiafiltraton	Haemofiltration	P value from paper
Days spent in hospital
Altieri 2004	30 patients Mean (± SD): 1.3 (4.7)	30 patients Mean (± SD)L 1.9 (4.9)	Not significant
Average number of episodes of hypotension/patient/month
Altieri 2004	30 patients Mean (± SD): 1.1 (1.5)	30 patients Mean (± SD): 0.5 (0.7)	P = 0.0169
Number of patients experiencing hypotension
Altieri 2004	2/30	0/30	P > 0.05
Predialysis systolic blood pressure (mm Hg)
Altieri 2004	30 patients Mean (± SD): 130.9 (18.5)	30 patients Mean (± SD): 140.2 (16.2)	P = 0.044
Predialysis diastolic blood pressure (mm Hg)
Altieri 2004	30 patients Mean (± SD): 75.3 (9.7)	30 patients Mean (± SD): 77.5 (10.4)	P > 0.05
Predialysis mean arterial pressure (mm Hg)
Altieri 2004	30 patients Mean (± SD): 93.8 (11.5)	30 patients Mean (± SD): 98.4 (10.8)	P > 0.05
Postdialysis systolic blood pressure (mm Hg)
Altieri 2004	30 patients Mean (± SD): 129 (19.8)	30 patients Mean (± SD): 1135.3 (15.7)	P > 0.05
Postdialysis diastolic blood pressure (mm Hg)
Altieri 2004	30 patients Mean (± SD): 75.3 (9.3)	30 patients Mean (± SD): 74.5 (7.9)	P > 0.05
Postdialysis mean arterial blood pressure (mm Hg)
Altieri 2004	30 patients Mean (± SD): 93.2 (11.6)	30 patients Mean (± SD): 94.8 (9.3)	P > 0.05
Number of patients experiencing hypertension
Altieri 2004	6/30	7/30	P > 0.05
Kt/V
Altieri 2004	30 patients Mean (± SD): 1.3 (0.1)	30 patients Mean (± SD): 1.2 (0.1)	P < 0.001
Predialysis serum B₂ microglobulin (mg/L)
Altieri 2004	30 patients Mean (± SD): 17.8 (5.0)	30 patients Mean (± SD): 19.3 (6.1)	Not significant
B₂ microglobulin clearance (mL/min)
Meert 2009	14 patients Mean (± SD): 67.2 (18.5)	14 patients Mean (± SD): 87.5 (9.6)	P < 0.017

Analysis 2.4

Comparison 2 Convection versus convection (haemofiltration versus haemodiafiltration), Outcome 4 Data from cross‐over studies.

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Study	Haemodiafiltration	Acid‐free biofiltration	P value from paper
Number of hospitalisations/patient during observation period
Movilli 1996	12 patients Mean (± SD): 0.33 (0.71)	12 patients Mean (± SD): 0.78 (0.93)	Not significant
Length of hospitalisation stay/patient (days/patient)
Movilli 1996	12 patients Mean (± SD): 2.70 (5.7)	12 patients Mean (± SD): 3.60 (5.2)	Not significant
Number of dialysis sessions with hypotension
Coll 2009	21 patients 7/545 sessions	21 patients 46/545 sessions	"On‐line HDF was associated with fewer hypotensive episodes than treatment with on‐line HDF without acetate (P=0.019)"
Movilli 1996	12 patients 10/72 sessions	12 patients 9/72 sessions	Not significant
Predialysis systolic blood pressure (mm Hg)
Ding 2002	9 patients Mean (± SD): 142.0 (10.0)	9 patients Mean (± SD): 142.0 (11.0)	Not significant
Predialysis mean arterial pressure (mm Hg)
Ding 2002	9 patients Mean (± SD): 94.0 (16.5)	9 patients Mean (± SD): 89.2 (17.7)	Not reported
Postdialysis systolic blood pressure (mm Hg)
Ding 2002	9 patients Mean (± SD): 141.0 (8.0)	9 patients Mean (± SD): 141.00 (12.1)	Not significant
Interdialysis symptom score
Ding 2002	9 patients Mean (± SD): 1.99 (2.49)	9 patients Mean (± SD): 2.57 (2.93)	Not significant
Kt/V
Movilli 1996	12 patients Mean (± SD): 1.32 (0.12)	12 patients Mean (± SD): 1.32 (0.13)	Not significant
Urea reduction ratio
Ding 2002	9 patients Mean (± SD): 71.0 (7.9)	9 patients Mean (± SD): 67.0 (6.5)	Not significant
Predialysis B₂ microglobulin (mg/L)
Coll 2009	21 patients Mean (± SD): 27.7 (7.2)	21 patients Mean (± SD): 27.4 (6.7)	Not significant
Ding 2002	9 patients Mean (± SD): 26.3 (7.9)	9 patients Mean (± SD): 25.9 (6.3)	Not significant
Number of dialysis sessions with side effects (nausea, vomiting, headaches)
Movilli 1996	12 patients 1/72 sessions	12 patients 1/72 sessions	Not significant

Analysis 3.1

Comparison 3 Convection versus convection (haemodiafiltration versus acetate‐free biofiltration), Outcome 1 Data from cross‐over studies.

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Convective compared with diffusive dialysis modalities for men and women with end‐stage kidney disease
Patient or population: men and women with end‐stage kidney disease Intervention: convective dialysis Comparison: diffusive dialysis
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Diffusion	Convection
All‐cause mortality	200 per 1000	Not significant	RR 0.87 (0.72 to 1.05)	11 (3396)	⊕⊕⊝⊝ low	Convective therapy has little or no effect on all‐cause mortality
Cardiovascular mortality	100 per 1000	75 per 1000	RR 0.75 (0.81 to 0.92)	6 (2889)	⊕⊕⊝⊝ low	Convective therapy may reduce cardiovascular mortality
Nonfatal cardiovascular events	130 per 1000	Not significant	RR 1.23 (0.93‐1.63)	2 (1688)	⊕⊝⊝⊝ very low	Convective therapy has uncertain effects on non‐fatal cardiovascular events
Health‐related quality of life	Not estimable	Not estimable	Not estimable	8 (988)	⊕⊕⊝⊝ very low	Convective therapy has uncertain effects on health‐related quality of life
The assumed risk* (e.g. the median control group risk across studies) is derived from data within dialysis registries for all‐cause mortality and cardiovascular mortality and the reported event rate in the available study for nonfatal cardiovascular events (CONTRAST (Dutch) Study 2005). The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE (Grading of Recommendations Assessment, Development, and Evaluation) Working Group grades of evidence (Guyatt 2011). Low quality: Indicates that our confidence in the effect estimate is limited: The true effect may be substantially difference from the estimated effect. Very low quality: Indicated that we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimated effect.

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Table 1. Categories of interventions used in individual studies and duration of follow‐up

Study ID	Intervention	Duration	Number of patients
Altieri 2004	HDF versus HF	12 months	39
Bammens 2004	HDF versus HD	2 weeks	14
Basile 2001	AFB versus HD	12 months	11
Beerenhout 2005	HF versus HD	12 months	40
Bolasco 2003	HF versus HDF versus HD	18 months	146
Coll 2009	AFB versus HDF	15 months	30
CONTRAST (Dutch) Study 2005	HDF versus HD	36 months	714
Cristofano 2004	HDF versus HD	1 session	12
Ding 2002	HDF versus AFB	36 weeks	12
Eiselt 2000	AFB versus HD	12 months	20
ESHOL Study 2011	HDF versus HD	36 months	906
Fox 1993	HF versus HD	1 session	9
Kantartzi 2013	HDF versus HD	3 months	24
Karamperis 2005	HDF versus HD	2 sessions	12
Lin 2001	HDF versus HD	15 months	67
Locatelli 1994	HDF versus HD	24 months	205
Lornoy 1998	HDF versus HD	1 session	8
Mandolfo 2008	HDF versus HD	6 weeks	8
Meert 2009	HDF versus HF	9 weeks	14
Movilli 1996	HDF versus AFB	6 months	12
Noris 1998	AFB versus HD	1 week	5
Ohtake 2012	HDF versus HD	12 months	22
Pedrini 2011a	HDF versus HD	12 months	69
PROFIL Study 2011	HF versus HD	24 months	48
Righetti 2010	HDF versus HD	18 months	24
Santoro 1999	AFB versus HD	48 months	371
Santoro 2005a	HF versus HD	36 months	64
Schiffl 1992	HF versus HD	48 months	32
Schiffl 2007	HDF versus HD	48 months	76
Schrander vd Meer 1998	AFB versus HD	12 months	24
Selby 2006a	AFB versus HD	4 weeks	12
Stefansson 2012	HDF versus HD	4 months	20
Teo 1987	HDF versus HD	8 months	13
Todeschini 2002	AFB versus HD	3 sessions	9
Tuccillo 2002	HDF versus HD	3 months	12
TURKISH HDF 2013	HDF versus HD	24 months	782
Vaslaki 2006	HDF versus HD	48 weeks	129
Verzetti 1998	AFB versus HD	12 months	41
Ward 2000	HDF versus HD	12 months	50
Wizemann 2000	HDF versus HD	24 months	44
AFB ‐ acetate‐free biofiltration; HDF ‐ haemodiafiltration; HD ‐ haemodialysis; HF ‐ haemofiltration

Table 1. Categories of interventions used in individual studies and duration of follow‐up

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Table 2. Description of included studies according with the interventions used

Categories of intervention	Study	Total number of studies	Total number of patients
HDF versus HD	Bammens 2004; Lin 2001; Locatelli 1994; Lornoy 1998; Teo 1987; Tuccillo 2002; Ward 2000; Wizemann 2000; Bolasco 2003; CONTRAST (Dutch) Study 2005; Cristofano 2004; Karamperis 2005; Mandolfo 2008; Pedrini 2011a; Righetti 2010; Schiffl 2007; Stefansson 2012; TURKISH HDF 2013; Vaslaki 2006 ESHOL Study 2011; Kantartzi 2013; Ohtake 2012	22	3299
HF versus HD	Beerenhout 2005; Fox 1993; Schiffl 1992; Bolasco 2003; Santoro 2005a; PROFIL Study 2011	6	325
AFB versus HD	Basile 2001; Santoro 1999; Eiselt 2000; Noris 1998; Schrander vd Meer 1998; Selby 2006a; Todeschini 2002; Verzetti 1998	8	487
HDF versus AFB	Coll 2009; Ding 2002; Movilli 1996	3	59
HDF versus HF	Altieri 2004; Bolasco 2003; Meert 2009	3	199
More than two treatment arms	Bolasco 2003; Locatelli 1994; Schiffl 1992	3	383
AFB ‐ acetate‐free biofiltration; HDF ‐ haemodiafiltration; HD ‐ haemodialysis; HF ‐ haemofiltration

Table 2. Description of included studies according with the interventions used

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Table 3. Summary of quality of life findings

Study ID	Comparison	Quality of Life scale used	Time of assessment	End of study result	Selective reporting of quality of life dimensions
Beerenhout 2005	HF versus HD	Kidney Disease Questionnaire	Before randomisation, at 6 months and at 1 year	No significant difference in scores in all five components of the scoring system between interventions	Yes
CONTRAST (Dutch) Study 2005	HDF versus HD	Kidney Disease Quality of Life‐Short Form	Median follow‐up of 2 years	There were no significant differences in changes in health‐related quality of life over time between groups (generic or kidney‐disease specific domains)	No
Kantartzi 2013	HDF versus HD	SF‐36	At 3 months	There were statistical significant differences in QoL for the total SF‐36 (36.1 (26.7 to 45.7) and 40.7 (30.2 to 62.8)), for classic low‐flux HD and high‐flux HDF, for bodily pain (45 (26.9 to 66.9) and 55 (35.6 to 87.5)), and for role limitations due to emotional functioning (0 (0 to 33.3) and 33.3 (0 to 100)), respectively No data were available for the end of the first phase of treatment	No
Lin 2001	HDF versus HD	Patient well‐being score	Once weekly for 15 months	Patients on HDF had significantly better scores ((physical well‐being score) MD 0.60, 95% CI 0.30 to 0.90).	No
Schiffl 2007	HDF versus HD	Kidney Disease Questionnaire	after 52 weeks	None of the other dimensions of the KDQ showed a change during the course of the study No data were available for the end of the first phase of treatment	Yes
Stefansson 2012	HDF versus HD	Physical functioning domain of IQOLA SF‐36 questionnaire	At day 60	With the exception of a lower score for social functioning with HDF (P < 0.05), there was no significant difference in quality of life between HD and HDF No data were available for the end of the first phase of treatment	No
Verzetti 1998	AFB	Subjective well‐being	Monthly	Reported well‐being significantly higher in patients receiving AFB in multivariate analysis although unclear whether between‐groups comparison was reported No data were available for the end of the first phase of treatment	No
Ward 2000	HDF versus HD	Kidney Disease Questionnaire	At 6 months and 1 year	No significant difference in scores in all five components of the scoring system between interventions	No
AFB ‐ acetate‐free biofiltration; HDF ‐ haemodiafiltration; HD ‐ haemodialysis; HF ‐ haemofiltration; SF‐36 ‐ Short‐Form Health Survey with 36 questions

Table 3. Summary of quality of life findings

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Comparison 1. Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	11	3396	Risk Ratio (IV, Random, 95% CI)	0.87 [0.72, 1.05]

2 Cardiovascular mortality Show forest plot	6	2889	Risk Ratio (IV, Random, 95% CI)	0.75 [0.61, 0.92]

3 Nonfatal cardiovascular event (rate/person‐years follow‐up) Show forest plot	1		Risk Ratio (IV, Random, 95% CI)	Totals not selected

4 Hospitalisation Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

4.1 Hospital admissions/year	1	45	Mean Difference (IV, Random, 95% CI)	0.20 [‐0.07, 0.47]
4.2 Days spent in hospital	2	67	Mean Difference (IV, Random, 95% CI)	‐1.22 [‐7.47, 5.03]
5 Hospitalisation (rate/person‐years follow‐up) Show forest plot	2	400	Risk Ratio (IV, Random, 95% CI)	1.23 [0.93, 1.63]

6 Change of dialysis modality Show forest plot	5	2919	Risk Ratio (IV, Random, 95% CI)	0.87 [0.41, 1.84]

7 Hypotension during dialysis (rate/person‐years follow‐up) Show forest plot			Other data	No numeric data

8 Dialysis sessions with hypotension Show forest plot	2	42	Mean Difference (IV, Random, 95% CI)	‐4.05 [‐15.39, 7.30]

9 Predialysis blood pressure Show forest plot	7		Mean Difference (IV, Random, 95% CI)	Subtotals only

9.1 Systolic blood pressure	7	1859	Mean Difference (IV, Random, 95% CI)	1.19 [‐1.46, 3.84]
9.2 Diastolic blood pressure	6	1154	Mean Difference (IV, Random, 95% CI)	‐0.25 [‐1.06, 0.56]
10 Maximal drop in blood pressure during dialysis Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

10.1 Systolic blood pressure	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
11 Kidney diseases questionnaire and well‐being scores Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

11.1 Inter‐dialysis patient well‐being score	1	67	Mean Difference (IV, Random, 95% CI)	0.60 [0.30, 0.90]
11.2 Physical symptoms	2	121	Mean Difference (IV, Random, 95% CI)	‐0.54 [‐1.52, 0.44]
11.3 Fatigue	1	45	Mean Difference (IV, Random, 95% CI)	0.0 [‐0.98, 0.98]
11.4 Depression	1	45	Mean Difference (IV, Random, 95% CI)	0.20 [‐0.50, 0.90]
11.5 Relationships	1	45	Mean Difference (IV, Random, 95% CI)	0.10 [‐0.73, 0.93]
11.6 Frustration	1	45	Mean Difference (IV, Random, 95% CI)	‐0.20 [‐1.61, 1.21]
12 Kt/V Show forest plot	14	2022	Mean Difference (IV, Random, 95% CI)	0.07 [‐0.00, 0.14]

13 Urea reduction ratio Show forest plot	3	879	Std. Mean Difference (IV, Random, 95% CI)	0.39 [0.06, 0.72]

14 Predialysis serum B₂ microglobulin Show forest plot	12	1813	Mean Difference (IV, Random, 95% CI)	‐5.55 [‐9.11, ‐1.98]

15 B₂ microglobulin clearance Show forest plot	3	65	Mean Difference (IV, Random, 95% CI)	13.05 [‐5.94, 32.04]

16 Dialysate B₂ microglobulin level Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

17 Data from cross‐over studies Show forest plot			Other data	No numeric data

17.1 Hospitalisation			Other data	No numeric data
17.2 Patients experiencing hypotension			Other data	No numeric data
17.3 Intradialytic hypotensive events			Other data	No numeric data
17.4 Symptomatic intradialytic hypotensive events			Other data	No numeric data
17.5 Predialysis systolic blood pressure (mm Hg)			Other data	No numeric data
17.6 Predialysis diastolic blood pressure (mm Hg)			Other data	No numeric data
17.7 Predialysis mean arterial pressure (mm Hg)			Other data	No numeric data
17.8 Postdialysis systolic blood pressure (mm Hg)			Other data	No numeric data
17.9 Postdialysis diastolic blood pressure (mm Hg)			Other data	No numeric data
17.10 Postdialysis fall in systolic blood pressure (mm Hg)			Other data	No numeric data
17.11 Postdialysis mean arterial pressure (mm Hg)			Other data	No numeric data
17.12 Difference between pre‐ and postdialysis systolic blood pressure (mm Hg)			Other data	No numeric data
17.13 Difference between pre‐ and postdialysis diastolic blood pressure (mm Hg)			Other data	No numeric data
17.14 Intradialysis mean systolic blood pressure (mm Hg)			Other data	No numeric data
17.15 Intradialysis mean diastolic blood pressure (mm Hg)			Other data	No numeric data
17.16 Intradialysis mean arterial pressure (mm Hg)			Other data	No numeric data
17.17 Kt/V			Other data	No numeric data
17.18 Urea reduction ratio			Other data	No numeric data
17.19 Predialysis serum B2 microglobulin level (mg/L)			Other data	No numeric data

Comparison 1. Convection (haemofiltration/haemodiafiltration/acetate‐free biofiltration) versus haemodialysis

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Comparison 2. Convection versus convection (haemofiltration versus haemodiafiltration)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Predialysis blood pressure Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Systolic blood pressure	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Diastolic blood pressure	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Kt/V Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4 Data from cross‐over studies Show forest plot			Other data	No numeric data

4.1 Days spent in hospital			Other data	No numeric data
4.2 Average number of episodes of hypotension/patient/month			Other data	No numeric data
4.3 Number of patients experiencing hypotension			Other data	No numeric data
4.4 Predialysis systolic blood pressure (mm Hg)			Other data	No numeric data
4.5 Predialysis diastolic blood pressure (mm Hg)			Other data	No numeric data
4.6 Predialysis mean arterial pressure (mm Hg)			Other data	No numeric data
4.7 Postdialysis systolic blood pressure (mm Hg)			Other data	No numeric data
4.8 Postdialysis diastolic blood pressure (mm Hg)			Other data	No numeric data
4.9 Postdialysis mean arterial blood pressure (mm Hg)			Other data	No numeric data
4.10 Number of patients experiencing hypertension			Other data	No numeric data
4.11 Kt/V			Other data	No numeric data
4.12 Predialysis serum B2 microglobulin (mg/L)			Other data	No numeric data
4.13 B2 microglobulin clearance (mL/min)			Other data	No numeric data

Comparison 2. Convection versus convection (haemofiltration versus haemodiafiltration)

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Comparison 3. Convection versus convection (haemodiafiltration versus acetate‐free biofiltration)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Data from cross‐over studies Show forest plot			Other data	No numeric data

1.1 Number of hospitalisations/patient during observation period			Other data	No numeric data
1.2 Length of hospitalisation stay/patient (days/patient)			Other data	No numeric data
1.3 Number of dialysis sessions with hypotension			Other data	No numeric data
1.4 Predialysis systolic blood pressure (mm Hg)			Other data	No numeric data
1.5 Predialysis mean arterial pressure (mm Hg)			Other data	No numeric data
1.6 Postdialysis systolic blood pressure (mm Hg)			Other data	No numeric data
1.7 Interdialysis symptom score			Other data	No numeric data
1.8 Kt/V			Other data	No numeric data
1.9 Urea reduction ratio			Other data	No numeric data
1.10 Predialysis B2 microglobulin (mg/L)			Other data	No numeric data
1.11 Number of dialysis sessions with side effects (nausea, vomiting, headaches)			Other data	No numeric data

Comparison 3. Convection versus convection (haemodiafiltration versus acetate‐free biofiltration)

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