Does increased removal of high-molecular-weight toxins improve the survival of hemodialysis patients?

This commentary discusses a small multicenter, prospective clinical trial in which patients with end-stage renal disease were randomized to treatment with online high-flux hemofiltration or low-flux hemodialysis. Over a 3-year follow-up period, survival was significantly better in patients who received online hemofiltration than in patients who received low-flux hemodialysis. In addition, the average duration, but not the frequency, of hospitalization, and the incidence of intradialytic hypotension, were lower in the hemofiltration group than in the hemodialysis group. The study supports the hypothesis that increased removal of large molecules can decrease the high morbidity and mortality associated with end-stage renal disease. However, the applicability of the findings to the general population of patients with end-stage renal disease might be limited by the small size of the study, the demographics of the study population, and the high dropout rate. Larger trials are needed to confirm this study's results and to establish the appropriate dose of convection for optimal outcomes.