Basile Carlo, Davenport Andrew, Blankestijn Peter J
Division of Nephrology, Clinical Research Branch, Miulli General Hospital, 70121, Acquaviva delle Fonti, Italy.
University College London Medical School, Royal Free Hospital, Centre for Nephrology, University College London, London, UK.
J Nephrol. 2017 Apr;30(2):181-186. doi: 10.1007/s40620-016-0343-0. Epub 2016 Sep 1.
The mortality rate of patients on maintenance dialysis remains alarmingly high, at approximately 15-20 % per year. Increasing dialyzer urea clearance has not been shown to improve survival and hence interest has shifted towards convective therapies, such as hemodiafiltration (HDF) which can remove middle molecular weight uremic toxins, which have been suggested to increase mortality in patients with end-stage kidney disease. During the last few years, four large prospective randomized controlled trials (RCTs) have been conducted in different European countries to compare survival outcomes in prevalent patients receiving conventional hemodialysis with online post-dilution HDF (OL HDF). Furthermore, a pooled individual participant data analysis from four RCTs was performed and four large meta-analyses on convective therapies have been published in the last 2 years. Taken together, these studies support the conclusion that high volume post-dilution OL HDF is associated with improved overall survival. This advantage results predominantly from a lower cardiovascular mortality, possibly due to better preservation of left ventricle mass and function. Improved intra-dialytic blood pressure stability may contribute to the beneficial effect of high volume post-dilution OL HDF on survival. The beneficial effect is not restricted to selected subgroups, such as age, comorbidity or dialysis vintage. There is no compelling evidence that high volume post-dilution OL HDF reduces mortality by improvements in traditional and non-traditional risk factors. There are still no studies or case reports published describing adverse clinical outcomes in more than 20 years of HDF clinical experience. In conclusion, most of the available data support the choice of high volume post-dilution HDF over the current dialysis techniques. However, considering that we live in the era of evidence-based medicine, the evidence supporting the superiority of high volume post-dilution OL HDF in comparison to hemodialysis is still missing: in fact, a new RCT targeting different convection volumes would be needed to definitively examine the dose-response effect shown in previous studies.
维持性透析患者的死亡率仍然高得惊人，每年约为15%-20%。提高透析器尿素清除率并未显示能改善生存率，因此人们的兴趣已转向对流疗法，如血液透析滤过（HDF），它可以清除中分子量尿毒症毒素，这些毒素被认为会增加终末期肾病患者的死亡率。在过去几年中，欧洲不同国家进行了四项大型前瞻性随机对照试验（RCT），以比较接受传统血液透析的现患患者与在线后稀释HDF（OL HDF）的生存结局。此外，对四项RCT进行了汇总个体参与者数据分析，并且在过去两年中发表了四项关于对流疗法的大型荟萃分析。综合来看，这些研究支持以下结论：高容量后稀释OL HDF与总体生存率提高相关。这一优势主要源于较低的心血管死亡率，可能是由于更好地保留了左心室质量和功能。透析期间血压稳定性的改善可能有助于高容量后稀释OL HDF对生存产生有益影响。这种有益效果并不局限于特定亚组，如年龄、合并症或透析龄。没有令人信服的证据表明高容量后稀释OL HDF通过改善传统和非传统风险因素来降低死亡率。在超过20年的HDF临床经验中，仍然没有发表描述不良临床结局的研究或病例报告。总之，大多数现有数据支持选择高容量后稀释HDF而非当前的透析技术。然而，考虑到我们生活在循证医学时代，与血液透析相比，支持高容量后稀释OL HDF优越性的证据仍然缺失：事实上，需要一项针对不同对流体积的新RCT来明确检验先前研究中显示的剂量反应效应。
