Zhang Yan, Winter Anke, Ferreras Belén Alejos, Carioni Paola, Arkossy Otto, Anger Michael, Kossmann Robert, Usvyat Len A, Stuard Stefano, Maddux Franklin W
Fresenius Medical Care Deutschland GmbH, Bad Homburg, Hessen, Germany.
Renal Research Institute, New York, USA.
BMC Nephrol. 2025 Jan 7;26(1):9. doi: 10.1186/s12882-024-03934-y.
Results from the CONVINCE clinical trial suggest a 23% mortality risk reduction among patients receiving high-volume (> 23 L) hemodiafiltration. We assessed the real-world effectiveness of blood-based kidney replacement therapy (KRT) with hemodiafiltration vs. hemodialysis in a large, unselected patient population treated prior to and during the COVID-19 pandemic.
In this retrospective cohort study, we analyzed pseudonymized data from 85,117 adults receiving in-center care across NephroCare clinics in Europe, the Middle East, and Africa during 2019-2022. Cox regression models with KRT modality and coronavirus disease 2019 (COVID-19) status as time-varying covariates, and adjusted for multiple confounders, were used to estimate all-cause (primary) and cardiovascular (secondary) mortality. Subgroup analyses were performed for age, dialysis vintage, COVID-19 status, diabetes, and cardiovascular disease.
At baseline, 55% of patients were receiving hemodialysis and 45% of patients were receiving hemodiafiltration. Baseline characteristics were similar between baseline modalities, except that hemodiafiltration patients were a median of 2 years younger, had higher percentage of fistula access (66% vs. 47%), and had longer mean dialysis vintages (4.4 years vs. 2.6 years). Compared with hemodialysis, hemodiafiltration was associated with an adjusted hazard ratio (HR) for all-cause mortality of 0.78 (95% confidence interval [Cl], 0.76-0.80), irrespective of COVID-19 infection. The pattern of a beneficial effect of hemodiafiltration was consistently observed among all analyzed subgroups. Among patients receiving high-volume hemodiafiltration (mean convection volume ≥ 23 L), the risk of death was reduced by 30% (HR, 0.70 [95% CI, 0.68-0.72]). Hemodiafiltration was also associated with a 31% reduced risk of cardiovascular death.
Our results suggest that hemodiafiltration has a beneficial effect on all-cause and cardiovascular mortality in a large, unselected patient population and across patient subgroups in real-world settings. Our study complements evidence from the CONVINCE trial and adds to the growing body of real-world evidence on hemodiafiltration.
CONVINCE临床试验结果表明，接受大容量（>23L）血液透析滤过的患者死亡风险降低23%。我们评估了在2019-2022年新冠疫情之前及期间接受治疗的大量未经过筛选的患者群体中，血液透析滤过与血液透析这两种以血液为基础的肾脏替代疗法（KRT）的实际效果。
在这项回顾性队列研究中，我们分析了2019年至2022年期间在欧洲、中东和非洲的NephroCare诊所接受中心治疗的85117名成年人的匿名数据。以KRT方式和2019冠状病毒病（COVID-19）状态作为随时间变化的协变量，并对多个混杂因素进行调整的Cox回归模型，用于估计全因（主要）死亡率和心血管（次要）死亡率。对年龄、透析时间、COVID-19状态、糖尿病和心血管疾病进行了亚组分析。
在基线时，55%的患者接受血液透析，45%的患者接受血液透析滤过。两种基线治疗方式的基线特征相似，但血液透析滤过患者的年龄中位数小2岁，动静脉内瘘通路的比例更高（66%对47%），平均透析时间更长（4.4年对2.6年）。与血液透析相比，无论是否感染COVID-19，血液透析滤过与全因死亡率的调整后风险比（HR）为0.78（95%置信区间[Cl]，0.76-0.80）。在所有分析的亚组中均一致观察到血液透析滤过的有益效果模式。在接受大容量血液透析滤过（平均对流体积≥23L）的患者中，死亡风险降低了30%（HR，0.70[95%CI，0.68-0.72]）。血液透析滤过还与心血管死亡风险降低31%相关。
我们的结果表明，在实际环境中，血液透析滤过对大量未经过筛选的患者群体以及各个患者亚组的全因死亡率和心血管死亡率均有有益影响。我们的研究补充了CONVINCE试验的证据，并增加了关于血液透析滤过的越来越多的实际证据。
