Key Points High-volume hemodiafiltration was associated with a 20% lower all-cause mortality risk compared with hemodialysis in incident patients. High-volume hemodiafiltration was associated with a 29% lower cardiovascular mortality risk compared with hemodialysis in incident patients. Associations between high-volume hemodiafiltration and lower mortality were consistent across demographic and clinical subgroups. Background Evidence for a survival benefit of hemodiafiltration (HDF) over high-flux hemodialysis largely comes from studies based on prevalent ESKD patients with longer dialysis exposure. By contrast, the effect of HDF on mortality of incident patients—those newly starting dialysis—remains less well understood. Methods We analyzed data from 18,515 incident patients (dialysis vintage <3 months) treated between 2019 and 2022 at Fresenius Medical Care NephroCare Clinics. Patients were classified as HDF or hemodialysis on the basis of their predominant dialysis modality during the first year of follow-up (≥75% of sessions). To assess the effect of HDF in the early phase after treatment initiation, follow-up was limited to 2 years. Cox proportional hazards models with inverse probability of treatment weighting were applied to estimate all-cause and cardiovascular disease mortality risk. Results Baseline characteristics between HDF and hemodialysis groups were comparable after inverse probability of treatment weighting. Over a median follow-up of 15.7 months (interquartile range, 6.4–24.0 months), HDF was associated with a lower risk of all-cause mortality compared with hemodialysis (11.7 versus 15.6 per 100 person-years; hazard ratio, 0.80; 95% confidence interval, 0.75 to 0.86). Furthermore, HDF was associated with a lower risk of cardiovascular disease mortality compared with hemodialysis (4.1 versus 6.7 per 100 person-years; hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80). Conclusions In the large real-world cohort of incident patients with ESKD who are in the early phase of dialysis treatment, online HDF was associated with a significant survival advantage compared with conventional hemodialysis. These findings reinforce the potential clinical benefits of HDF and support early adoption of HDF upon dialysis initiation. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2026_07_22_CJASNJuly.21.7.7222.mp3

KEY POINTS:High-volume hemodiafiltration was associated with a 20% lower all-cause mortality risk compared with hemodialysis in incident patients. High-volume hemodiafiltration was associated with a 29% lower cardiovascular mortality risk compared with hemodialysis in incident patients. Associations between high-volume hemodiafiltration and lower mortality were consistent across demographic and clinical subgroups. BACKGROUND:Evidence for a survival benefit of hemodiafiltration (HDF) over high-flux hemodialysis largely comes from studies based on prevalent ESKD patients with longer dialysis exposure. By contrast, the effect of HDF on mortality of incident patients-those newly starting dialysis-remains less well understood. METHODS:We analyzed data from 18,515 incident patients (dialysis vintage <3 months) treated between 2019 and 2022 at Fresenius Medical Care NephroCare Clinics. Patients were classified as HDF or hemodialysis on the basis of their predominant dialysis modality during the first year of follow-up (≥75% of sessions). To assess the effect of HDF in the early phase after treatment initiation, follow-up was limited to 2 years. Cox proportional hazards models with inverse probability of treatment weighting were applied to estimate all-cause and cardiovascular disease mortality risk. RESULTS:Baseline characteristics between HDF and hemodialysis groups were comparable after inverse probability of treatment weighting. Over a median follow-up of 15.7 months (interquartile range, 6.4-24.0 months), HDF was associated with a lower risk of all-cause mortality compared with hemodialysis (11.7 versus 15.6 per 100 person-years; hazard ratio, 0.80; 95% confidence interval, 0.75 to 0.86). Furthermore, HDF was associated with a lower risk of cardiovascular disease mortality compared with hemodialysis (4.1 versus 6.7 per 100 person-years; hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80). CONCLUSIONS:In the large real-world cohort of incident patients with ESKD who are in the early phase of dialysis treatment, online HDF was associated with a significant survival advantage compared with conventional hemodialysis. These findings reinforce the potential clinical benefits of HDF and support early adoption of HDF upon dialysis initiation.

Key PointsCompared with high-flux hemodialysis, postdilution high volume hemodiafiltration was associated with a lower number of hospital admissions.Compared with high-flux hemodialysis, postdilution high volume hemodiafiltration was associated with reduced days spent in the hospital.BackgroundPatients with ESKD undergoing hemodialysis experience high rates of hospitalizations and mortality, partly due to the incomplete removal of some toxic uremic molecules. To improve outcomes, multiple modalities of kidney replacement therapy have been developed, including high-flux hemodialysis and on-line hemodiafiltration (HDF). Notably, on-line high-volume HDF (HV-HDF) has demonstrated mortality benefits over high-flux hemodialysis in some randomized trials.MethodsThis retrospective cohort study evaluated hospitalization outcomes among in-center dialysis patients treated with HV-HDF and high-flux hemodialysis at Fresenius Medical Care NephroCare centers across Europe, the Middle East, and Africa between January 2019 and December 2022. Data were extracted from the European Clinical Database. The primary outcome was all-cause hospitalization; secondary outcomes included cause-specific hospitalizations. Negative binomial regression was used to estimate incidence rate ratios (IRRs) for hospital outcomes, incorporating inverse probability of treatment weighting to adjust for baseline differences between treatment groups.ResultsA total of 71,669 patients were included, with 45% receiving hemodialysis and 55% receiving HDF. During the follow-up period, patients in the HDF group underwent a total of 12,741,453 HDF treatments, with a mean convection volume of 25.8 L (84% with CV >= 23L). Compared with hemodialysis, treatment with HDF was associated with a lower incidence of both hospital admissions (adjusted IRR, 0.80; 95% confidence interval, 0.79 to 0.82) and days spent in the hospital (adjusted IRR, 0.80; 95% confidence interval, 0.78 to 0.82). These reductions were consistent across subgroups analyzed and across most major causes of hospitalization, including cardiovascular disease, infections, and fluid-related complications.ConclusionsIn this large, real-world cohort spanning multiple regions and dialysis centers, HV-HDF was associated with significantly lower rates of both hospital admissions and days spent in the hospital compared with treatment with high-flux hemodialysis. These findings suggest that HV-HDF may have the potential to reduce morbidity in patients with ESKD.

Gastrointestinal bleeding (GIB) is the most common bleeding event in dialysis,1 yet known incidence rates are based on small studies and the influence of patient characteristics is unknown. We used a nationally representative sample of dialysis patients treated in the United States (US) to characterize the incidence rates of major GIB episodes requiring hospitalization overall and by age, sex, and history of GIB comorbidity. We used data from a kidney care network from Jan 2018 through Mar 2021. Analysis included data from adult dialysis patients (age ≥ 18 years) who were treated with dialysis for ≥ 30 days. We excluded data from patients who started dialysis on or after Jan 2021 to provide a 3-month minimum follow up for outcomes to occur. GIB hospitalization was identified from international classification of diseases (ICD) diagnosis codes recorded as the primary, secondary, or tertiary discharge reason for hospitalization. ICD clusters defining GIB hospitalization and lesion location were based on the US Healthcare Cost and Utilization Project.2 We calculated the incidence of GIB hospitalization per 1,000 person-years (per 1000 py). Time at risk excluded GIB hospital admission time. Analysis included 366,839 adults on dialysis (mean age of 62.6 years, 57.7% male, 55.8% white race). A total of 25,057 patients (6.8%) experienced GIB hospitalization, with 18,407 (73.5%) having a single event and 6,650 (26.5%) experiencing recurrent events. The standardized incidence rate of GIB hospitalization was 52.6 per 1000 py (95% CI: 52.1–53.1). Among all GIB episodes, 6,623 were classified as upper GIB, 4,378 as lower GIB, with 2,905 episodes having an upper and lower GIB diagnosed during the same event. A remarkable number of episodes (n = 16,961) did not have a specified lesion location in the ICD code; there were no differences in patient characteristics for those with a known versus unknown lesion location. Assuming missingness at random, the standardized incidence rate of GIB hospitalization was higher for upper GIB (11.4 per 1000 py, 95% CI: 11.2–11.7) versus lower GIB events (7.5 per 1000 py, 95% CI: 7.3–7.7). The incidence rate of GIB hospitalization progressively increased with age, being about three times higher in individuals aged 75 and older versus 18–44 (Table 1). Females had a slight, but statistically significant higher GIB hospitalization incidence rate compared to males. A baseline GIB comorbidity was associated with a four times higher incidence rate of GIB hospitalization. Major GIB events requiring hospitalization affect about 53 out of every 1000 people on dialysis every year in the US. In the general population, GIB hospitalization affects about 1 of every 1000 people each year. This more than 50-fold higher rate in the standardized incidence of GIB hospitalization reveals a remarkable burden and unmet need in the dialysis population.3 Sixty percent of GIB hospitalizations involved upper GIB, and 40% involved lower. Over 25% of patients had multiple GIB hospitalizations. Rates rose with age and were four times higher with prior GIB. These findings highlight the burden of GIB within this vulnerable population, emphasizing the need for improved strategies for detection, such as data driven prediction algorithms, and treatment before the need for hospitalization. This study’s findings should be interpreted considering certain limitations, including reliance on hospitalization and comorbidity data collected as part of routine dialysis therapy.

Results from the CONVINCE clinical trial suggest a 23

Abstract Background and Aims Data is often collected during kidney dialysis treatments, providing data on a large scale and at a constant flow. As multinational datasets are scarce, Apollo Dial DB was created by a global provider that contains longitudinal observational data across six continents. This database is fully anonymised and can be used to better understand modality practice of global patients from a variety of healthcare systems for quality improvement and research efforts. Our aim was to detail patterns of dialysis modalities used among patients treated in 40 countries across six continents represented in the first version of the global database. Method Apollo Dial DB, a global anonymised dialysis database, contains demographics, diagnoses, laboratories, medications, treatments, quality of life, and outcomes from six continents and 40 countries. Data was harmonised from different electronic systems and anonymised based on logic established in a re-identification risk assessment. Data is consolidated and stored in a central cloud environment. The initial version of the dataset contains data on more than 360 variables from January 2018 to March 2021 and will be updated periodically. Results The first version of the Apollo Dial DB includes data on 543,169 patients, with 4.6% from Asia-Pacific (AP), 13.9% from Europe, Middle East, and Africa (EMEA), 7.0% from Latin America (LA), and 74.5% from North America (NA) countries. Most of the patients included in the database are between 45-64 years old at the initiation of dialysis. Overall, Apollo Dial DB contains information on 140,016,249 dialysis treatment observations. Depending on the region, different treatment patterns could be observed (Table 1 and Fig. 1). In EMEA a higher proportion of patients received hemodiafiltration with post-dilution, especially in Northern and Southern Europe as well as in South Africa. Peritoneal dialysis was more frequently used in LA and NA than in other regions. CCPD was mainly used in NA, whereas CAPD was common in LA and EMEA. For a more detailed look across the six continents Fig. 1 illustrates incentre hemodialysis modality patterns on a minor world region level. For incentre hemodialysis treatments, the majority of treatments from the minor regions in AP, LA, and NA had HD treatments. However, the majority treatments from EMEA minor regions are receiving incentre HDF treatments. Conclusion In a descriptive analysis, we defined modality treatment patterns in major world regions. These findings act as benchmarks for the nephrology community and expand upon scarce point prevalent information on modality practice patterns used throughout the world [1]. Apollo Dial DB offers opportunities for investigators to conduct global analytics and advance the state of the art.