Hemodiafiltration versus Hemodialysis in End-Stage Kidney Disease: A Systematic Review and Meta-analysis

Rationale & Objective The use of hemodiafiltration (HDF) as a kidney replacement therapy (KRT) in patients with end-stage kidney disease (ESKD) has sparked a debate regarding its advantages over conventional hemodialysis (HD). The present study aims to shed light on this controversy by comparing mortality rates and cause-specific deaths between ESKD patients receiving HDF and those undergoing HD. Study Design Systematic review and meta-analysis of randomized controlled trials (RCTs). The search was conducted on PubMed, EMBASE, and Cochrane Central on July 01, 2023. Setting & Participants Adult patients with ESKD on regular KRT. Selection Criteria for Studies RCTs evaluating HDF versus HD. Crossover trials and studies with overlapping populations were excluded. Data Extraction Two authors independently extracted the data following predefined search criteria and quality assessment. Analytical Approach Primary outcomes were all-cause mortality, cardiovascular (CV) mortality, deaths related to infections, and kidney transplant. We also evaluated the endpoints for deaths related to malignancy, myocardial infarction, stroke, arrhythmias, and sudden death. The risk of bias was accessed with Cochrane’s RoB2 tool. Results We included 5 RCTs with 4,143 patients, of which 2,078 (50.1%) underwent HDF, while 2065 (49.8%) were on HD. Overall, HDF was associated with a lower risk of all-cause mortality (RR 0.81; 95% CI 0.73-0.91; p<0.001; I2=7%) and a lower risk of CV-related deaths (RR 0.75; 95% CI 0.61-0.92; p=0.007; I2=0%). The incidence of infection-related deaths was also significantly different between therapies RR 0.69; 0.50-0.95; p=0.02; I2 = 26%). Limitations In individual studies, the HDF groups achieved varying levels of convection volume. Conclusions Compared to those undergoing HD, patients receiving HDF experienced a reduction in all-cause mortality, CV mortality, and infections-related mortality. These results provide compelling evidence supporting the use of HDF as a beneficial intervention in ESKD patients undergoing KRT.