title: Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: a systematic review and meta-analysis of randomized trials.
abstract: BACKGROUND
  Whether convective modalities of dialysis, including hemofiltration (HF) and hemodiafiltration (HDF), improve cardiovascular outcomes and mortality is unclear.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  Patients receiving HDF, HF, or standard hemodialysis (HD).
  
  
  METHODS
  Randomized controlled trials.
  
  
  METHODS
  Convective modalities of dialysis (HDF and HF) versus standard HD.
  
  
  RESULTS
  The primary outcome was clinical cardiovascular outcomes. Secondary outcomes were all-cause mortality, episodes of symptomatic hypotension, dialysis adequacy, and β2-microglobulin level. Relative risks (RRs) or weighted mean differences with 95% CIs for individual trials were pooled using random-effects models.
  
  
  RESULTS
  The search yielded 16 trials including 3,220 patients. Therapies assessed were convective modalities (HDF or HF) compared with standard HD. Compared with HD, convective modalities did not significantly reduce the risk of cardiovascular events (RR, 0.85; 95% CI, 0.66-1.10) or all-cause mortality (RR, 0.83; 95% CI, 0.65-1.05). Convective modalities reduced symptomatic hypotension (RR, 0.49; 95% CI, 0.30-0.81) and improved serum β2-microglobulin levels (-5.95 mg/L; 95% CI, -10.27 to -1.64), but had no impact on small-molecule clearance (weighted mean difference in Kt/V, 0.04; 95% CI, -0.04 to 0.12). There was a nonsignificant trend to a greater likelihood of receiving a kidney transplant for participants allocated to filtration therapies (RR, 1.19; 95% CI, 0.99-1.42).
  
  
  CONCLUSIONS
  The trials were predominantly of suboptimal quality and underpowered, with imbalance in some prognostic variables at baseline. Intention-to-treat analysis was not used in some trials. Our analysis was limited to published outcomes.
  
  
  CONCLUSIONS
  The potential benefits of convective modalities over standard HD for cardiovascular outcomes and mortality remain unproved. Further high-quality randomized trials are needed to define the impact of these modalities on clinically important outcomes.
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Camperdown, Australia.
authors.forename: Amanda Y
authors.initials: AY
authors.lastname: Wang
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Camperdown, Australia.
authors.forename: Toshiharu
authors.initials: T
authors.lastname: Ninomiya
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Camperdown, Australia; Department of Nephrology, Concord Repatriation General Hospital, Concord, Australia.
authors.forename: Anas
authors.initials: A
authors.lastname: Al-Kahwa
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Camperdown, Australia.
authors.forename: Vlado
authors.initials: V
authors.lastname: Perkovic
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Camperdown, Australia; Department of Nephrology, Concord Repatriation General Hospital, Concord, Australia.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Gallagher
authors.affiliation: Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.
authors.forename: Carmel
authors.initials: C
authors.lastname: Hawley
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Camperdown, Australia; Department of Nephrology, Concord Repatriation General Hospital, Concord, Australia. Electronic address: mjardine@georgeinstitute.org.au.
authors.forename: Meg J
authors.initials: MJ
authors.lastname: Jardine
mesh_terms: D002318:Cardiovascular Diseases / Q000453:epidemiology*; D015897:Comorbidity; D017583:Hemodiafiltration; D006440:Hemofiltration; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D006435:Renal Dialysis; D016896:Treatment Outcome
keywords: Hemodiafiltration; all-cause mortality; cardiovascular diseases; clinical trial; end-stage renal disease, systematic review; hemodialysis; hemofiltration; meta-analysis; randomized controlled trial