Does hemofiltration offer a survival advantage over conventional hemodialysis in adults with kidney failure?
For adults with kidney failure who were judged to be good candidates, high-dose hemofiltration resulted in lower all-cause mortality then conventional hemodialysis (NNT = 22 per year). Note that the benefit was not seen in patients with diabetes mellitus or pre-existing cardiovascular disease.
Randomized controlled trial (nonblinded)
High-dose hemofiltration is an option for patients with chronic kidney failure who can tolerate a high convection volume (> 23 liters/session, 3 sessions/week). Although it not widely used in the United States, previous studies have suggested lower mortality with this approach. In this study, 1360 adults with kidney failure who had received at least 3 months of hemodialysis and who were judged to be good candidates for high-dose hemofiltration were randomized to receive continued hemodialysis or high-dose hemofiltration. Groups were balanced at baseline and analysis was by intention to treat. The patients' mean age was 62 years, 37% were female, and the median months of previous hemodialysis was 30 to 35 months. After a median of 30 months' follow-up, only approximately 2% of patients were lost to follow-up (though previously noncompliant patients were excluded from the trial). All-cause mortality was significantly lower in the hemofiltration group (17.3% vs 21.9%; hazard ratio [HR] = 0.77; 95% CI 0.65 - 0.93; number needed to treat [NNT] = 22 per year). The lower all-cause mortality rate was seen only in patients without diabetes mellitus (HR = 0.65; 0.48 - 0.87), not in those with a history of diabetes (HR = 0.97; 0.72 - 1.31). It was also not seen in participants with pre-existing cardiovascular disease (HR = 0.99; 0.76 - 1.28). The number of hospitalizations and adverse events were similar. A total of 92% of hemofiltration sessions achieved the target volume.
Mark H. Ebell, MD, MS
University of Georgia