#321 Hemodiafiltration for ESRD patients

Abstract Background and Aims This systematic review and meta-analysis were designed to determine the effect of hemodiafiltration (HDF), or hemofiltration (HF) compared to hemodialysis on the prognosis of end-stage renal disease (ESRD) patients. Method PubMed, Embase, and Web of Science were searched for published studies from reception to 18 September 2023, and updated search on October 15, 2023. Randomized clinical trials (RCTs) or cohort studies evaluated prognosis of hemodiafiltration, or hemofiltration compared to hemodialysis in patients with ESRD were included. Data was synthesized based on heterogeneity with corresponding model selected, and trial sequential analyses were conducted. The primary outcome was all-cause mortality, and secondary outcome was cardiovascular mortality and dialysis adequacy. Outcomes were reported as relative risk (RR), hazard ratio (HR), or mean difference (MD) with a 95% confidence interval (95% CI). Results There were 26 RCTs, 10 cohort studies, and total of 36 articles included in the meta-analysis. Pooled results of RCTs showed a statistically significant difference in all-cause mortality between HDF/HF group and standard hemodialysis group (RR = 0.86; 95% CI 0.78-0.96; I2 = 29%; Fig. 1). Trial sequence analysis (TSA) showed that the all-cause mortality curve crossed the traditional and TSA boundaries, but it was not yet as informative as desired. Subgroup analysis found that ESRD patients treated with hemodiafiltration had a 13% lower risk of death (RR = 0.87; 95% CI 0.78-0.97; Fig. 1) with no heterogeneity (I2 = 0%). In contrast, the effect of hemofiltration on mortality risk in ESRD patients was not significant (RR = 0.70; 95% CI 0.39-1.29; Fig. 1). A similarly statistically significant difference in cardiovascular mortality (RR = 0.747; 95% CI 0.607-0.917; I2 = 0%; Fig. 2) for RCTs. In addition, HDF/HF treatment was significantly associated with improved dialysis adequacy (Assessed by Kt/V) in ESRD patients (MD: 0.09; 95% CI 0.01-0.17; I2 = 96%). The combined results of cohort studies showed a 28.6% reduction in mortality risk in ESRD patients treated with HDF (HR = 0.714; 95% CI 0.575-0.886; I2 = 84%; Fig. 3), with an HR for cardiovascular mortality of 0.708 (95% CI 0.604-0.829; I2 = 0%; Fig. 4). Conclusion Overall, HDF/HF was associated with reduced all-cause mortality and cardiovascular mortality in patients with ESRD and contributed to improved dialysis adequacy.