Mortality reduction by post-dilution online-haemodiafiltration: a cause-specific analysis

Menso J Nubé (1) , Sanne A. E. Peters (2, 3) , Peter Blankestijn (3) , Bernard Canaud (4) , Andrew Davenport (5) , Muriel P.C. Grooteman (1) , Gulay Asci (6) , Francesco Locatelli (7) , Francisco Maduell (8) , Marion Morena (9, 10) , Ercan Ok (6) , Ferran Torres (11, 8) , Michiel Bots (3)

1 VU University Medical Center [Amsterdam]
2 University of Oxford
3 University Medical Center [Utrecht]
4 Fresenius Medical Care Deutschland
5 UCL - University College of London [London]
6 Ege university
7 Alessandro Manzoni Hospital
8 Hospital Clinic Barcelona
9 PhyMedExp - Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046]
10 CHRU Montpellier - Centre Hospitalier Régional Universitaire [Montpellier]
11 UAB - Universitat Autònoma de Barcelona = Autonomous University of Barcelona = Universidad Autónoma de Barcelona

Background: From an individual participant data (IPD) meta-analysis from four randomized controlled trials comparing haemodialysis (HD) with post-dilution online-haemodiafiltration (ol-HDF), previously it appeared that HDF decreases all-cause mortality by 14% (95% confidence interval 25; 1) and fatal cardiovascular disease (CVD) by 23% (39; 3). Significant differences were not found for fatal infections and sudden death. So far, it is unclear, however, whether the reduced mortality risk of HDF is only due to a decrease in CVD events and if so, which CVD in particular is prevented, if compared with HD. Methods: The IPD base was used for the present study. Hazard ratios and 95% confidence intervals for cause-specific mortality overall and in thirds of the convection volume were calculated using the Cox proportional hazard regression models. Annualized mortality and numbers needed to treat (NNT) were calculated as well. Results: Besides 554 patients dying from CVD, fatal infections and sudden death, 215 participants died from 'other causes', such as withdrawal from treatment and malignancies. In this group, the mortality risk was comparable between HD and ol-HDF patients, both overall and in thirds of the convection volume. Subdivision of CVD mortality in fatal cardiac, non-cardiac and unclassified CVD showed that ol-HDF was only associated with a lower risk of cardiac casualties [0.64 (0.61; 0.90)]. Annual mortality rates also suggest that the reduction in CVD death is mainly due to a decrease in cardiac fatalities, including both ischaemic heart disease and congestion. Overall, 32 and 75 patients, respectively, need to be treated by high-volume HDF (HV-HDF) to prevent one all-cause and one CVD death, respectively, per year. Conclusion: The beneficial effect of ol-HDF on all-cause and CVD mortality appears to be mainly due to a reduction in fatal cardiac events, including ischaemic heart disease as well as congestion. In HV-HDF, the NNT to prevent one CVD death is 75 per year.

Mots clés: meta-analysis; cardiovascular disease; convection volume; haemodiafiltration; mortality

Domaines: Urologie et Néphrologie

Menso J Nubé, Sanne A. E. Peters, Peter Blankestijn, Bernard Canaud, Andrew Davenport, et al.. Mortality reduction by post-dilution online-haemodiafiltration: a cause-specific analysis. Nephrology Dialysis Transplantation, 2017, 32 (3), pp.548-555. ⟨10.1093/ndt/gfw381⟩. ⟨hal-01793180⟩