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      Effect of online hemodiafiltration compared with hemodialysis on quality of life in patients with ESRD: A systematic review and meta-analysis of randomized trials

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          Abstract

          Background

          End-stage renal disease (ESRD) is related to high morbidity, mortality, and impaired health-related quality of life. While hemodialysis (HD) is the current life-saving standard of treatment for patients with ESRD, their quality of life (QoL) remains far from desirable. Online HDF (OL-HDF), due to its convenience, could improve the QoL of patients with ESRD, however, this remains uncertain.

          Objective

          We aimed to assess the body of evidence of OL-HDF compared to HD regarding QoL in patients with ESRD.

          Methods

          We comprehensively searched in multiple data bases from their inception to February 2018. Reviewers working independently and in duplicate appraised the quality and included randomized controlled trials (RCTs) that evaluated, in patients with ESRD and HD or OL-HDF, QoL (Short Form Health Survey with 36 questions (SF-36) with physical component score (PCS) and mental component score (MCS) as well as scores about social activity, fatigue, and emotion). A meta-analysis of each outcome of interest was performed using a random-effects model.

          Results

          Six moderate quality RCTs met the inclusion criteria. Meta-analysis of 4 RCTs including a total of 1,209 patients showed that OL-HDF was associated with a lower yet non-significant score of PCS: MD (mean difference) -0.77 (95% CI -1.94 to 0.41, p = 0.20), and MCS: MD -1.25 (95% CI -3.10 to 0.59, p = 0.18); indicating a poorer QoL in patients on OL-HDF. Meta-analysis of 4 RCTs including a total of 845 patients showed OL-HDF was associated with a significant increase in the score of social activity compared to HD: SMD (standardized mean difference): 1.95 (95% CI 0.05 to 3.86, p = 0.04), indicating a better QoL in patients on OL-HDF; but regarding fatigue and emotion, there was no significant improvement when compared to HD by meta-analysis of 3 RCTs (133 patients).

          Conclusions

          The body of evidence suggests that OL-HDF does not improve QoL in patients with ESRD when compared to HD.

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          Most cited references16

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          Treatment tolerance and patient-reported outcomes favor online hemodiafiltration compared to high-flux hemodialysis in the elderly.

          Large cohort studies suggest that high convective volumes associated with online hemodiafiltration may reduce the risk of mortality/morbidity compared to optimal high-flux hemodialysis. By contrast, intradialytic tolerance is not well studied. The aim of the FRENCHIE (French Convective versus Hemodialysis in Elderly) study was to compare high-flux hemodialysis and online hemodiafiltration in terms of intradialytic tolerance. In this prospective, open-label randomized controlled trial, 381 elderly chronic hemodialysis patients (over age 65) were randomly assigned in a one-to-one ratio to either high-flux hemodialysis or online hemodiafiltration. The primary outcome was intradialytic tolerance (day 30-day 120). Secondary outcomes included health-related quality of life, cardiovascular risk biomarkers, morbidity, and mortality. During the observational period for intradialytic tolerance, 85% and 84% of patients in high-flux hemodialysis and online hemodiafiltration arms, respectively, experienced at least one adverse event without significant difference between groups. As exploratory analysis, intradialytic tolerance was also studied, considering the sessions as a statistical unit according to treatment actually received. Over a total of 11,981 sessions, 2,935 were complicated by the occurrence of at least one adverse event, with a significantly lower occurrence in online hemodiafiltration with fewer episodes of intradialytic symptomatic hypotension and muscle cramps. By contrast, health-related quality of life, morbidity, and mortality were not different in both groups. An improvement in the control of metabolic bone disease biomarkers and β2-microglobulin level without change in serum albumin concentration was observed with online hemodiafiltration. Thus, overall outcomes favor online hemodiafiltration over high-flux hemodialysis in the elderly.
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            A comparison of on-line hemodiafiltration and high-flux hemodialysis: a prospective clinical study.

            Some of the morbidity associated with chronic hemodialysis is thought to result from retention of large molecular weight solutes that are poorly removed by diffusion in conventional hemodialysis. Hemodiafiltration combines convective and diffusive solute removal in a single therapy. The hypothesis that hemodiafiltration provides better solute removal than high-flux hemodialysis was tested in a prospective, randomized clinical trial. Patients were randomized to either on-line postdilution hemodiafiltration or high-flux hemodialysis. The groups did not differ in body size, treatment time, blood flow rate, or net fluid removal. The filtration volume in hemodiafiltration was 21 +/-1 L. Therapy prescriptions were unchanged for a 12-mo study period. Removal of both small (urea and creatinine) and large (ss(2)-microglobulin and complement factor D) solutes was significantly greater for hemodiafiltration than for high-flux hemodialysis. The increased urea and creatinine removal did not result in lower pretreatment serum concentrations in the hemodiafiltration group. Pretreatment plasma beta(2)-microglobulin concentrations decreased with time (P< 0.001); however, the decrease was similar for both therapies (P = 0.317). Pretreatment plasma complement factor D concentrations also decreased with time (P<0.001), and the decrease was significantly greater with hemodiafiltration than with high-flux hemodialysis (P = 0.010). The conclusion is that on-line hemodiafiltration provides superior solute removal to high-flux hemodialysis over a wide molecular weight range. The improved removal may not result in lower pretreatment plasma concentrations, however, possibly because of limitations in mass transfer rates within the body.
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              Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease.

              Convective dialysis modalities (haemofiltration (HF), haemodiafiltration (HDF), and acetate-free biofiltration (AFB)) removed excess body fluid across the dialysis membrane with positive pressure and accumulated middle- and larger-size accumulated solutes more efficiently than haemodialysis (HD). This increased larger solute removal combined with use of ultra-pure dialysis fluid in convective dialysis is hypothesised to reduce the frequency and severity of symptoms during dialysis as well as improve clinical outcomes. Convective dialysis therapies (HDF and HF) are associated with lower mortality compared to diffusive therapy (HD) in observational studies. This is an update of a review first published in 2006.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Funding acquisitionRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                18 October 2018
                2018
                : 13
                : 10
                : e0205037
                Affiliations
                [1 ] Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
                [2 ] Division of Nephrology, Toranomon Hospital, Tokyo, Japan
                [3 ] Division of Endocrinology, Medical School and University Hospital “Dr. Jose E. Gonzalez”, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
                [4 ] Plataforma INVEST Medicina UANL KER Unit Mayo Clinic, Medical School and University Hospital “Dr. Jose E. Gonzalez”, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
                UNSW Sydney, AUSTRALIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0003-0825-2512
                Article
                PONE-D-18-16646
                10.1371/journal.pone.0205037
                6193628
                30335792
                308b14ca-4367-4a86-b11d-f0723c20cf31
                © 2018 Suwabe et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 June 2018
                : 18 September 2018
                Page count
                Figures: 7, Tables: 3, Pages: 15
                Funding
                Funded by: Grant-in-Aid for Progressive Renal Disease Research from the Ministry of Health, Labour and Welfare of Japan
                Award Recipient :
                Funded by: Okinaka Memorial Institute for Medical Research, Toranomon Hospital
                Award Recipient :
                This study was supported in part by a Grant-in-Aid for Progressive Renal Disease Research from the Ministry of Health, Labour and Welfare of Japan ( http://www.mhlw.go.jp/) and by Okinaka Memorial Institute for Medical Research, Toranomon Hospital ( http://okiken.tokyo/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Research and Analysis Methods
                Mathematical and Statistical Techniques
                Statistical Methods
                Metaanalysis
                Physical Sciences
                Mathematics
                Statistics
                Statistical Methods
                Metaanalysis
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Fatigue
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Fatigue
                Medicine and Health Sciences
                Nephrology
                Chronic Kidney Disease
                Biology and Life Sciences
                Psychology
                Emotions
                Social Sciences
                Psychology
                Emotions
                Medicine and Health Sciences
                Clinical Medicine
                Clinical Trials
                Randomized Controlled Trials
                Medicine and Health Sciences
                Pharmacology
                Drug Research and Development
                Clinical Trials
                Randomized Controlled Trials
                Research and Analysis Methods
                Clinical Trials
                Randomized Controlled Trials
                Biology and Life Sciences
                Anatomy
                Renal System
                Kidneys
                Medicine and Health Sciences
                Anatomy
                Renal System
                Kidneys
                Medicine and Health Sciences
                Nephrology
                Medical Dialysis
                Medicine and Health Sciences
                Health Care
                Quality of Life
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                All relevant data are within the paper and its Supporting Information files.

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