Effect of membrane permeability on inflammation and arterial stiffness: a randomized trial

Association of familial Mediterranean fever and epicardial adipose tissue: A systematic review and meta‐analysis

Background and Aim

Some studies reported a positive link between familial Mediterranean fever (FMF) and epicardial adipose tissue. Our meta‐analysis aimed to evaluate whether there is a significant association between FMF and increased epicardial adipose tissue thickness.

Methods

We searched the following databases: PUBMED, WOS, OVID, SCOPUS, and EMBASE. Inclusion criteria were any original articles that reported epicardial adipose tissue in FMF patients with no age restriction, excluding reviews, case reports, editorials, animal studies, and non‐English studies. Thirty eligible studies were screened full text but only five studies were suitable. We used RevMan software (5.4) for the meta‐analysis.

Results

The total number of patients included in the meta‐analysis in the FMF patients group is 256 (mean age = 24.3), and the total number in the control group is 188 (mean age = 24.98). The pooled analysis between FMF patients and controls was [mean difference = 0.82 (95% CI = 0.25–1.39), p‐value = 0.005]. We observed heterogeneity that was not solved by random effects (p > 0.00001). We performed leave one out test by removing the Kozan et al. study, and the heterogeneity was solved (p = 0.07), and the results were (MD = 0.98, 95% CI = 0.52–1.43, p‐value < 0.0001).

Conclusion

FMF patients are at increased risk of developing epicardial adipose tissue compared to controls. More multicenter studies with higher sample sizes are needed to support our results.

Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Effect of Hemodiafiltration Versus Hemodialysis on Cognitive Function Among Patients With End-Stage Renal Disease: A Multicenter Study

Background: Cognitive impairment (CI) and dementia are common in patients with end-stage renal disease (ESRD) undergoing hemodialysis. Their cause is multifactorial. Our study is first to compare the impact of hemodialysis (HD) and online hemodiafiltration (HDF) on patients’ cognitive outcomes.

Methods: This was a cross sectional, multicenter cohort study. Adult ESRD patients aged >18 years on regular high flux HD or online HDF were recruited in the study. Clinical, laboratory, daily activities and cognitive functions assessment were assessed in all the involved individuals.

Results: A total of 241 patients were successfully recruited into the study: 164 treated with high flux HD and 77 treated with HDF. Hypertension and diabetes were the commonest associated comorbidities. 85.9% of patients were functionally independent with no significant difference between those on HD versus HDF. 81.3% of our patients showed different degrees of CI. HDF has no superiority in the improvement of cognitive functions. Age, vitamin D level and haemoglobin (Hb) were the most independent predictors of cognitive function impairment among HD patients.

Conclusions: Cognitive function impairment is a common problem in hemodialysis and is associated with multiple risk factors. HDF showed no beneficial effect over HD. There is no superiority of online HDF versus high flux HD in improving cognitive functions.

Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There is also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Effect of hemodiafiltration on measured physical activity: primary results of the HDFIT randomized controlled trial

Background

Dialysis patients are typically inactive and their physical activity (PA) decreases over time. Uremic toxicity has been suggested as a potential causal factor of low PA in dialysis patients. Post-dilution high-volume online hemodiafiltration (HDF) provides greater higher molecular weight removal and studies suggest better clinical/patient-reported outcomes compared with hemodialysis (HD).

Methods

HDFIT was a randomized controlled trial at 13 clinics in Brazil that aimed to investigate the effects of HDF on measured PA (step counts) as a primary outcome. Stable HD patients (vintage 3–24 months) were randomized to receive HDF or high-flux HD. Treatment effect of HDF on the primary outcome from baseline to 3 and 6 months was estimated using a linear mixed-effects model.

Results

We randomized 195 patients (HDF 97; HD 98) between August 2016 and October 2017. Despite the achievement of a high convective volume in the majority of sessions and a positive impact on solute removal, the treatment effect HDF on the primary outcome was +538 [95% confidence interval (CI) −330 to 1407] steps/24 h after dialysis compared with HD, and was not statistically significant. Despite a lack of statistical significance, the observed size of the treatment effect was modest and driven by steps taken between 1.5 and 24.0 h after dialysis, in particular between 20 and 24 h (+197 steps; 95% CI −95 to 488).

Conclusions

HDF did not have a statistically significant treatment effect on PA 24 h following dialysis, albeit effect sizes may be clinically meaningful and deserve further investigation.

Effects of medium cut-off dialysis membranes on inflammation and oxidative stress in patients on maintenance hemodialysis

PURPOSE

Medium cut-off membranes were developed for providing increased clearance of larger middle-molecule uremic toxins. We compared the effect of low-flux, medium cut-off, and high-flux membranes on chronic inflammation and oxidative stress in patients with maintenance hemodialysis.

METHODS

A total of 42 patients were enrolled in this study. Total antioxidant status, total oxidant status, paraoxonase-1, ischemia-modified albumin, total Thiol, disulfide bond, and native Thiol were measured to determine oxidative stress. C-reactive protein was measured to define inflammation.

RESULTS

37% of the total patients were females, and the mean age was 52.9 ± 16 years. Serum albumin and Kt/V were similar between groups during the study period. We did not find any significant difference at baseline in the 3rd and 6th months of the study when we compared the inflammatory marker and oxidative indicator levels between three hemodialysis membranes in the whole study group. In the subgroup analysis of 19 patients with a high C-reactive protein level, we found that the medium cut-off membrane significantly reduced serum C-reactive protein level, when compared to low-flux and high-flux membrane [2.8 mg/L vs. 13.7 mg/L and 6.1 mg/L, respectively, p = 0.05]. However, we did not find a significant change in oxidative stress indicators in patients with high C-reactive protein levels between the three dialysers.

CONCLUSION

The medium cut-off membrane has favorable effects on inflammation in patients with maintenance hemodialysis. However, this positive effect could not be demonstrated in oxidative stress.

A Systematic Review and Meta-analysis of Nonpharmacologic-based Interventions for Aortic Stiffness in End-Stage Renal Disease

Introduction

Increased carotid-femoral pulse wave velocity (cf-PWV) in end-stage renal disease (ESRD) indicates enhanced aortic stiffness and mortality risk. We conducted a systematic review and meta-analysis of nonpharmacologic interventions in adults with ESRD to determine their effects on cf-PWV, systolic blood pressure (SBP), and intervention-associated adverse events.

Methods

MEDLINE, EMBASE, and EBM databases were searched. Study screening, selection, data collection, and methodological quality assessments were performed by 2 independent reviewers. Pooled-effect estimates from mean differences and 95% confidence intervals (CIs) were calculated using random effect models.

Results

A total of 2166 subjects with ESRD from 33 studies (17 randomized; 16 nonrandomized) were included. Four intervention-comparator pairs were meta-analyzed. Quality of evidence ranged from very low to moderate. Kidney transplantation decreased cf-PWV (−0.70 m/s; CI: –1.3 to −0.11; P = 0.02) and SBP (−8.3 mm Hg; CI: −13.2 to −3.3; P < 0.001) over pretransplantation. In randomized trials, control of fluid overload by bio-impedance reduced cf-PWV (−1.90 m/s; CI: −3.3 to −0.5); P = 0.02) and SBP (−4.3 mm Hg; CI: −7.7 to −0.93); P = 0.01) compared with clinical assessment alone. Cross-sectional studies also demonstrated significantly lower cf-PWV and SBP in normovolemia compared with hypervolemia (P ≤ 0.01). Low calcium dialysate decreased cf-PWV (−1.70 m/s; CI: −2.4 to −1.0; P < 0.00001) without affecting SBP (−1.6 mm Hg; CI: −8.9 to 5.8; P = 0.61). Intradialytic exercise compared with no exercise reduced cf-PWV (−1.13 m/s; CI: −2.2 to −0.03; P = 0.04), but not SBP (+0.5 mm Hg; CI: −9.5 to 10.4); P = 0.93).

Conclusions

Several nonpharmacologic interventions effectively decrease aortic stiffness in ESRD. The impact of these interventions on cardiovascular outcomes and mortality risk reduction in ESRD requires further study.

Design and methodology of the impact of HemoDiaFIlTration on physical activity and self-reported outcomes: a randomized controlled trial (HDFIT trial) in Brazil

BACKGROUND

End stage renal disease (ESRD) patients require a renal replacement therapy (RRT) to filter accumulated toxins and remove excess water, which are associated with impaired physical function. Hemodialysis (HD) removes middle-molecular weight (MMW) toxins less efficiently compared to hemodiafiltration (HDF); we hypothesized HDF may improve physical function. We detailed the design and methodology of the HDFIT protocol that is testing whether changing from HD to HDF effects physical activity levels and various outcomes.

METHODS

HDFIT is a prospective, multi-center, unblinded, randomized control trial (RCT) investigating the impact of dialysis modality (HDF verses HD) on objectively measured physical activity levels, self-reported quality of life, and clinical/non-clinical outcomes. Clinically stable patients with HD vintage of 3 to 24 months without any severe limitation ambulation were recruited from sites throughout southern Brazil. Eligible patients were randomized in a 1:1 ratio to either: 1) be treated with high volume online HDF for 6 months, or 2) continue being treated with high-flux HD. This study includes run-in and randomization visits (baseline), 3- and 6-month study visits during the interventional period, and a 12-month observational follow up. The primary outcome is the difference in the change in steps per 24 h on dialysis days from baseline to the 6-month follow up in patients treated with HDF versus HD. Physical activity is being measured over one week at study visits with the ActiGraph ( www.actigraphcorp.com ). For assessment of peridialytic differences during the dialysis recovery period, we will analyze granular physical activity levels based on the initiation time of HD on dialysis days, or concurrent times on non-dialysis days and the long interdialytic day.

DISCUSSION

In this manuscript, we provide detailed information about the HDFIT study design and methodology. This trial will provide novel insights into peridialytic profiles of physical activity and various self-reported, clinical and laboratory outcomes in ESRD patients treated by high volume online HDF versus high-flux HD. Ultimately, this investigation will elucidate whether HDF is associated with patients having better vitality and quality of life, and less negative outcomes as compared to HD.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov on 20 April 2016 ( NCT02787161 ).

The relation of novel cardiovascular risk parameters in patients with familial Mediterranean fever

Objective

In this study, we aimed at correlating the thickness of epicardial adipose tissue and levels of Vitamin D with cardiac risk in patients with familial Mediterranean fever.

Methods

Sixty-five patients with familial Mediterranean fever and 38 healthy controls with matching age and sex were included in the study. The patients with a history of familial Mediterranean fever attacks within the previous two weeks or with any history of inflammatory or cardiovascular disease were excluded. Data regarding age, gender, weight, height, waist circumference, body mass index (calculated as weight/height²), pulse wave velocity, serum Vitamin D levels from fasting blood samples, and Homeostatic Model Assessment for insulin resistance were obtained for the patients and controls. The epicardial adipose tissue was visualized as an echo-free space between the outer surface of myocardium and visceral pericardium using two-dimensional echocardiography, and the thickness of epicardial adipose tissue was measured in parasternal long-axis view at the end of diastole.

Results

The patients with familial Mediterranean fever had significantly higher levels of C-reactive protein, epicardial adipose tissue, and pulse wave velocity (p < 0.001, <0.05, <0.005, respectively) as compared with the control group. However, the serum Vitamin D levels in the two groups were observed to be similar (p = 0.486). Weak but significant positive correlations were observed between epicardial adipose tissue thickness and C-reactive protein (r = 0.302, p < 0.005), epicardial adipose tissue thickness and pulse wave velocity (r = 0.263, p < 0.01), and C-reactive protein and pulse wave velocity (r = 0.235, p < 0.05).

Conclusion

Thickness of epicardial adipose tissue and pulse wave velocity were observed to increase in patients with familial Mediterranean fever.

Arterial stiffness in end-stage renal disease-pathogenesis, clinical epidemiology, and therapeutic potentials

Arterial stiffness is an important risk factor for cardiovascular morbidity and mortality in patients with end-stage renal disease (ESRD). Arterial stiffness aggravates cardiovascular risk via multiple pathways, such as augmentation of aortic systolic pressure, subendocardial hypoperfusion, and excess pulsatile energy transmission from macro- to microcirculation. Pathogenesis of the arteriosclerotic process in ESRD is complex and not yet fully understood. Several factors unique to ESRD, such as mineral metabolism disturbances, vascular calcifications, formation of advanced glycation end-products, and acute and chronic volume overload, are proposed to play a particular role in the progression of arteriosclerosis in ESRD. As these and other mechanistic pathways of arterial stiffening in ESRD are elucidated, there is hope that this knowledge will be translated into novel therapeutic interventions targeting arterial stiffness. In the meantime, blood pressure (BP) lowering via strict volume control and appropriate use of antihypertensive drugs is a fundamental step in reversing accelerated arterial stiffening and modifying the cardiovascular risk profile of ESRD patients. In this article, we review the pathogenesis, clinical epidemiology, and therapies targeting arterial stiffness in ESRD, discussing recent advances and high-priority goals of future research in these important areas.

Cardiovascular risk of circulating endotoxin level in prevalent hemodialysis patients

Background

Cardiovascular diseases (CVDs) are a major cause of morbidity and mortality in patients with end stage renal disease (ESRD). Circulating endotoxins may have toxic effect on myocardial functions and are speculated as pathogens of accelerated atherosclerosis and hemodialysis (HD) patients.

Objective

We aimed to assess the possible relation between circulating endotoxin levels and left ventricular functions parameters, common carotid artery intimal media thickness (CIMT) in prevalent HD patients.

Patients and Methods

Forty stable prevalent HD patients with mean age (47.97 ± 14.42) year using regular conventional hemodialysis sessions in Ain shams university hemodialysis unit, Cairo, Egypt were randomly selected. Diabetics, congestive heart failure and those with history of myocardial infarction or coronary artery disease were excluded from the study. All patients were studied by CBC and routine chemistry, as well as hs CRP, Intact PTH, lipid profile and endotoxin level by ELISA before and after the HD session, Delta change of endotoxin (pre dialysis endotoxin-post dialysis endotoxin) was calculated, resting Doppler echocardiographic and carotid duplex.

Results

Mean of Pre-HD session serum endotoxin level was (0.356 ± 0.090) EU/mL and the mean of post -HD endotoxin levels was (0.367 ± 0.110) EU/mL. Significant positive correlation between post dialysis endotoxin, MV E/A ratio and grades of left ventricular diastolic dysfunction (P < 0.05) and significant correlation between delta change in endotoxin and EF% (r = -0.36,P = 0.02). By stepwise linear regression analysis for determinants of MVE/A post -HD endotoxin level independently associated with MV E/A ratio (ß = 0.350, P = 0.027). We did not detect any significant correlation between CCA atherosclerosis and neither pre nor post- HD endotoxin level nor with delta change of pre and post HD endotoxin levels.

Conclusion

Acute increase in post dialytic circulating endotoxin level in prevalent HD patients may be associated with both left ventricular systolic and diastolic dysfunction and that attempts to reduce endotoxin level may have a positive impact on cardiovascular complications in HD Patients.

The Effect of Neutral Peritoneal Dialysis Solution with Low Glucose-Degradation-Product on the Fluid Status and Body Composition--A Randomized Control Trial

Background

Previous studies report conflicting results on the benefit of peritoneal dialysis (PD) patients treated with low glucose degradation product (GDP) solution. The effects of low GDP solution on body fluid status and arterial pulse wave velocity (PWV) have not been studied.

Methods

We randomly assigned 68 incident PD patients to low GDP (Intervention Group) or conventional solutions (Control Group); 4 dropped off before they received the assigned treatment. Patients were followed for 52 weeks for changes in ultrafiltration, residual renal function, body fluid status and arterial PWV.

Result

After 52 weeks, Intervention Group had higher overhydration (3.1 ± 2.6 vs 1.9 ± 2.2 L, p = 0.045) and extracellular water volume (17.7 ± 3.9 vs 15.8 ± 3.1 L, p = 0.034) than Control Group. There was no significant difference in PWV between groups. There was no significant difference in residual renal function between the Groups. Intervention Group had lower ultrafiltration volume than Control Group at 4 weeks (0.45 ± .0.61 vs 0.90 ± 0.79 L/day, p = 0.013), but the difference became insignificant at later time points. Intervention Group had lower serum CRP levels than Control Group (4.17 ± 0.77 vs 4.91 ± 0.95 mg/dL, p < 0.0001).

Conclusion

Incident PD patients treated with low GDP solution have less severe systemic inflammation but trends of less ultrafiltration, and more fluid accumulation. However, the effects on ultrafiltration and fluid accumulation disappear with time. The long term effect of low GDP solution requires further study.

Trial Registration

ClinicalTrials.gov NCT00966615

Bioimpedance spectroscopy for the detection of fluid overload in Chinese peritoneal dialysis patients

BACKGROUND

Fluid overload probably contributes to the cardiovascular risk of peritoneal dialysis (PD) patients. We studied the relationship between over-hydration as determined by bioimpedance spectroscopy and dialysis adequacy, nutritional status, and arterial stiffness in Chinese PD patients.

METHODS

We studied 122 asymptomatic prevalent PD patients: bioimpedance spectroscopy, arterial pulse wave velocity, dialysis adequacy and nutritional status were determined.

RESULTS

Of the 122 patients, 88 (72.1%) had over-hydration of ≥ 1 L, while 25 (20.5%) were ≥ 5 L. Over-hydration significantly correlated with total body water (r = 0.474, p < 0.001) and extracellular water (r = 0.755, p < 0.001). Over-hydration was more severe in male and diabetic patients, and significantly correlated with Charlson's comorbidity score, blood pressure, body mass index, body weight, peritoneal transport characteristics, and carotid-femoral pulse wave velocity. Over-hydration significantly correlated with Kt/V (r = -0.287, p = 0.016), serum albumin level (r = -0.465, p < 0.001) and malnutrition inflammation score (r = 0.410, p = 0.006), but not residual renal function.

CONCLUSION

Over-hydration is common in asymptomatic Chinese PD patients. The degree of over-hydration is particularly pronounced in patients who are inadequately dialyzed, have multiple comorbid conditions and low serum albumin levels. Over-hydration is associated with high blood pressure and arterial stiffness, and may contribute to the excessive risk of cardiovascular disease in this group of patients.

Convective therapies versus low-flux hemodialysis for chronic kidney failure: a meta-analysis of randomized controlled trials

BACKGROUND

Although convective therapies have gained popularity for the optimal removal of uremic solutes, their benefits and potential risks have not been fully elucidated. We conducted a meta-analysis of all randomized controlled trials comparing convective therapies with low-flux hemodialysis in patients with chronic kidney failure.

METHODS

We performed a literature search using MEDLINE (inception-December 2012), Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, scientific abstracts from meetings and bibliographies of retrieved articles. Randomized controlled trials comparing the effect of convective therapies including high-flux hemodialysis, hemofiltration or hemodiafiltration versus low-flux hemodialysis were included. Random-effects model meta-analyses were used to examine continuous and binary outcomes.

RESULTS

Sixty-five (29 crossover and 36 parallel-arm) trials were identified (n = 12 182). Convective therapies resulted in a decrease in all-cause mortality [relative risk (RR) 0.88; 95% confidence interval (CI) 0.76, 1.02, P = 0.09], cardiovascular mortality (RR 0.84; 95% CI 0.71, 0.98, P = 0.03), all-cause hospitalization (RR 0.91; 95% CI 0.82, 1.01; P = 0.08) and therapy-related hypotension (RR 0.55, 95% CI 0.35, 0.87, P = 0.01). Convective therapies also resulted in an increase in the clearance of several low-molecular-weight (urea, creatinine and phosphate), middle-sized (β-2 microglobulin and leptin) and protein-bound (homocysteine, advanced glycation end-products and pentosidine) solutes and a decrease in inflammatory markers (interleukin-6). There was no impact of convective therapies on cardiac morphological and functional parameters, and blood pressure and anemia parameters.

CONCLUSIONS

Although convective therapies are associated with improved clearance of uremic solutes, the potential long-term benefits of specific convective modalities require further study.

Membrane Bioincompatibility and Ultrafiltration Effects on Pulse Wave Analysis during Haemodialysis

Membrane bioincompatibility was demonstrated by successive white blood cell counts and C3a generation. Pulse wave analysis was obtained by applanation tonometry (SphygmoCor) in a sequential way: basal, after 30 minutes with nul ultrafiltration, and after a complete dialysis with ultrafiltration. At 15 minutes of haemodialysis, significant decrease in leukocyte count occurred: 6801 ± 1186 versus 4412 ± 1333 (P < 0.001), while C3a levels sharply increased from 427 ± 269 to 3501 ± 1638 ng/mL (P < 0.000). No changes were observed in augmentation index without ultrafiltration: 26.1 ± 11.1 versus 26.6 ± 12.4. Only aortic systolic blood pressure was lower at 15 minutes: 120.1 ± 17.7 versus 110.4 ± 25.8 mmHg (P = 0.009), in agreement with a reduction in brachial systolic blood pressure: 135.1 ± 18.1 versus 122.7 ± 27.4 mmHg (P = 0.01), without changes in aortic or brachial diastolic blood pressure. Important changes in pulse wave analysis were observed after a complete haemodialysis session: augmentation index 29.9 ± 10.1 versus 18.6 ± 15.0, aortic systolic blood pressure 139.8 ± 25.5 versus 119.4 ± 28.5 mmHg (P < 0.00), without changes in aortic diastolic blood pressure. In summary, haemodialysis with cellulose diacetate acutely induced a transient state of immunoactivation due to bioincompatibility, this phenomenon was nondetectable by pulse wave analysis. Complete haemodialysis session led to important changes in pulse wave analysis.

High-flux versus low-flux membranes for end-stage kidney disease

BACKGROUND

Clinical practice guidelines regarding the use of high-flux haemodialysis membranes vary widely.

OBJECTIVES

We aimed to analyse the current evidence reported for the benefits and harms of high-flux and low-flux haemodialysis.

SEARCH METHODS

We searched Cochrane Renal Group's specialised register (July 2012), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1948 to March 2011), and EMBASE (1947 to March 2011) without language restriction.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared high-flux haemodialysis with low-flux haemodialysis in people with end-stage kidney disease (ESKD) who required long-term haemodialysis.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors for study characteristics (participants and interventions), risks of bias, and outcomes (all-cause mortality and cause-specific mortality, hospitalisation, health-related quality of life, carpal tunnel syndrome, dialysis-related arthropathy, kidney function, and symptoms) among people on haemodialysis. Treatment effects were expressed as a risk ratio (RR) or mean difference (MD), with 95% confidence intervals (CI) using the random-effects model.

MAIN RESULTS

We included 33 studies that involved 3820 participants with ESKD. High-flux membranes reduced cardiovascular mortality (5 studies, 2612 participants: RR 0.83, 95% CI 0.70 to 0.99) but not all-cause mortality (10 studies, 2915 participants: RR 0.95, 95% CI 0.87 to 1.04) or infection-related mortality (3 studies, 2547 participants: RR 0.91, 95% CI 0.71 to 1.14). In absolute terms, high-flux membranes may prevent three cardiovascular deaths in 100 people treated with haemodialysis for two years. While high-flux membranes reduced predialysis beta-2 microglobulin levels (MD -12.17 mg/L, 95% CI -15.83 to -8.51 mg/L), insufficient data were available to reliably estimate the effects of membrane flux on hospitalisation, carpal tunnel syndrome, or amyloid-related arthropathy. Evidence for effects of high-flux membranes was limited by selective reporting in a few studies. Insufficient numbers of studies limited our ability to conduct subgroup analyses for membrane type, biocompatibility, or reuse. In general, the risk of bias was either high or unclear in the majority of studies.

AUTHORS' CONCLUSIONS

High-flux haemodialysis may reduce cardiovascular mortality in people requiring haemodialysis by about 15%. A large well-designed RCT is now required to confirm this finding.