PracticeUpdate Conference Series ISN WCN 2019

Hemodiafiltration Offers Benefits Over Hemodialysis in Pediatric Setting But randomized, controlled trials are needed before it can become standard of care.

C ompared with hemodialysis, hemodiafiltration is safe and effective and is associated with benefits that include a lack of progression in vascular measures, an increase in height, and improved outcomes in the pediatric population, according to a multicenter trial presented at WCN 2019. Presenter Rukshana Shroff, MD, PhD, of the Great Ormond Street Hospital for Children and University College London in the United Kingdom, told Elsevier’s PracticeUpdate that studies such as this are important because, “children on dialysis have a 30% higher mortality compared with their peers. They also have a high burden of comorbidity and a poor quality of life.” For this non-randomized, parallel-arm clinical trial, Dr. Shroff and her colleagues used the International Paediatric Dialysis Network registry to identify 177 children from 28 centers in 10 countries across Europe and North America. Among these children, 133, including 78 on hemodialysis and 55 on hemo- diafiltration, completed 1 year of follow-up. These two groups of patients were similar with regard to age, gender, underlying renal disease, comorbid- ities, dialysis vintage, access type, blood flow and presence of residual renal function. Patients were assessed via imaging studies (eg, carotid intima-media thickness, pulse wave veloc- ity and echocardiogram) and 24-hour ambulatory blood pressure monitoring for mean arterial pres- sure (MAP). In addition, every 6months, researchers assessed anthropometric and biochemical meas- ures and had patients complete health-related quality-of-life questionnaires.

There were 44 dropouts in the trial, primarily due to transplantation (79%). There were no deaths. Among patients who received hemodiafiltration, the median convective volume achieved was 13.33 (interquartile range 12.4–14.5) mL/m 2 /session. The annualized change in carotid intima-media thickness (cIMT) SD score was 10-fold lower in the hemodiafiltration group, compared with the hemodialysis group (0.013 vs 0.48; P = .002;). A propensity score analysis adjusted for potential confounders revealed that children on hemodial- ysis had a +0.47 greater increase in annualized cIMT SD score (95% confidence interval 0.07–0.87; P = .02), compared with those on hemodiafiltration. The 24-hour mean arterial pressure MAP SD score increased among patients on hemodialysis but diminished among those on hemodiafiltration. In addition, serum β2-microglobulin, parathyroid hormone, and high-sensitivity C-reactive protein were lower and hemoglobin was higher in hemo- diafiltration patients. After adjusting for country and baseline charac- teristics, predictors of higher cIMT SD score and MAP SD score at 12 months were hemodialysis group, higher inter-dialytic weight gain and ultra- filtration rate, and higher β2-microglobulin. The height SD score increased in those who underwent hemodiafiltration but remained static in those on hemodialysis. Importantly, the type of vascular access, blood flow rate, and residual renal function did not correlate with cIMT SD score, which the authors suggested indicates that convective clearance is a significant determinant of outcome.

Dr. Rukshana Shroff

PRACTICEUPDATE CONFERENCE SERIES • WCN 2019 12