Background
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.

Objectives
To compare convective (HF, HDF, or AFB) with diffusive (HD) dialysis modalities on clinical outcomes (mortality, major cardiovascular events, hospitalisation and treatment-related adverse events) in men and women with end-stage kidney disease (ESKD).

Search methods
We searched the Cochrane Renal Group's Specialised Register (to 18 February 2015) through contact with a Trials' Search Co-ordinator using search terms relevant to this review.

Selection criteria
We included randomised controlled trials comparing convective therapy (HF, HDF, AFB) with another convective therapy or diffusive therapy (HD) for treatment of ESKD.

Data collection and analysis
Two independent authors identified studies, extracted data and assessed study risk of bias. We summarised treatment effects using the random effects model. We reported results as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous data together with 95% confidence intervals (CI). We assessed for heterogeneity using the Chi2 test and explored the amount of variation in treatment estimates beyond that expected by chance using the I2 statistic.

Main results
Twenty studies comprising 667 participants were included in the 2006 review. In that review, there was insufficient evidence of treatment effects on major clinical outcomes to draw clinically meaningful conclusions. Searching to February 2015 identified 40 eligible studies comprising 3483 participants overall. In total, 35 studies (4039 participants) compared HF, HDF or AFB with HD, three studies (54 participants) compared AFB with HDF, and three studies (129 participants) compared HDF with HF.

Risks of bias in all studies were generally high resulting in low confidence in estimated treatment effects. Convective dialysis had no significant effect on all-cause mortality (11 studies, 3396 participants: RR 0.87, 95% CI 0.72 to 1.05; I2 = 34%), but significantly reduced cardiovascular mortality (6 studies, 2889 participants: RR 0.75, 95% CI 0.61 to 0.92; I2 = 0%). One study reported no significant effect on rates of nonfatal cardiovascular events (714 participants: RR 1.14, 95% CI 0.86 to 1.50) and two studies showed no significant difference in hospitalisation (2 studies, 1688 participants: RR 1.23, 95% CI 0.93 to 1.63; I2 = 0%). One study reported rates of hypotension during dialysis were significantly reduced with convective therapy (906 participants: RR 0.72, 95% CI 0.66 to 0.80). Adverse events were not systematically evaluated in most studies and data for health-related quality of life were sparse. Convective therapies significantly reduced predialysis levels of B2 microglobulin (12 studies, 1813 participants: MD -5.55 mg/dL, 95% CI -9.11 to -1.98; I2 = 94%) and increased dialysis dose (Kt/V urea) (14 studies, 2022 participants: MD 0.07, 95% CI -0.00 to 0.14; I2 = 90%) compared to diffusive therapy, but results across studies were very heterogeneous. Sensitivity analyses limited to studies comparing HDF with HD showed very similar results. Directly comparative data for differing types of convective dialysis were insufficient to draw conclusions.

Studies had important risks of bias leading to low confidence in the summary estimates and were generally limited to patients who had adequate dialysis vascular access.

Authors' conclusions
Convective dialysis may reduce cardiovascular but not all-cause mortality and effects on nonfatal cardiovascular events and hospitalisation are inconclusive. However, any treatment benefits of convective dialysis on all patient outcomes including cardiovascular death are unreliable due to limitations in study methods and reporting. Future studies which assess treatment effects of convection dose on patient outcomes including mortality and cardiovascular events would be informative.

Haemodiafiltration, haemofiltration and haemodialysis for end‐stage kidney disease

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring “natural” medicine focussing on lifestyle and diet; (3) encouraging the reuse of “household” hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

/pdf/green-nephrology-and-eco-dialysis-a-position-statement-by-202eilxm5p.pdf

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

Introduction Sustainable growth and environmental issues are currently a topic for all human activities, and dialysis represents a real challenge in this field because of high water and power consumption and the production of large amounts of care-related waste. In this article we describe data collection implemented in the NephroCare centres in France and the changes observed during a 13-year period regarding environmental parameters. Methods Monthly data collection (eco-reporting) was implemented in NephroCare centres in France in 2005. It covers three topics designed as key performance indicators (KPIs): electricity and water consumption and care-related waste production expressed, respectively, as kilowatt-hour (kWh), litres (L) and kilograms per session. We report on the three action plans (2005-10, 2011-14 and 2015-18) and changes observed during this 13-year period. Results During the period, power and water consumption declined by 29.6% (from 23.1 to 16.26 kWh/session) and 52% (from 801 to 382 L/session), respectively. At the same time, the yearly number of dialysis sessions has increased from 169 335 to 399 336. The sources of savings came both from improvements in the dialysis technology (dialysis machines and water treatment systems) and from updating and remodelling of the dialysis unit equipment and buildings. The care-related waste decreased from 1.8 to 1.1 kg because of regular staff training and the retrofiltration system, allowing the voiding of the remaining saline solution after dialysis. These savings have been estimated as equivalent to 102 440 tons of carbon dioxide. Discussion Implementation of KPIs and their regular monitoring by trained staff to evaluate water and power consumption and the reduction of care-related water production are essential to implement actions to reduce the impact of dialysis on the environment. These data show the importance of water treatment and dialysis technology to decrease water and power consumption and the production of care-related waste as well as upgrading or remodelling of buildings housing dialysis units. Other measures are discussed, including the reuse of rejected water by reverse osmosis, as well as behavioural changes that are needed to reach sustainable development of dialysis. Conclusion The first step to reach 'green' dialysis is to collect precise information from defined KPIs. This is the only way to design action plans to reduce the impact of dialysis therapy on the environment. Beyond this, the nephrology community must be sensitized to this challenge to be proactive and to anticipate future regulations.

Haemodialysis therapy and sustainable growth: a corporate experience in France.

Resumen Introduccion La hemodiafiltracion on-line (HDF-OL) es actualmente la tecnica mas efectiva. Varios estudios aleatorizados y metaanalisis han observado una reduccion de la mortalidad, con una asociacion en relacion directa con el volumen convectivo. En el momento presente no esta bien establecido si el aumento del flujo del liquido de dialisis (Qd) puede suponer mejores resultados en terminos de eficacia convectiva y depurativa. El objetivo del estudio fue valorar, en pacientes en tratamiento con HDF-OL, el efecto de la variacion del Qd sobre el volumen convectivo y su capacidad depurativa. Material y metodos Se incluyeron 59 pacientes, 45 varones y 14 mujeres que se encontraban en programa de HDF-OL con monitor 5008 Cordiax con autosustitucion. Cada paciente fue analizado en 5 sesiones con HDF-OL posdilucional, con dializadores de helixona, en las que solo se vario el Qd (300, 400, 500, 600 y 700 ml/min). En cada sesion se determinaron concentracion de urea (60 Da), creatinina (113 Da), β2-microglobulina (11.800 Da), mioglobina (17.200 Da) y α1-microglobulina (33.000 Da) en suero al inicio y al final de cada sesion, para calcular el porcentaje de reduccion de estos solutos. Resultados Se objetivo un aumento de litros de Qd por sesion, desde 117,9 ± 6,4 L con Qd de 300 ml/min hasta 232,4 ± 12 L con Qd 700 ml/min. No se determinaron cambios en el volumen de sustitucion ni en el volumen convectivo. En terminos de difusion, el incremento del Qd mostro un aumento significativo de la dosis de dialisis, con un aumento de Kt de 68 ± 6,9 L con Qd 300 ml/min hasta 75,5 ± 7,3 L con Qd 700 ml/min (p  Conclusion La variacion del Qd en HDF-OL no modifica el volumen convectivo. Un mayor Qd mostro un discreto incremento de la depuracion de la urea, sin variaciones en las medianas ni en las grandes moleculas. Es recomendable optimizar el Qd al minimo posible que garantice una adecuada dosis de dialisis y permita racionalizar el consumo de agua y concentrado de dialisis.

/pdf/optimizacion-del-flujo-del-liquido-de-dialisis-en-la-10jadw3wv1.pdf

Optimización del flujo del líquido de diálisis en la hemodiafiltración on-line


 Recent findings, including the CONVINCE study report, suggests the superiority of high-volume hemodiafiltration over high-flux hemodialysis in improving patients’ outcomes. Despite positive patient outcomes, concerns have arisen about the potential negative environmental impact of high-volume hemodiafiltration, as it may lead to increased water and dialysis fluid consumption and higher waste production.
 In this manuscript, we address the environmental impact of high-volume HDF, focusing on three key factors: water treatment consumption, dialysis fluid consumption, and solute efficiency markers of HD and HDF.
 By optimizing HDF prescription through adjustments in operational capabilities, such as reducing the QD/QB ratio to 1,2 rather than 1,5 and incorporating automated ultrafiltration and substitution control, it has been demonstrated that HDF delivers a higher dialysis dose for small and middle-molecule uremic compounds with the same dialysis fluid consumption and at equal dialysis doses dialysis fluid consumption is reduced. This finding is supported by real-world data from 26 031 patients who underwent high-volume postdilution hemodiafiltration at a reduced dialysis flow (550 ml/min) and achieved an effective OCMKt/V of 1.70.
 In addition, simulation modeling calculations, using blood extraction coefficient, dialysate saturation coefficient, and solute clearances with urea (small MW) and ß2M (middle MW), consistently show postdilution HDF's superiority to HD. This holds true even with a significant reduction in dialysis flow down to 440 ml/min reflecting QD/QB ratio of 1,2. Postdilution HDF generates high ultrafiltrate flow (up to 35% of blood flow), delivering saturated ultrafiltrate to the lower solute concentration containing effluent dialysate, thus enhancing solute clearance which opens the way to reduce the dialysis flow.
 In conclusion, our analysis, combining simulation and real-world data, suggests that postdilution HDF could be a more environmentally friendly treatment option compared to conventional hemodialysis. Additionally, automated user-friendly functions that minimize dialysis fluid use, can further strengthen this environmental benefit while enhancing efficiency.

Does online high-volume hemodiafiltration offer greater efficiency and sustainability compared to high-flux hemodialysis? A detailed simulation analysis anchored in real-world data

Cost reduction and quality improvement seem to be conflicting issues. However, online hemodiafiltration (oHDF) with new automatic functions offers a cost-efficient therapy compared to hemodialysis (HD). Seven dialysis centers conducted a randomized clinical trial with cross-over design: high-flux HD vs. postdilutional oHDF with functions coupling both dialysate and substitution flow rates to blood flow rates. During the 6 weeks of the study, all treatment parameters remained unchanged for HD and oHDF, apart from dialysate and substitution flow rate. Treatment data were recorded during each treatment, and predialytic and postdialytic concentrations of urea were recorded at the end of each study phase. The analysis involved 956 treatments of 54 patients. The mean dialysate consumption was 123.2 ± 6.4 l for HD and 113.4 ± 14.9 l for oHDF (p < 0.0001), the mean dialysis dose was 1.42 ± 0.23 for HD and 1.47 ± 0.26 for oHDF (p < 0.0001); oHDF resulted in a lower dialysate consumption (8.0% less) and a slightly increased dialysis dose (Kt/V 3.5% higher) compared to HD. oHDF with the investigated automatic functions offers substantial savings in dialysate consumption without decreasing dialysis dose.

Dialysate saving by automated control of flow rates: comparison between individualized online hemodiafiltration and standard hemodialysis.

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Dialysate saving by automated control of flow rates: comparison between individualized online hemodiafiltration and standard hemodialysis.