Key takeaways:

• The weighted cumulative incidence of death was lower for patients using hemodiafiltration at 2 years.
• Adults with preexisting CVD benefited more from hemodiafiltration vs. those without preexisting CVD.

Risks for all-cause mortality were lower for patients using hemodiafiltration vs. those using high-flux hemodialysis, according to study data published in the Journal of the American Society of Nephrology.

Evidence comparing survival rates for patients using high-volume post-dilution hemodiafiltration (HDF) vs. high-flux hemodialysis (HD) has been underpowered and may have limited feasibility in clinical practice, according to Giovanni F. M. Strippoli, MD, PhD, professor of nephrology at University of Bari, Italy, and colleagues.

Data derived from Strippoli GFM, et al. J Am Soc Nephrol. 2026;doi:10.1681/ASN.0000001225.

Using inverse probability weighting approaches, the researchers aimed to emulate a target trial to compare patient survival with HDF vs. high-flux HD.

“Causal inference methods, including target trial emulation, allow observational data to be analyzed in ways that mimic randomized allocation and can estimate treatment effects in real-world populations,” Strippoli and colleagues wrote. “We aimed to emulate a target trial comparing HDF with high-flux HD for all-cause mortality using a large multinational cohort.”

The researchers collected data from the European Clinical Database, a multinational registry including patients receiving HDF or high-flux HD from a Fresenius Medical Care dialysis center across eight European countries between 2014 and 2019.

After identifying 19,539 patients on dialysis eligible for the study, the researchers created a pseudo-population consisting of 19,758 patients to compare all-cause mortality risks between those on HDF (n = 8,641; mean age, 64 years; 63% men) or high-flux HD (n = 11,117; mean age, 64 years; 62% men). Follow-up began 91 days after patients started dialysis.

Results showed that after a median follow-up of 16 months, risks for all-cause mortality were lower for patients using HDF vs. high-flux HD (HR = 0.72; 95% CI, 0.67-0.77).

In addition, patients using HDF had a lower weighted cumulative incidence of death (20.6%) vs. patients using high-flux HD (22.3%) at 2 years, according to the researchers.

Furthermore, patients with preexisting CVD appeared to benefit more from HDF compared with patients without preexisting CVD, the researchers wrote.

Overall, the findings suggest that high-volume post-dilution HDF was linked to lower mortality risks compared with high-flux HD, according to the researchers.

More data are needed to identify the role of hemodiafiltration in healthcare settings and address study limitations, including potential survivor bias and limited generalizability for patients on dialysis who are less clinically stable, the researchers wrote.

“Future research should focus on implementation strategies, longer-term outcomes, patient-reported measures, and mechanistic pathways to further inform personalized dialysis care,” Strippoli and colleagues wrote.