Abstract
BackgroundGlobally, there is increased clinical interest and uptake of hemodiafiltration (HDF) for increased removal of uremic toxins. To date, there has been no epidemiological analysis of HDF in China. We present HDF practice patterns and associated mortality risk in Shanghai.MethodsThis is an observational, prospectively collected, retrospective analysis of 9351 Chinese patients initiating hemodialysis in Shanghai from 2007 to 2014. The primary exposure was hemodialysis sub-modality at inception, classified into hemodiafiltration (HDF) and hemodialysis (HD), with adjustment for concommitant hemoperfusion. The primary outcome was patient mortality. We used Cox proportional hazards regression and Fine and Gray’s proportional subhazards regression, with multiple imputation of missing co-variates by the chained equation method, adjusting for demographic and clinical variables.ResultsOverall, patients in the cohort were younger, with a more males, and with a lower body mass index when compared to corresponding non-Asian cohorts. Mortality rate was low although it doubled over the period of observation. HDF utilization increased from 7% of patients in 2007 to 42% of patients in 2014. The majority of patients received HDF once a week. The adjusted hazard ratio of death (95% confidence intervals) for HDF versus HD was 0.85 (0.71–1.03), and corresponding sub-hazard ratio 0.86 (0.71–1.03). There was strong effect modification by age. In those aged 40–60 years, the hazard ratio (95% confidence intervals) was 0.65 (0.45–0.94), and sub-hazard ratio also 0.65 (0.45–0.95).ConclusionsOur study has certain limitations resulting from the limited number of co-variates available for modelling, missing data for some co-variates, and the lack of verification of data against source documentation. Notwithstanding, there is evidence of clinical benefit from HDF in China, and potential to improve patient outcomes through the greater removal of middle and larger uremic solutes.
Highlights
There is increased clinical interest and uptake of hemodiafiltration (HDF) for increased removal of uremic toxins
We describe and analyses the evolving practice patterns and outcomes of HDF in China using the Shanghai Renal Registry (SRR), which was begun in 1996 by the Shanghai Society of Nephrology and Shanghai Center for Hemodialysis Quality Control
The final dataset for analysis consisted of 9351 patients over 29,250 patient-years, in which 982 patients died, 259 underwent kidney transplants, 240 changed to peritoneal dialysis (PD), and 7870 patients were censored (5484 because of end of follow-up, 64 for return of renal function, 2294 for transfer out to the SRR network, and 28 for loss to follow-up)
Summary
There is increased clinical interest and uptake of hemodiafiltration (HDF) for increased removal of uremic toxins. There has been no epidemiological analysis of HDF in China. China has one of the largest – if not the largest - chronic kidney disease (CKD) populations on the globe [1]. According to the latest report from the Chinese Renal Data System [2], there were 447,435 prevalent patients on hemodialysis (HD) and 74,138 on peritoneal dialysis (PD) at the end of 2016 (https://www.cnrds.net). There is an increasing prevalence of risk factors for progressive CKD, most notably diabetes mellitus and increased body size [3,4,5]. There is increasing health literacy amongst healthcare consumers in developed areas of China, who have grown accustomed to advanced standards in healthcare, especially in larger cities. The largest rural to urban migration in human history has led to generally better access to health services and higher incomes for most people [6]
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