{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T11:02:16Z","timestamp":1790074936777,"version":"4.0.1"},"reference-count":33,"publisher":"Ovid Technologies (Wolters Kluwer Health)","license":[{"start":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T00:00:00Z","timestamp":1786579200000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["JASN"],"abstract":"\n Key Points<\/jats:title>\n \n \n \n Randomized trials suggested that hemodiafiltration improved survival over high-flux hemodialysis, but real-world evidence is limited.<\/jats:p>\n <\/jats:list-item>\n \n Target trial emulation showed that hemodiafiltration was associated with lower mortality than high-flux hemodialysis.<\/jats:p>\n <\/jats:list-item>\n \n The findings supported broader use of hemodiafiltration when technically feasible and clinically appropriate.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>\n \n Background<\/jats:title>\n Randomized trials suggest that high-volume postdilution hemodiafiltration (HDF) may improve survival compared with high-flux hemodialysis, but evidence from routine clinical practice and from regions underrepresented in trials remains limited.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We emulated a target trial comparing HDF with high-flux hemodialysis using data from European Clinical Database, a multinational registry of dialysis patients treated in 8 European countries. Adults receiving thrice-weekly in-center dialysis between 2014 and 2019 were eligible. Follow-up began 91 days after dialysis initiation. Sustained treatment strategies were defined as receipt of the assigned modality for at least 90% of sessions. Inverse probability weighting was used to emulate randomized treatment assignment. The primary outcome was all-cause mortality, with kidney transplantation treated as a competing event.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Among 19,539 eligible patients at day 91, inverse probability weighting created a weighted pseudopopulation of 19,758 patients (8641 HDF; 11,117 hemodialysis). During a median follow-up of 16 months (interquartile range, 6\u201332), 4282 deaths occurred. HDF was associated with a lower risk of all-cause mortality compared with high-flux hemodialysis (hazard ratio, 0.72; 95% confidence interval, 0.67 to 0.77). At 2 years, the weighted cumulative incidence of death was 20.6% in the HDF group and 22.3% in the hemodialysis group, corresponding to an absolute risk reduction of 1.7% points. The results were consistent across sensitivity analyses, including analyses accounting for country, competing risks, informative censoring, protocol adherence, and an intention-to-treat\u2013like exposure definition. The association was broadly similar across prespecified subgroups, with only a stronger relative benefit observed among patients with preexisting cardiovascular disease (interaction\n P<\/jats:italic>\n < 0.001). Higher delivered convective volumes were associated with better survival; however, these findings should be interpreted cautiously because higher convective volumes may reflect patient stability and center expertise rather than a causal dose\u2013response relationship.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n In this large multinational target trial emulation, sustained high-volume postdilution HDF was associated with lower mortality than high-flux hemodialysis.<\/jats:p>\n <\/jats:sec>","DOI":"10.1681\/asn.0000001225","type":"journal-article","created":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T16:30:45Z","timestamp":1786638645000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Hemodiafiltration versus High-Flux Hemodialysis and Risk of Mortality"],"prefix":"10.1681","author":[{"given":"Giovanni F.M.","family":"Strippoli","sequence":"first","affiliation":[{"name":"Department of Precision and Regenerative Medicine and Jonian Area (Dimepre-J), University of Bari, Bari, Italy"},{"name":"School of Public Health, University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Tripepi","sequence":"additional","affiliation":[{"name":"Institute of Clinical Physiology (CNR-IFC), Reggio Calabria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6854-2816","authenticated-orcid":false,"given":"Bernard","family":"Canaud","sequence":"additional","affiliation":[{"name":"School of Medicine, Montpellier University, Montpellier, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9546-4507","authenticated-orcid":false,"given":"Stefano","family":"Stuard","sequence":"additional","affiliation":[{"name":"Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts"},{"name":"Fresenius Medical Care, Global Medical Office, Palazzo Pignano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Franklin W.","family":"Maddux","sequence":"additional","affiliation":[{"name":"Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2745-1429","authenticated-orcid":false,"given":"Len A.","family":"Usvyat","sequence":"additional","affiliation":[{"name":"Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts"},{"name":"Renal Research Institute, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-9363-6986","authenticated-orcid":false,"given":"Paola","family":"Carioni","sequence":"additional","affiliation":[{"name":"Fresenius Medical Care, Global Medical Office, Palazzo Pignano, Italy"},{"name":"Renal Research Institute, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matteo","family":"Savoia","sequence":"additional","affiliation":[{"name":"Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8422-7269","authenticated-orcid":false,"given":"Germaine","family":"Wong","sequence":"additional","affiliation":[{"name":"School of Public Health, University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6616-1996","authenticated-orcid":false,"given":"Carmine","family":"Zoccali","sequence":"additional","affiliation":[{"name":"Renal Research Institute, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,8,13]]},"reference":[{"issue":"6 suppl 1","key":"B1-20260922","first-page":"S1","article-title":"2024 USRDS 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Dial."},{"issue":"5","key":"B5-20260922","doi-asserted-by":"crossref","first-page":"749","DOI":"10.2215\/CJN.09410721","article-title":"Mass transport in high-flux hemodialysis","volume":"17","author":"Mohajerani","year":"2022","journal-title":"Clin J Am Soc Nephrol."},{"issue":"6","key":"B6-20260922","doi-asserted-by":"crossref","first-page":"968","DOI":"10.1053\/j.ajkd.2014.01.435","article-title":"Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: a systematic review and meta-analysis of randomized trials","volume":"63","author":"Susantitaphong","year":"2014","journal-title":"Am J Kidney Dis."},{"issue":"5","key":"B7-20260922","first-page":"CD006258","article-title":"Haemodiafiltration, haemofiltration, and haemodialysis for end-stage kidney disease","volume":"2015","author":"Nistor","year":"2015","journal-title":"Cochrane Database Syst 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Kidney J."},{"issue":"12","key":"B26-20260922","doi-asserted-by":"crossref","first-page":"2663","DOI":"10.1093\/ndt\/gfad136","article-title":"Haemodiafiltration for all: are we CONVINCEd?","volume":"38","author":"Shroff","year":"2023","journal-title":"Nephrol Dial Transplant."},{"issue":"1","key":"B27-20260922","doi-asserted-by":"crossref","first-page":"sfad247","DOI":"10.1093\/ckj\/sfad247","article-title":"Unmasking the CONVINCE trial: is hemodiafiltration ready to steal the spotlight?","volume":"17","author":"Meena","year":"2024","journal-title":"Clin Kidney J."},{"issue":"20","key":"B28-20260922","first-page":"e42","article-title":"Effect of hemodiafiltration or hemodialysis on mortality in kidney failure","volume":"389","author":"Piccoli","year":"2023","journal-title":"N Engl J Med."},{"issue":"8","key":"B29-20260922","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1056\/NEJMe2307709","article-title":"Improving dialysis techniques for 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Emulation"],"short-title":[],"issued":{"date-parts":[[2026,8,13]]},"references-count":33,"URL":"https:\/\/doi.org\/10.1681\/asn.0000001225","relation":{},"ISSN":["1046-6673","1533-3450"],"issn-type":[{"value":"1046-6673","type":"print"},{"value":"1533-3450","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,13]]},"assertion":[{"value":"2026-04-22","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-10","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}