Haemodiafiltration, haemofiltration and haemodialysis for adults with kidney failure.

In 30 seconds

This Cochrane systematic review and meta-analysis assessed randomised trials comparing convective dialysis (haemofiltration, haemodiafiltration or acetate-free biofiltration) with diffusive haemodialysis or expanded haemodialysis in adults with kidney failure. It included 62 studies and 6,897 participants; 54 studies compared convective therapy with haemodialysis. Convective dialysis likely reduced all-cause mortality (RR 0.88, 95% CI 0.80 to 0.96) and cardiovascular mortality (RR 0.78, 95% CI 0.66 to 0.92). Evidence suggested little or no difference in cardiovascular morbidity, fatigue, vascular access problems, hospitalisation or physical quality of life.

Key findings

• Convective dialysis likely reduced all-cause death versus diffusive therapy (RR 0.88, 95% CI 0.80 to 0.96; 15 studies, 5463 participants).
• Cardiovascular death was likely lower with convective dialysis (RR 0.78, 95% CI 0.66 to 0.92; 9 studies, 4761 participants).
• Cardiovascular morbidity was likely similar between modalities (RR 1.05, 95% CI 0.90 to 1.22; 2 studies, 2074 participants).
• Comparative evidence for fatigue, vascular access problems, hospitalisation and physical quality of life showed little or no difference or remained inconclusive.

Why it matters

The mortality findings suggest that dialysis modality may be relevant to long-term outcomes in adults with kidney failure. However, the review found no clear advantage for several patient-important outcomes, and evidence for direct comparisons among convective modalities was limited. The results therefore help frame modality discussions while highlighting uncertainty beyond mortality.

What to keep in mind

Evidence for mortality was rated moderate certainty due to indirectness; several other outcomes had low-certainty evidence because of imprecision or indirectness. Direct comparisons between convective modalities were limited and underpowered.