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RESULTSA total of 71,669 patients were included, with 45% receiving hemodialysis and 55% receiving HDF. During the follow-up period, patients in the HDF group underwent a total of 12,741,453 HDF treatments, with a mean convection volume of 25.8 L (84% with CV≥23L). Compared with hemodialysis, treatment with HDF was associated with a lower incidence of both hospital admissions (adjusted IRR, 0.80; 95% confidence interval, 0.79 to 0.82) and days spent in the hospital (adjusted IRR, 0.80; 95% confidence interval, 0.78 to 0.82). These reductions were consistent across subgroups analyzed and across most major causes of hospitalization, including cardiovascular disease, infections, and fluid-related complications.KEY POINTSCompared with high-flux hemodialysis, postdilution high volume hemodiafiltration was associated with a lower number of hospital admissions. Compared with high-flux hemodialysis, postdilution high volume hemodiafiltration was associated with reduced days spent in the hospital.CONCLUSIONSIn this large, real-world cohort spanning multiple regions and dialysis centers, HV-HDF was associated with significantly lower rates of both hospital admissions and days spent in the hospital compared with treatment with high-flux hemodialysis. These findings suggest that HV-HDF may have the potential to reduce morbidity in patients with ESKD.BACKGROUNDPatients with ESKD undergoing hemodialysis experience high rates of hospitalizations and mortality, partly due to the incomplete removal of some toxic uremic molecules. To improve outcomes, multiple modalities of kidney replacement therapy have been developed, including high-flux hemodialysis and on-line hemodiafiltration (HDF). Notably, on-line high-volume HDF (HV-HDF) has demonstrated mortality benefits over high-flux hemodialysis in some randomized trials.METHODSThis retrospective cohort study evaluated hospitalization outcomes among in-center dialysis patients treated with HV-HDF and high-flux hemodialysis at Fresenius Medical Care NephroCare centers across Europe, the Middle East, and Africa between January 2019 and December 2022. Data were extracted from the European Clinical Database. The primary outcome was all-cause hospitalization; secondary outcomes included cause-specific hospitalizations. Negative binomial regression was used to estimate incidence rate ratios (IRRs) for hospital outcomes, incorporating inverse probability of treatment weighting to adjust for baseline differences between treatment groups.

RESULTSAt baseline, 55% of patients were receiving hemodialysis and 45% of patients were receiving hemodiafiltration. Baseline characteristics were similar between baseline modalities, except that hemodiafiltration patients were a median of 2 years younger, had higher percentage of fistula access (66% vs. 47%), and had longer mean dialysis vintages (4.4 years vs. 2.6 years). Compared with hemodialysis, hemodiafiltration was associated with an adjusted hazard ratio (HR) for all-cause mortality of 0.78 (95% confidence interval [Cl], 0.76-0.80), irrespective of COVID-19 infection. The pattern of a beneficial effect of hemodiafiltration was consistently observed among all analyzed subgroups. Among patients receiving high-volume hemodiafiltration (mean convection volume ≥ 23 L), the risk of death was reduced by 30% (HR, 0.70 [95% CI, 0.68-0.72]). Hemodiafiltration was also associated with a 31% reduced risk of cardiovascular death.CONCLUSIONSOur results suggest that hemodiafiltration has a beneficial effect on all-cause and cardiovascular mortality in a large, unselected patient population and across patient subgroups in real-world settings. Our study complements evidence from the CONVINCE trial and adds to the growing body of real-world evidence on hemodiafiltration.BACKGROUNDResults from the CONVINCE clinical trial suggest a 23% mortality risk reduction among patients receiving high-volume (> 23 L) hemodiafiltration. We assessed the real-world effectiveness of blood-based kidney replacement therapy (KRT) with hemodiafiltration vs. hemodialysis in a large, unselected patient population treated prior to and during the COVID-19 pandemic.METHODSIn this retrospective cohort study, we analyzed pseudonymized data from 85,117 adults receiving in-center care across NephroCare clinics in Europe, the Middle East, and Africa during 2019-2022. Cox regression models with KRT modality and coronavirus disease 2019 (COVID-19) status as time-varying covariates, and adjusted for multiple confounders, were used to estimate all-cause (primary) and cardiovascular (secondary) mortality. Subgroup analyses were performed for age, dialysis vintage, COVID-19 status, diabetes, and cardiovascular disease.