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RESULTSBaseline characteristics between HDF and hemodialysis groups were comparable after inverse probability of treatment weighting. Over a median follow-up of 15.7 months (interquartile range, 6.4-24.0 months), HDF was associated with a lower risk of all-cause mortality compared with hemodialysis (11.7 versus 15.6 per 100 person-years; hazard ratio, 0.80; 95% confidence interval, 0.75 to 0.86). Furthermore, HDF was associated with a lower risk of cardiovascular disease mortality compared with hemodialysis (4.1 versus 6.7 per 100 person-years; hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80).KEY POINTSHigh-volume hemodiafiltration was associated with a 20% lower all-cause mortality risk compared with hemodialysis in incident patients. High-volume hemodiafiltration was associated with a 29% lower cardiovascular mortality risk compared with hemodialysis in incident patients. Associations between high-volume hemodiafiltration and lower mortality were consistent across demographic and clinical subgroups.CONCLUSIONSIn the large real-world cohort of incident patients with ESKD who are in the early phase of dialysis treatment, online HDF was associated with a significant survival advantage compared with conventional hemodialysis. These findings reinforce the potential clinical benefits of HDF and support early adoption of HDF upon dialysis initiation.BACKGROUNDEvidence for a survival benefit of hemodiafiltration (HDF) over high-flux hemodialysis largely comes from studies based on prevalent ESKD patients with longer dialysis exposure. By contrast, the effect of HDF on mortality of incident patients-those newly starting dialysis-remains less well understood.METHODSWe analyzed data from 18,515 incident patients (dialysis vintage <3 months) treated between 2019 and 2022 at Fresenius Medical Care NephroCare Clinics. Patients were classified as HDF or hemodialysis on the basis of their predominant dialysis modality during the first year of follow-up (≥75% of sessions). To assess the effect of HDF in the early phase after treatment initiation, follow-up was limited to 2 years. Cox proportional hazards models with inverse probability of treatment weighting were applied to estimate all-cause and cardiovascular disease mortality risk.

Background and objectivesIron plays a critical role beyond erythropoiesis, yet the prognostic significance of iron deficiency (ID) independent of anemia remains poorly defined in the peritoneal dialysis (PD) population. This study aimed to evaluate the association between iron status, specifically transferrin saturation (TSAT), and mortality in PD patients, independent of hemoglobin levels.Design, setting, participants, and measurementsWe conducted a retrospective cohort study of 11,013 adults who initiated PD at a large US dialysis network between December 2004 and January 2011. Patients had at least 180 days on PD and baseline data on TSAT, ferritin, hemoglobin, albumin, and white blood cell count. The primary outcome was all-cause mortality. Broadly adjusted associations between iron parameters and mortality were assessed using Cox proportional hazards models and restricted cubic splines, with adjustments for demographic, clinical, treatment-related, and laboratory variables including hemoglobin and ESA use.ResultsIron deficiency, defined as TSAT ≤20%, was present in 10% of patients at PD initiation. The cohort was 54% male and 70% Caucasian, with a mean age of 55 years; 39% had diabetes. While 91% received erythropoiesis-stimulating agents, only 34% received IV iron. After comprehensive adjustment, TSAT ≤20% remained independently associated with increased mortality (adjusted HR: 1.26; 95% CI: 1.12-1.42). Spline analyses showed a sharp rise in mortality risk at TSAT levels below 25%. Ferritin was inconsistently associated with mortality risk. During follow-up, 2704 deaths occurred (24.6% of the cohort) over a median 440-day follow-up.ConclusionsIron deficiency is common in incident PD patients and is associated with increased mortality risk, independent of anemia. These findings challenge current anemia-centric treatment paradigms and suggest that iron status, particularly TSAT, should be routinely assessed in PD patients regardless of hemoglobin levels. A prospective, randomized trial is warranted to evaluate whether proactive iron management improves outcomes in this population.

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.

RESULTSThe cumulative lag 0-3 risk of hospitalization associated with heat exposure was highest in the West (rate ratio [RR]: 1.099; 95% confidence interval [CI]: 1.041, 1.160), whereas the highest risk of mortality was observed in the Northwest region (RR: 1.097; 95% CI: 1.007, 1.195). We observed significant increases in the risk of hospitalization at the low- and mid-latitude bands and a significant increase in the risk of mortality in the mid-latitude band.CONCLUSIONWe observed spatial heterogeneity across US climate regions. The strongest effects of heat exposure were observed in the Ohio Valley, South, and West regions for hospitalization and the Upper Midwest, Southeast, and Northwest regions for mortality. Findings may be used to inform targeted interventions to patients with ESKD residing in areas with higher risks of adverse health outcomes following heat exposure.BACKGROUNDThe impact of heat exposure on patients with end-stage kidney disease (ESKD) is of growing concern in the context of climate change. In this study, we investigated the association of heat exposure with hospitalization and mortality, and how the risk of these adverse health outcomes varied by climate region in the US.METHODSWe obtained hospitalization and mortality data for patients with ESKD receiving in-center hemodialysis treatment between 2012 and 2018 at Fresenius Kidney Care facilities located within the contiguous US. We used the treatment facility location to assign heat exposure using maximum universal thermal climate index temperature data. We conducted a space-time-stratified case-crossover study using conditional Poisson regression with distributed lag nonlinear models to examine the effects of heat exposure at the 95th percentile of the region-specific temperature distribution for lags of three days. Stratified analyses were run to assess differences in associations across nine climate regions and three latitude bands.

Artificial intelligence (AI) is rapidly transforming the delivery of kidney care through predictive analytics, machine learning, deep learning, and generative AI technologies. To meet this challenge, the American Society of Nephrology convened an AI Workgroup to provide a framework for the responsible use of AI in nephrology. The group outlines foundational principles to guide AI development: prioritizing patient benefit, ensuring clinician oversight, and advancing innovation in high-burden disease areas. Its set of foundational assumptions are grounded in the physician always being in the loop and an overarching goal to benefit patients with kidney diseases. This review provides an overview of the clinical uses of AI in nephrology and offers practical guidance for nephrologists seeking to incorporate AI into CKD and AKI management, dialysis, and transplantation care. It also highlights key challenges-such as data quality, equity, transparency, and clinical integration-that must be addressed to ensure the responsible and effective implementation of AI in kidney care.

RESULTSHigher variability in fluid overload significantly increased mortality risk. A 1 % increase in the SD of the FO/ECW ratio was linked to a 5.3 % increase in the hazard ratio for mortality (HR: 1.053, 95 % CI: 1.045-1.062, p < 0.001). Patients in the highest quartile of fluid overload variability had a 46 % higher risk of death than those in the lowest quartile (HR: 1.46, 95 % CI: 1.28-1.67, p < 0.001). These associations remained consistent in patients who survived beyond the first and second years.CONCLUSIONSFluid overload variability significantly predicts mortality in KF patients, independent of average fluid overload levels, variability in BP pressure, and other potential confounders. Comprehensive fluid management strategies addressing both the level and variability of fluid status may improve clinical outcomes. Randomized controlled trials are necessary to confirm our hypothesis-generating findings.BACKGROUNDThe prognosis for kidney failure (KF) patients on long-term hemodialysis is poor, with fluid overload being a significant modifiable risk factor for mortality. Previous studies have focused on static measurements of fluid status, but the impact of long-term fluid fluctuations on clinical outcomes has not been thoroughly investigated.METHODSWe studied a cohort of 9,178 incident KF patients at Fresenius NephroCare dialysis centers across seven countries in Europe and the Middle East. Fluid status was assessed using bioimpedance spectroscopy, providing precise measurements of the fluid overload/extracellular water (FO/ECW) ratio. Fluid overload variability was calculated as the standard deviation (SD) of the FO/ECW ratio over the first three years. Time-dependent Cox regression models, adjusted for 47 covariates, evaluated the association between fluid overload variability and one-year mortality. We also analyzed mortality risk by quartiles of fluid overload variability.

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.