Unmasking the CONVINCE trial: is hemodiafiltration ready to steal the spotlight in real-world practice?
Priti Meena, Francesco Locatelli
Abstract
Hemodialysis (HD) is the predominant modality for kidney replacement therapy worldwide. Despite continuous endeavors to enhance the technology, the mortality and morbidity rate for hemodialysis remain exceptionally higher in respect to the general population. Hemodiafiltration (HDF) technique expands the solute elimination by employing both convective and diffusion mechanisms to enhance the overall removal of solutes of higher molecular weight, theoretically resulting in better outcomes. Several observational studies have provided suggestions of improved outcomes associated with online HDF (OL-HDF). However, the results of the randomized control trial (RCTs) remain uncertain and inconclusive. The discrepancies observed among these RCTs can be ascribed to various factors, including differences in the study designs, control groups, potential presence of selection bias, and confounding variables like convective volume. Blankenstijn et al. recently published in the New England Journal of Medicine, the results of CONVINCE trial a multinational, pragmatic RCT demonstrating a survival benefit of high-dose HDF compared to high-flux HD. In this editorial comment, we discuss the strength of this important trial and its limitations. The main reservation is related to the general applicability of these results. The feasibility of global implementation of OL HDF, particularly in middle and low-income countries, is also discussed.