Kidney Week 2025 Annual Meeting-Big Questions in Maintenance Dialysis

Video Transcription

Video Summary

The session “Big Questions in Maintenance Hemodialysis” featured four talks spanning dialysis modality, anemia therapy, cardio-metabolic drugs in dialysis, and implementation science.<br /><br />Rukhsana Shroff argued for broader adoption of hemodiafiltration (HDF). Standard thrice-weekly HD/PD restores only ~15% of kidney function and outcomes remain poor. HDF adds convection via infusion of sterile, ultrapure substitution fluid, improving removal of “middle molecules” (e.g., β2-microglobulin). Randomized trials and meta-analyses suggest HDF reduces all-cause and cardiovascular mortality versus high-flux HD, especially when high convection volumes are achieved (≈>23 L/session). CONVINCE showed ~23% mortality reduction but highlights selection issues (patients able to reach high volumes tend to be younger with fistulas and fewer comorbidities). Beyond survival, HDF may improve physical and cognitive quality of life and reduce infection-related hospitalization; pediatric data suggest better vascular measures, blood pressure, inflammation, bone health, and growth. Barriers include regulatory requirements for IV-quality fluid, infrastructure/machine upgrades, staff training, costs, and environmental concerns, though newer machines may reduce dialysate use.<br /><br />Kirsten Johansson reviewed HIF-prolyl hydroxylase inhibitors (HIF-PHIs) for CKD anemia. They stabilize HIF, increasing endogenous EPO and potentially improving iron availability (lower hepcidin). In trials, vadadustat was non-inferior to darbepoetin for hemoglobin but failed MACE non-inferiority in non-dialysis CKD; in dialysis it met MACE non-inferiority. Draft KDIGO guidance suggests ESAs first-line, considering HIF-PHIs when oral therapy is preferred or for ESA hyporesponsiveness, while avoiding them in higher-risk patients (recent thrombosis/CV events, active malignancy, etc.) and not combining with ESAs.<br /><br />Shahzad Kovesdy discussed off-label use of SGLT2 inhibitors and GLP-1 receptor agonists in dialysis. Pharmacokinetics suggest minimal dialyzability and no major toxic accumulation; glycosuric effects are absent, but potential cardiovascular/metabolic benefits may persist. Evidence is limited to small studies and observational data suggesting possible benefit. For potassium binders, sodium zirconium cyclosilicate effectively lowers pre-dialysis potassium (approved for this use), but a large outcomes trial was stopped early for no difference in major clinical events despite improved potassium control.<br /><br />Megan Urbanski presented dissemination and implementation (D&I) science to close the “know–do gap” (often ~17 years to routine care). She distinguished effectiveness (“does it work?”) from implementation (“how do we help people do it?”), outlined frameworks (e.g., RE-AIM, CFIR), implementation strategies (ERIC), outcomes (adoption, fidelity, sustainability), and hybrid trial designs, emphasizing nephrology’s need to embed D&I to translate evidence into practice and reduce inequities.

Asset Subtitle

Moderator(s): David Charytan, Tammy Sirich

Presentation(s):

Hemodiafiltration: Is It Time for Broad Adoption? - Rukshana Shroff
HIF-PHIs vs. Erythropoiesis-Stimulating Agents: When to Use Which? - Kirsten Johansen
SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Potassium Binders: Will They Become Part of ESKD Care? - Csaba Kovesdy
How Do We Move from Generating Evidence to Implementing New Treatments in Clinical Care? - Megan Urbanski

Meta Tag

Date 11/7/2025

Pathway 1 Dialysis

Pathway 2 Hypertension and Cardiorenal Disorders

Session ID 507230

Keywords

maintenance hemodialysis

hemodiafiltration (HDF)

convection volume threshold 23 L/session

middle molecule clearance

beta-2 microglobulin

high-flux hemodialysis comparison

dialysis mortality reduction

HIF-prolyl hydroxylase inhibitors (HIF-PHIs)

CKD anemia therapy

vadadustat vs darbepoetin

KDIGO anemia guidance

SGLT2 inhibitors in dialysis

GLP-1 receptor agonists in dialysis

dissemination and implementation science (RE-AIM, CFIR, ERIC)