The Impact of Dialysate Flow Rate on Hemodialysis Adequacy: A Systematic Review and Meta-Analysis

Patients with kidney failure treated with maintenance hemodialysis (HD) require appropriate small molecule clearance. Historically, a component of measuring ‘dialysis adequacy’ has been quantified using urea kinetic modeling that is dependent on the HD prescription. However, the impact of dialysate flow rate on urea clearance remains poorly described in vivo and its influence on other patient important outcomes of adequacy is uncertain. We searched EMBASE, MEDLINE, and the Cochrane Library from inception until April 2022 for randomized controlled trials and observational trials comparing a higher dialysate flow rate (800 mL/min) and lower dialysate flow rate (300 mL/min) with a standard dialysis flow rate (500 mL/min) in adults (age ≥ 18 years) treated with maintenance HD (>90 consecutive days). We conducted a random effects meta-analysis to estimate pooled mean difference in dialysis adequacy as measured by Kt/V or urea reduction ratio (URR). A total of 3118 studies were identified. Of those, 9 met eligibility criteria and 4 were included in meta-analysis. A higher dialysate flow rate (800 mL/min) increased single pool Kt/V by 0.08 (95% CI: 0.05 to 0.10, p-value < 0.00001), and URR by 3.38 (95% CI: 1.97 to 4.78, p-value < 0.00001) in comparison to a dialysate flow rate of 500 mL/min. Clinically relevant outcomes including symptoms, cognition, physical function and mortality were lacking and studies were generally at a moderate risk of bias due to issues with randomization sequence generation, allocation concealment and blinding. A higher dialysate flow increased urea-based markers of dialysis adequacy. Additional high-quality research is needed to determine the clinical, economic and environmental impacts of higher dialysate flow rates.