Rationale & Objective:
The female survival advantage is diminished with hemodialysis. We evaluated the associations between measures of hemodialysis adequacy and quality and cardiovascular outcomes and mortality by sex.
Study Design:
Systematic review of randomized controlled trials and observational studies. Electronic databases (MEDLINE, EMBASE, CENTRAL) were searched from inception to August 1, 2024.
Setting & Study Populations:
Adults living with kidney failure treated with maintenance hemodialysis, stratified by sex.
Selection Criteria for Studies:
Studies comparing higher versus lower measures of hemodialysis adequacy and quality (Kt/V, urea reduction ratio, ultrafiltration rate, treatment time) as exposures and reporting mortality (cardiovascular-related, all-cause), major adverse cardiovascular events, or cardiovascular-related hospitalization as outcomes.
Data Extraction:
Data were extracted independently in duplicate.
Analytical Approach:
Results were synthesized following Synthesis Without Meta-analysis reporting guidelines.
Results:
Thirty-one studies (n = 1,402,002 participants) reported results by sex; only 10 studies reported the interaction by sex. Multiple measures of adequacy with varying definitions of 'higher' and 'lower' values were reported, with Kt/V being the most common. Three studies reported a greater decrease in all-cause mortality in female than in male individuals with higher single-pool Kt/V; 1 study reported no difference by sex. One study reported a greater decrease in all-cause mortality in female than in male individuals with higher urea reduction ratio; 1 study reported no difference by sex. One study reported a greater decrease in all-cause mortality in female than in male individuals with greater weekly hemodialysis treatment times; 1 study reported no difference by sex. Two studies reported greater all-cause mortality with higher ultrafiltration rate in female than in male individuals.
Limitations:
Inconsistent reporting of hemodialysis adequacy and quality measures. Inconsistent inclusion of factors known to impact important clinical outcomes.
Conclusions:
Although the results should be interpreted with caution due to significant study heterogeneity, female individuals may derive greater benefit from higher values of hemodialysis adequacy and quality measures than male individuals.