A bi-national cross-sectional survey of clinician attitudes towards haemodiafiltration in Australia and New Zealand.

Abstract

Background: High convection volume hemodiafiltration may improve survival compared to high-flux hemodialysis, however there is significant variation in its use. Clinician attitudes towards hemodiafiltration are poorly understood but may explain differences in practice patterns. Method(s): A 17-question online survey was administered from February 2017 to January 2018. Clinicians involved in the care of hemodialysis patients were invited to participate via the Australian and New Zealand Society of Nephrology. The survey addressed domains of clinician knowledge; hemodiafiltration prescription; perceived benefits, harms, and barriers to use; and indications and contraindications. Result(s): Eighty-two responses were received from clinicians affiliated with 49 of 81 hemodialysis units (60 unit response rate). Hemodiafiltration was prescribed by 87 of respondents, but generally to less than 25 of patients. The percentage of respondents prescribing hemodiafiltration to most of their patients was greater for those in privately funded (60) than publicly funded units (28). Only 26 of respondents considered the level of evidence supporting the superiority of hemodiafiltration over high-flux hemodialysis to be high. Its key benefits were perceived to be superior middle molecule clearance, hemodynamic stability, phosphate clearance, and amyloid prevention. Common indications included frequent intradialytic symptoms, intradialytic hypotension, and uremic polyneuropathy. Few respondents (14) agreed hemodiafiltration conveyed harm to patients, however 25 considered frequent circuit clotting to be a relative contraindication. Although most respondents (63) believed hemodiafiltration was more expensive than high-flux hemodialysis, this was not a barrier to its use. Three-quarters of respondents prescribed post-dilution hemodiafiltration, but only 55 targeted a convection volume greater than 20L. Conclusion(s): Most clinicians in Australia and New Zealand prescribe hemodiafiltration, but generally to a small proportion of patients, and high convection volumes are not routinely targeted. Although no specific barriers to its use were identified, the majority of clinicians did not consider the level of evidence supporting its use to be high.