A Swedish nationwide study suggests that implementation of advanced therapies and guideline-recommended treatments have contributed to reductions in death and major adverse cardiovascular events (MACE) among patients receiving hemodialysis (HD) therapies over the last decade.

Using the Swedish Renal Registry, Marie Evans, MD, PhD, of Karolinska Institutet in Stockholm, Sweden, and colleagues studied 6612 patients initiating some form of HD  2006 to 2015. During this period, the investigators found more working arteriovenous fistulas (AVFs), increasing adoption of hemodiafiltration, more than thrice-weekly HD regimens, and a decreasing ultrafiltration rate. Unlike in the United States, outpatient hemodiafiltration is standard practice in Sweden, which provides universal healthcare.

With respect to medication and supplements, Dr Evans’ team found greater use of non-calcium phosphate binders, the calcimimetic cinacalcet, and vitamin D3, all used to treat chronic kidney disease mineral bone disorders (CKD-MBD). The investigators observed that mean phosphate levels decreased during the period.

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Results showed that 1-year mortality declined from 13.2% during 2006 to 2007 to 11.1% during 2014 to 2015 among patients with kidney disease, the investigators reported online in Nephrology Dialysis Transplantation. Excess death risk compared with the general Swedish population also declined from 6-fold to 5.6-fold. Among patients with kidney disease, the risks for death from any cause and MACE decreased by 6% and 4%, respectively, every 2 years. These gains virtually disappeared after adjustment for treatment advances.

“The multivariable analyses suggested that the improvements in outcomes could, at least in part, be explained by the increasing implementation of these therapeutic advances, as the differences in mortality and MACE were almost eliminated by adjustments for the changes of these treatments,” Dr Evan’s group wrote. The investigators noted that the risk for mortality and cardiovascular complications among patients still remains unacceptably high.


Evans M, Xu H, Rydell H, et al. Association between implementation of novel therapies and improved survival in patients starting hemodialysis: the Swedish Renal Registry 2006-2015. Published online December 16, 2020. Nephrol Dial Transplant.  doi:10.1093/ndt/gfaa357