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Sex Differences in Associations Between Measures of Hemodialysis Adequacy and Quality, Cardiovascular Outcomes, and Mortality: A Systematic Review

Year: 2026

Type: review

Abstract: 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. Plain-Language Summary Female individuals treated with maintenance hemodialysis have lower survival compared to male individuals, which may be linked to current hemodialysis adequacy and quality targets that do not account for potential sex-based differences. Our study systematically reviewed the literature to compare the associations between measures of hemodialysis adequacy or quality and cardiovascular outcomes and cardiovascular and all-cause mortality by sex. We analyzed 31 studies (n = 1,402,002 participants). The majority of the studies reported higher Kt/V was associated with lower all-cause mortality in both female and male individuals. However, female individuals may derive greater benefit from higher measurements of hemodialysis adequacy and quality compared to male individuals. There is limited research examining the association between measures of hemodialysis adequacy and quality and clinical outcomes by sex; further studies examining sex-specific hemodialysis prescriptions are warranted.

Source: Kidney Medicine

DOI: 10.1016/j.xkme.2026.101246