What’s new in dialysis in 2025?

Cardiovascular mortality among hemodialysis patients remains strikingly high—around 10% per year—despite substantial advances in dialysis technology and medical care. Historically, several strategies extrapolated from the general population have failed to improve outcomes: The landmark 4D and AURORA trials showed no cardiovascular or survival benefit from statin therapy in dialysis patients, whereas high-volume online hemodiafiltration (ESHOL, CONVINCE) significantly reduced all-cause mortality, though without a specific reduction in cardiovascular deaths. More recently, large randomized controlled trials have again underscored the difficulty of improving cardiovascular outcomes in dialysis through pharmacological means: The ACHIEVE and ALCHEMIST trials found no clinical benefit from low-dose spironolactone on cardiovascular mortality or heart-failure hospitalization, and the DIALIZE-Outcomes trial showed that improved potassium control with sodium zirconium cyclosilicate did not reduce sudden cardiac death or arrhythmic events. Taken together, these neutral findings emphasize the complex, multifactorial nature of cardiovascular risk in dialysis, driven by “non-traditional” mechanisms such as inflammation, vascular calcification, oxidative stress, and intradialytic myocardial ischemia. In this context, recent studies from the Avignon group in France have identified intradialytic and pre-­dialysis exercise as a promising non-pharmacological intervention capable of mitigating myocardial stunning and improving cardiac function. In summary, while classical cardioprotective strategies continue to fall short, emerging evidence highlights the potential of innovative, physiology-based approaches—optimizing dialysis modalities and leveraging exercise-induced cardioprotection—to address the persistent cardiovascular burden of uremia.