Hemodiafiltration: Clinical Practice of Today and a Look into the Future
In brief
High-volume hemodiafiltration lowers deaths and hospitalizations versus standard dialysis
A review of trials, pooled analyses, and real-world studies reports that high-volume hemodiafiltration improves survival and reduces hospitalizations compared with conventional high-flux hemodialysis, with benefits linked to the convective volume achieved. The treatment can be delivered safely in routine practice, but wider adoption requires investment and the best targets for individual patients remain unsettled.
- Journal
- Journal of the American Society of Nephrology : JASN (Q1)
- Published
- 22 September 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Peter J Blankestijn, Sanne Roos, Claudia Barth, Michiel L Bots, Krister Cromm, Andrew Davenport, et al.
- PMID
- 42771831
- DOI
- 10.1681/ASN.0000001282
Why clinicians should know about it
- Picked for Nephrology (paper of the day, 25 September 2026): High-volume HDF improves mortality vs conventional HD
Abstract
Hemodiafiltration (HDF) with online production of substitution fluid has emerged as kidney replacement therapy and is increasingly adopted worldwide. Recent randomized controlled trials, individual participant data meta-analyses, and large real-world studies have demonstrated that high-volume HDF improves clinical outcomes compared with conventional high-flux hemodialysis (HD), including reduction in all-cause mortality and hospitalization. Importantly, these benefits appear dose-dependent, with achieved convective volume serving as a modifiable treatment target. Beyond survival, data suggest advantages in patient reported outcomes and evidence for cost-effectiveness. This review provides a practical overview of contemporary HDF delivery, focusing on the prescription variables that determine treatment performance, including vascular access, blood flow rate, filtration fraction, treatment time, dialyzer characteristics, and machine technology. Current evidence suggests that high-volume post-dilution HDF can be achieved safely and reproducibly in routine clinical practice using standard thrice-weekly treatment schedules and contemporary dialysis platforms. Monitoring should extend beyond conventional small-solute clearance metrics to include indicators of middle-molecule removal and patient-centered outcomes. Future developments are expected to move HDF from a uniform prescription strategy towards a more individualized approach. Emerging data support refinement of convection-volume targets according to patient characteristics and treatment response, while incorporation of patient-reported outcomes and predictive models may facilitate precision-based therapy. Advances in automation, digital monitoring, biosensors, and artificial intelligence are most likely to further optimize treatment delivery and personalization. Although implementation requires investment in infrastructure, training, and quality assurance, growing evidence suggests that these costs may be offset by improved clinical outcomes, reduced healthcare utilization, and enhanced sustainability. Collectively, current evidence supports high-volume HDF as among the most effective dialysis modality currently available and it is likely to become the global standard for kidney replacement therapy.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.