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Prescribing chronic intermittent high-volume hemodiafiltration

Prescribing chronic intermittent high-volume hemodiafiltration
Authors:
Muriel PC Grooteman, MD, PhD
Peter J Blankestijn, MD
Section Editor:
Paul M Palevsky, MD
Deputy Editor:
Eric N Taylor, MD, MSc, FASN
Literature review current through: Apr 2025. | This topic last updated: Jan 21, 2025.

INTRODUCTION — 

Hemodiafiltration (HDF) is a form of kidney replacement therapy (KRT) that utilizes convective in combination with diffusive clearance, which is used in standard hemodialysis. Compared with standard hemodialysis, HDF removes more middle-molecular-weight solutes. Chronic intermittent high-volume HDF is not widely used in the United States but is common in Europe, Japan, and other countries.

This topic reviews practical aspects of prescribing chronic intermittent high-volume HDF, including patient selection and dosing recommendations. The basic principles underlying solute removal and replacement fluid in HDF, calculations of solute clearance in HDF, and the technical aspects and clinical outcomes of HDF are discussed elsewhere. (See "Technical aspects of hemodiafiltration" and "Outcomes associated with chronic hemodiafiltration".)

GENERAL PRINCIPLES

Modes of replacement fluid infusion — For chronic kidney replacement therapy (KRT), most clinicians use a specific type of HDF termed online HDF [1], in which the replacement fluid is produced by the dialysis machine. Once produced, replacement fluid may be infused upstream of the dialyzer (predilution) or downstream of the dialyzer (postdilution) (figure 1). Infusion both upstream and downstream of the dialyzer (mixed-dilution) or into the middle of the dialyzer blood pathway (mid-dilution) is less common. (See "Technical aspects of hemodiafiltration", section on 'Components and technology of online HDF'.)

Pre- and postdilution infusion can be performed with all HDF machines and dialyzers. Special equipment is required to perform mid- or mixed dilution HDF.

Achieved Kt/V — In contrast to standard hemodialysis, the achieved Kt/V among patients undergoing HDF depends on the mode of replacement fluid infusion. (See 'Modes of replacement fluid infusion' above and "Technical aspects of hemodiafiltration".)

Compared with postdilution HDF, predilution HDF delivers a lower achieved Kt/V due to a decrease in the concentration difference of the solute with respect to blood and dialysate. If predilution HDF is used, the dialysis time or blood flow may need to be increased in order to achieve the Kt/V target. With postdilution HDF, Kt/V will be slightly higher than standard hemodialysis when the same blood flow, dialyzer, and time are used due to the addition of convection to the diffusive clearance.

Calculation of effective convection volume — For postdilution HDF (figure 2), the effective convection volume is equal to the substitution volume plus the net ultrafiltration volume (ie, the treatment-induced weight loss).

For pre-, mid-, or mixed-dilution HDF (figure 1), the effective convection volume is the total volume above, multiplied by the dilution fraction (DF). The DF is the plasma water concentration of any solute at the dialyzer inlet relative to its concentration leaving the patient. DF is reduced below 1 due to infusion of replacement fluid into the blood upstream of the dialyzer (Qiu). DF is calculated from the plasma water flow leaving the patient (Qpw), divided by plasma water flow at the dialyzer inlet (Qpw + Qiu). The Qpw is estimated using the equation below:

 Qpw  =  Qb (1 - blood hematocrit)  x  0.93

Where Qb is the blood flow rate leaving the patient, and 0.93 represents the fraction of plasma that is water since 7 percent of the plasma volume consists of nonwater components such as protein and lipid. A more accurate approximation for the fraction of plasma that is water can be calculated from total plasma protein concentration [2].

To achieve a target effective convection flow rate (Qfeff), the ultrafiltration rate in predilution (Qfpre) must be increased by a factor of 1/DF so that Qfpre = Qfeff/DF. In general, if predilution HDF is used, the ultrafiltration rate should be at least 30 to 50 percent of blood flow entering the dialyzer in order to achieve the target of an effective convection rate of at least 20 percent of the undiluted blood flow rate [3].

Determinants of effective convection volume — The effective convection volume is determined by blood flow, treatment time, and the filtration fraction (table 1). These parameters are discussed below.

●Blood flow and treatment duration – An adequate blood flow rate and treatment time are required to achieve the minimum effective convection volume (table 1) (see 'Target effective convection volume' below). A reliable vascular access is required to accomplish acceptable blood flow rates.

In clinical practice, the effective or achieved blood flow rate is on average 5 percent lower than the set blood flow rate [4-6]; the difference may be as high as 50 percent in individual patients, especially in patients with catheters [7].

●Filtration fraction – The filtration fraction is the convection volume divided by the processed blood volume (or convective flow rate ÷ blood flow rate). The filtration fraction is not set as a separate treatment parameter but is adjusted by altering the substitution ratio, the substitution flow rate, or the target substitution volume, depending on the equipment used. On some HDF machines, feedback systems are available to maximize substitution flow rates [8].  

The filtration fraction is most precisely calculated from the plasma water flow rate or volume rather than the blood flow rate or volume. However, clinicians use the blood flow rate since the blood flow rate is readily available at the bedside [3].

When the blood flow rate is used to calculate the filtration fraction, hemoconcentration can vary markedly with variations in hematocrit and plasma protein content. In addition, the actual blood flow may be lower than the set blood flow, resulting in a higher actual filtration fraction as the recorded filtration (or substitution) fraction keeps pace with set blood flow.

At high filtration fractions, more plasma water is extracted from the blood, and convection volume increases. This results in increased hemoconcentration inside the dialyzer. In postdilution HDF, the maximal filtration fraction is limited by an increase in transmembrane pressure (TMP). The increased TMP is caused by hemoconcentration, which may result in clotting, altered membrane performance, and increased filter entrance pressure [9]. These parameters change during the treatment and may be enhanced by changes in net ultrafiltration rate (eg, by individualized ultrafiltration profiles) [10]. Hence, the tolerance for a certain filtration fraction may change during the treatment.

TMP causes alarms and interrupts dialysis, which decreases the total dialysis time. The total convection volume is associated with the frequency of TMP alarms during online postdilution HDF [11]. This problem may be mitigated by automated machine configurations that utilize TMP-controlled treatments [11,12]. Another approach is the automatic adaptation of the substitution flow rate to changes in blood viscosity, based on TMP assessment and pressure transmitted by the peristaltic blood pump [13,14] or on assessment of the global hydraulic permeability coefficient of the dialysis system (ultrafiltration flow ÷ TMP) [8,15].

PATIENT EVALUATION — 

Several patient factors affect the ability to optimally prescribe chronic intermittent high-volume hemodiafiltration (HDF):

●Reliable vascular access – Intermittent HDF generally requires a vascular access that can reliably achieve blood flow rates of at least 350 mL/min in adults and 5 to 8 mL/min/kg body weight or 150 to 240 mL/min/m2 body surface area in children [16]. Although the achieved blood flow rate tends to be lower in central venous catheters as compared with fistulae [6,7,13], central venous catheters may be used successfully for HDF [17].

●Relative contraindications to postdilution HDF – Postdilution HDF is preferred (see 'Modes of replacement fluid infusion' above and 'Postdilution HDF preferred' below) but may be impractical for patients at high risk of bleeding or for those with elevated blood viscosity:

•Because postdilution HDF requires anticoagulation, often at higher doses than required for hemodialysis (see 'Anticoagulation' below), a high risk of bleeding may preclude the procedure. In contrast to postdilution HDF, hemodialysis (or predilution HDF) may be performed without or with minimal anticoagulation. (See "Anticoagulation for the hemodialysis procedure", section on 'Patients at high risk for bleeding'.)

•The presence of a condition that increases blood viscosity (such as high hematocrit, cryoglobulinemia, gammopathies) also may complicate postdilution HDF. In postdilution HDF, the high rate of ultrafiltration causes significant increases in the hematocrit and serum protein concentration as blood flows through the dialyzer; this increases viscosity in the blood compartment. Additional increases in viscosity may cause membrane fouling and unmanageable increases in transmembrane pressure (TMP).

Predilution HDF may be used to minimize or avoid anticoagulation and to mitigate high TMP in patients with increased blood viscosity. However, clearance rates are lower with predilution HDF compared with postdilution HDF, and the majority of clinical trials reporting benefit with HDF have used postdilution volume replacement.

HEMODIAFILTRATION (HDF) PRESCRIPTION

Postdilution HDF preferred — We prescribe postdilution HDF rather than predilution, mixed dilution, or mid-dilution HDF [18]. In postdilution HDF, the infusate is delivered into the tubing downstream of the dialyzer (figure 1) (see 'Modes of replacement fluid infusion' above). The majority of clinical trials have used postdilution HDF, and postdilution HDF is the most effective modality for middle-molecule clearance [19].

Pre- or mixed dilution might be preferable in selected cases (eg, with very low blood flow rates or high filter pressures). When substitution fluid is infused in predilution mode, the convection volume should be doubled in order to obtain a comparable clearance.

Dose — The prescribed dose of HDF should define both a minimum urea clearance (which is referred to by the formula "Kt/V") and a minimum effective convection volume.

Minimum Kt/V — We target a minimum Kt/V of 1.2 to 1.4 per session, which is the same as for standard hemodialysis. Strategies to achieve target Kt/V in HDF are similar to those in hemodialysis. (See "Prescribing and assessing adequate hemodialysis".)

Studies that demonstrated improved survival with HDF all achieved this minimum Kt/V in addition to a minimum convection volume [20-30]. (See "Prescribing and assessing adequate hemodialysis", section on 'The optimal amount of dialysis'.)

Target effective convection volume — We target an effective convection volume of at least 23 L/session or 70 L/week when HDF is delivered in postdilution mode. Strategies to increase convection volume are detailed below. (See 'Patients with suboptimal convection volumes' below.)

An adequate convection volume is achieved by prescribing a sufficiently long treatment time and a high blood flow rate (table 1) [20-22]. A typical postdilution HDF regimen consists of four-hour sessions performed three times weekly with a blood flow rate of 350 to 400 mL/min. More intense schedules (daily, nightly, longer sessions, etc) have not been extensively studied in randomized trials, although limited data are available [31].

Convection volumes <23 L/session may have insufficient benefit to justify the increased complexity and cost of HDF. However, in patients with small body size, convection volumes <23 L/session may deliver a body surface area (BSA)-adjusted convection volume of ≥23 L/session, which is associated with improved survival [32]. Conversely, it is possible that patients with large body size may derive additional benefit by targeting convection volumes substantially >23 L/session to achieve a BSA-adjusted convection volume of at least 23 L/session. Thus, for patients with very small or large body size, some clinicians adjust the target convection volume to BSA (figure 3) [33] using the following formula: 23 L × (individual BSA [m2] / 1.73 m2).

When HDF is performed with high convection volumes in postdilution mode, most studies report a survival benefit compared with conventional hemodialysis (HD) [20,22,30,32-35]. However, the values of convection volume associated with benefit in such studies are variable, ranging from 17 to 23 L per session. Our convection volume target of 23 L/session is based on a predominance of these data suggesting benefit with convection volumes >20 L/session, and randomized trial data reporting survival advantages (relative to HD) with convection volumes of at least 23 L per session [30].

Patients with suboptimal convection volumes — For patients who have a convection volume less than target (ie, <23 L/session), we sequentially increase treatment time, blood flow rate, and filtration fraction until the convection volume is ≥ 23 L/session (table 1) (see 'Determinants of effective convection volume' above). This sequential approach is detailed below [36,37]:

●We increase the time of the HDF session in 30-minute increments to a maximum of 4.5 hours. However, many patients are unwilling to extend treatment time to >4 hours.

●If convection volume is less than target despite increased treatment time, we then increase the blood flow rate (Qb) by 50 mL/min per treatment, safety limits permitting, to at least 400 mL/min. Using a needle size larger than 16G (ie, 14G or 15G) typically helps to achieve adequate Qb. (See 'Cannulation needles' below.)

●If convection volume is still less than target despite increasing time and optimizing blood flow rate, we increase filtration fraction by 2 percent per treatment up to a maximum of 33 percent. Increasing filtration fraction may result in filter clotting and/or excessive transmembrane pressure (TMP); in such patients we review and optimize anticoagulation and we ensure that the patient’s ESA dosing has not resulted in Hb >target. (See 'Anticoagulation' below and "Treatment of anemia in patients on dialysis", section on 'Target Hb levels'.)

Dialyzer — In general, dialyzers used in conventional high-flux hemodialysis can also be used for online HDF. High-flux dialyzers with certain design features, such as a larger surface area and fiber diameter and a shorter fiber length, may be favorable for ol-HDF. (See "Technical aspects of hemodiafiltration".)

Access — Intermittent HDF generally requires a vascular access that can reliably achieve high blood flow rates (see 'Patient evaluation' above). Access issues specific to the HDF prescription are discussed below:

Cannulation needles — We generally use a needle size of 14G or 15G rather than smaller needles (eg, ≥16G). Larger needles used for puncture of the vascular access facilitate greater blood flow rate [4], an important determinant of effective convection volume. (See 'Determinants of effective convection volume' above and 'Patient evaluation' above.)

We do not use single-needle dialysis systems for HDF, as this method cannot provide adequate convection volumes. In single-needle dialysis, only one needle is inserted into the fistula and utilizes two pumps for the arterial and venous line. During single-needle hemodialysis, effective blood flow rates are approximately half of the rates during double-needle treatment [38], and the blood flow varies, resulting in variations in transmembrane pressure (TMP) and filtration fraction.

Patients with catheters — The achieved blood flow rate tends to be lower in central venous catheters as compared with fistulae [6,7,13]. However, central venous catheters may be used successfully for HDF [17]. (See 'Patient evaluation' above.)

Anticoagulation — As for routine hemodialysis, anticoagulation for HDF consists of a standard dose of unfractionated heparin given as a bolus at the start of the dialysis treatment with an additional mid-treatment dose, or a continuous infusion during treatment, or a standard dose of low-molecular-weight heparin (LMWH) (see "Anticoagulation for the hemodialysis procedure"). However, HDF often requires a higher dose of anticoagulant than is commonly used for hemodialysis. We start with the same dose of anticoagulation for HDF as for standard hemodialysis. If clotting or high filter entrance pressure occurs, the dose of LMWH is increased by 25 to 50 percent.

In our experience, the dose of the prescribed anticoagulant, either unfractionated heparin or LMWH, is approximately 10 to 20 percent higher in patients treated with online postdilution HDF than in hemodialysis patients [22,39]. Injection of LMWH in the outlet blood line seems most effective [40,41].

Both platelet activation and coagulation activity are increased during online postdilution HDF as compared with hemodialysis [42-44]. The increase in coagulation results from a combination of greater hemoconcentration and shear stress within the dialyzer and possibly removal of anticoagulant medication [42-44].

MONITORING — 

An assessment of the HDF regimen in stable patients is performed once per month by most clinicians. The assessment should include a review of the Kt/V, effective convection volume, ultrafiltration requirement per session, hemodynamic stability during dialysis sessions, blood pressure control, a review of intradialytic or interdialytic symptoms, and laboratory monitoring for anemia, metabolic bone disease, and electrolyte disturbances.

However, there is a paucity of evidence to support such assessments at monthly intervals.

DRUG DOSING — 

Little data are available on drug dosing in online postdilution HDF. As with extracorporeal drug removal by conventional hemodialysis (HD), removal of a specific drug by HDF (and the need for concomitant dosing adjustments) depends on molecular weight, protein binding, and volume of distribution [45,46]. However, drugs larger than 1 kD may be cleared more extensively with HDF than with standard HD since the removal of such drugs is dependent on convection rather than diffusion. HDF does not effectively remove molecules >60 kD and protein-bound drugs [47].

In clinical practice, we administer drugs with a molecular weight of 0.5-50 kD, low protein binding, and a small volume of distribution preferentially after treatment. If the therapeutic window is small, and/or toxicity high, we advise therapeutic drug monitoring [48].

Drug dosing tables are available [47]. However, the majority of the data on drug dosing in convective techniques is derived from studies in intensive care patients. In these patients, protein binding and volume of distribution can be quite different from stable individuals [49].

IMPLEMENTING AN HDF PROGRAM — 

As data demonstrating the benefits of HDF continue to accumulate, the use of online HDF (ol-HDF) is expected to expand rapidly worldwide, including in regions where it is not yet common (eg, North America). Implementing an ol-HDF program is eminently feasible: HDF has been used as treatment for end-stage kidney disease for over 30 years [50] and ol-HDF accounts for approximately 10 percent of dialysis sessions globally [51].

However, potential barriers exist when starting an ol-HDF program. As presented below, such barriers include costs, potential risks of the procedure, staff training, and adherence to region-specific regulatory standards:

●Costs – Implementing an ol-HDF program requires financial investments in equipment, organization, and training. However, once ol-HDF has become a routine treatment, its cost in most regions is likely comparable with those of hemodialysis with high-flux dialyzers [52,53].

●Risks – HDF requires the infusion of large volumes of fluid. There is a potential risk of transmitting infection or inducing inflammatory reactions if the infusion fluid is not ultrapure (see "Technical aspects of hemodiafiltration", section on 'Microbiological safety'). Additionally, the high rate of ultrafiltration could result in loss of nutritional and other relevant substances and endothelial or blood cell activation during the treatment.

However, studies of HDF have not suggested safety concerns providing HDF is performed according to recommendations. Inflammatory mechanisms have not been shown to be activated, and more infections do not appear to occur [34,54]. In fact, some studies suggest that inflammatory markers are lower during HDF [55,56]. Some data suggest that activation of platelets and coagulation with HDF is more pronounced than with standard hemodialysis [42-44]. The clinical relevance of these effects is uncertain.

●Training – Because chronic maintenance HDF is more complex than conventional hemodialysis, additional training is required for dialysis staff.

●Regulatory issues – The majority of manufacturers provide systems licensed for ol-HDF worldwide, including the United States [57].

Equipment for ol-HDF must comply with the International Electrotechnical Commission standards 60601-2-16 [58]. These standards require manufacturers to perform formal risk analysis for their equipment and implement means to reduce risk to acceptable levels. The FDA has adopted these standards.

The International Organization for Standardization (ISO) 23500-2019 E, "Quality of dialysis fluid for hemodialysis and related therapies," recommends that dialysis fluid used for high-flux hemodialysis should be ultrapure (<0.1 colony-forming unit [CFU]/mL, <0.03 endotoxin unit [EU]/mL). The infusate for HDF must be sterile and nonpyrogenic [59]. ISO recognizes that it is not possible to confirm compliance by testing the infusate, since there is no test for absolute sterility. Instead, the standards require that online replacement fluid be prepared using a process validated by the manufacturer of the equipment. (See "Technical aspects of hemodiafiltration", section on 'Microbiological safety'.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)

SUMMARY AND RECOMMENDATIONS

●General principles – Chronic intermittent high-volume hemodiafiltration (HDF) is a form of kidney replacement therapy (KRT) that utilizes convective in combination with diffusive clearance, which is used in standard hemodialysis. For chronic KRT, most clinicians use a specific type of HDF termed online HDF, in which the replacement fluid is produced by the dialysis machine. Replacement fluid may be infused upstream of the dialyzer (predilution) or downstream of the dialyzer (postdilution) (figure 1). (See 'General principles' above.)

●Patient evaluation – Intermittent HDF generally requires a vascular access that can reliably achieve high blood flow rates. Postdilution HDF may be impractical for patients at high risk of bleeding or for those with elevated blood viscosity. (See 'Patient evaluation' above.)

●HDF prescription – A typical intermittent HDF regimen consists of four-hour sessions performed three times weekly with a blood flow rate of 350 to 400 mL/min.

•Postdilution HDF preferred – For patients treated with chronic intermittent HDF, we suggest postdilution HDF rather than predilution, mixed dilution, or mid-dilution HDF (Grade 2C). Postdilution HDF is the most effective modality for middle-molecule clearance. (See 'Postdilution HDF preferred' above.)  

•Dose – The prescribed dose of HDF should define both a minimum urea clearance (which is referred to by the formula "Kt/V") and a minimum effective convection volume.

-The minimum Kt/V is the same as for standard hemodialysis, which is 1.2 to 1.4 per session. (See "Prescribing and assessing adequate hemodialysis", section on 'The optimal amount of dialysis'.)

-For patients treated with chronic intermittent HDF, we suggest targeting an effective convection volume ≥23 L/treatment rather than lower volumes (Grade 2C). Lower volumes may have insufficient benefit to justify the increased complexity and cost of HDF. For patients who have a convection volume less than target, we sequentially increase treatment time, blood flow rate, and filtration fraction until the convection volume is ≥ 23 L/session (table 1). (See 'Target effective convection volume' above and 'Patients with suboptimal convection volumes' above.)

•Access – For puncture of the vascular access, we generally use a needle size of 14G or 15G rather than smaller needles (eg, ≥16G). Larger needles facilitate a greater blood flow rate, an important determinant of effective convection volume. Although the achieved blood flow rate tends to be lower in central venous catheters as compared with fistulae, catheters may be used successfully for HDF. (See 'Access' above.)

•Anticoagulation – The approach to anticoagulation for intermittent HDF is similar to that for conventional hemodialysis. However, HDF often requires a higher dose of anticoagulant compared with hemodialysis. (See 'Anticoagulation' above.)

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  46. Keller F, Wilms H, Schultze G, et al. Effect of plasma protein binding, volume of distribution and molecular weight on the fraction of drugs eliminated by hemodialysis. Clin Nephrol 1983; 19:201.
  47. Zandvliet AS, Touw DJ, Penne EL. Medication and hemodiafiltration. In: Hemodiafiltration: Theory, Technology, and Clinical Practice, Nube MJ, Grooteman MPC, Blankestijn PJ (Eds), Springer International Publishing, 2016. p.307.
  48. Jager NG, Zandvliet AS, Touw DJ, Penne EL. Optimization of anti-infective dosing regimens during online haemodiafiltration. Clin Kidney J 2017; 10:282.
  49. Blot SI, Pea F, Lipman J. The effect of pathophysiology on pharmacokinetics in the critically ill patient--concepts appraised by the example of antimicrobial agents. Adv Drug Deliv Rev 2014; 77:3.
  50. Maduell F, Broseta JJ, Gómez M, et al. Determining factors for hemodiafiltration to equal or exceed the performance of expanded hemodialysis. Artif Organs 2020; 44:E448.
  51. Ficociello LH, Busink E, Sawin DA, Winter A. Global real-world data on hemodiafiltration: An opportunity to complement clinical trial evidence. Semin Dial 2022; 35:440.
  52. Lévesque R, Marcelli D, Cardinal H, et al. Cost-Effectiveness Analysis of High-Efficiency Hemodiafiltration Versus Low-Flux Hemodialysis Based on the Canadian Arm of the CONTRAST Study. Appl Health Econ Health Policy 2015; 13:647.
  53. Ramponi F, Ronco C, Mason G, et al. Cost-effectiveness analysis of online hemodiafiltration versus high-flux hemodialysis. Clinicoecon Outcomes Res 2016; 8:531.
  54. den Hoedt CH, Grooteman MP, Bots ML, et al. The Effect of Online Hemodiafiltration on Infections: Results from the CONvective TRAnsport STudy. PLoS One 2015; 10:e0135908.
  55. Locatelli F, Mastrangelo F, Redaelli B, et al. Effects of different membranes and dialysis technologies on patient treatment tolerance and nutritional parameters. The Italian Cooperative Dialysis Study Group. Kidney Int 1996; 50:1293.
  56. den Hoedt CH, Bots ML, Grooteman MP, et al. Online hemodiafiltration reduces systemic inflammation compared to low-flux hemodialysis. Kidney Int 2014; 86:423.
  57. 510(k) Premarket Notification. US Food and Drug Administration (FDA). Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K231534 (Accessed on June 18, 2024).
  58. International Organization for Standardization. ISO 23500-1:2019. Preparation and quality management of fluids for haemodialysis and related therapies - Part 1: General requirements. Available at: https://www.iso.org/standard/67614.html (Accessed on July 08, 2021).
  59. Ward RA, Vienken J, Silverstein DM, et al. Regulatory Considerations for Hemodiafiltration in the United States. Clin J Am Soc Nephrol 2018; 13:1444.
Topic 108216 Version 22.0

References

1 : Global prevalent use, trends and practices in haemodiafiltration.

2 : Aqueous solute concentrations and evaluation of mass transport coefficients in peritoneal dialysis.

3 : Online haemodiafiltration: definition, dose quantification and safety revisited.

4 : Correction of discrepancy between prescribed and actual blood flow rates in chronic hemodialysis patients with use of larger gauge needles.

5 : Study of discrepancies between recorded and actual blood flow in hemodialysis patients.

6 : Difference between delivered and prescribed blood flow in hemodialysis.

7 : Effective flow performances and dialysis doses delivered with permanent catheters: a 24-month comparative study of permanent catheters versus arterio-venous vascular accesses.

8 : Hemodiafiltration: Technical and Medical Insights.

9 : Mixed predilution and postdilution online hemodiafiltration compared with the traditional infusion modes.

10 : Blood-membrane interactions during dialysis.

11 : Evaluation of a new online hemodiafiltration mode with automated pressure control of convection.

12 : Divert to ULTRA: differences in infused volumes and clearance in two on-line hemodiafiltration treatments.

13 : High-volume postdilution hemodiafiltration is a feasible option in routine clinical practice.

14 : Impact of the 5008 monitor software update on total convective volume.

15 : Consequences of increasing convection onto patient care and protein removal in hemodialysis.

16 : Hemodiafiltration: the addition of convective flow to hemodialysis.

17 : Treatment policy rather than patient characteristics determines convection volume in online post-dilution hemodiafiltration.

18 : Haemodiafiltration-optimal efficiency and safety.

19 : Effective removal of protein-bound uraemic solutes by different convective strategies: a prospective trial.

20 : Effect of online hemodiafiltration on all-cause mortality and cardiovascular outcomes.

21 : High-efficiency postdilution online hemodiafiltration reduces all-cause mortality in hemodialysis patients.

22 : Mortality and cardiovascular events in online haemodiafiltration (OL-HDF) compared with high-flux dialysis: results from the Turkish OL-HDF Study.

23 : Mortality risk for patients receiving hemodiafiltration versus hemodialysis: European results from the DOPPS.

24 : Mortality risk for patients receiving hemodiafiltration versus hemodialysis.

25 : Hemodiafiltration Versus Hemodialysis and Survival in Patients With ESRD: The French Renal Epidemiology and Information Network (REIN) Registry.

26 : Chronic inflammation and mortality in haemodialysis: effect of different renal replacement therapies. Results from the RISCAVID study.

27 : New insights into the effect of haemodiafiltration on mortality: the Romanian experience.

28 : Long-term outcomes in online hemodiafiltration and high-flux hemodialysis: a comparative analysis.

29 : ESHOL study reanalysis: All-cause mortality considered by competing risks and time-dependent covariates for renal transplantation.

30 : Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure.

31 : Eight-Year Experience with Nocturnal, Every-Other-Day, Online Haemodiafiltration.

32 : Haemodiafiltration and mortality in end-stage kidney disease patients: a pooled individual participant data analysis from four randomized controlled trials.

33 : Higher convection volume exchange with online hemodiafiltration is associated with survival advantage for dialysis patients: the effect of adjustment for body size.

34 : Optimal convection volume for improving patient outcomes in an international incident dialysis cohort treated with online hemodiafiltration.

35 : Nocturnal, every-other-day, online haemodiafiltration: an effective therapeutic alternative.

36 : Optimization of the convection volume in online post-dilution haemodiafiltration: practical and technical issues.

37 : Achieving high convection volumes in postdilution online hemodiafiltration: a prospective multicenter study.

38 : What is single needle cannulation hemodialysis: is it adequate?

39 : The prescribed dose of low molecular weight heparin increases after assigning patients to hemodiafiltration (HDF) treatment

40 : Where and When To Inject Low Molecular Weight Heparin in Hemodiafiltration? A Cross Over Randomised Trial.

41 : Arterial Versus Venous Port Site Administration of Nadroparin for Preventing Thrombosis of Extracorporeal Blood Circuits in Patients Receiving Hemodiafiltration Treatment.

42 : Post-dilution haemodiafiltration and low-flux haemodialysis have dissimilar effects on platelets: a side study of CONTRAST.

43 : Comparative analysis of procoagulatory activity of haemodialysis, haemofiltration and haemodiafiltration with a polysulfone membrane (APS) and with different modes of enoxaparin anticoagulation.

44 : The anticoagulant activity of enoxaparin sodium during on-line hemodiafiltration and conventional hemodialysis.

45 : Drug clearance by continuous haemodiafiltration. Analysis of sieving coefficients and mass transfer coefficients of diffusion.

46 : Effect of plasma protein binding, volume of distribution and molecular weight on the fraction of drugs eliminated by hemodialysis.

47 : Effect of plasma protein binding, volume of distribution and molecular weight on the fraction of drugs eliminated by hemodialysis.

48 : Optimization of anti-infective dosing regimens during online haemodiafiltration.

49 : The effect of pathophysiology on pharmacokinetics in the critically ill patient--concepts appraised by the example of antimicrobial agents.

50 : Determining factors for hemodiafiltration to equal or exceed the performance of expanded hemodialysis.

51 : Global real-world data on hemodiafiltration: An opportunity to complement clinical trial evidence.

52 : Cost-Effectiveness Analysis of High-Efficiency Hemodiafiltration Versus Low-Flux Hemodialysis Based on the Canadian Arm of the CONTRAST Study.

53 : Cost-effectiveness analysis of online hemodiafiltration versus high-flux hemodialysis.

54 : The Effect of Online Hemodiafiltration on Infections: Results from the CONvective TRAnsport STudy.

55 : Effects of different membranes and dialysis technologies on patient treatment tolerance and nutritional parameters. The Italian Cooperative Dialysis Study Group.

56 : Online hemodiafiltration reduces systemic inflammation compared to low-flux hemodialysis.

57 : Online hemodiafiltration reduces systemic inflammation compared to low-flux hemodialysis.

58 : Online hemodiafiltration reduces systemic inflammation compared to low-flux hemodialysis.

59 : Regulatory Considerations for Hemodiafiltration in the United States.