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Outcomes associated with chronic hemodiafiltration

Outcomes associated with chronic hemodiafiltration
Authors:
Gihad E Nesrallah, MD, MSc, FRCPC
Matthew B Rivara, MD
Section Editor:
Jeffrey S Berns, MD
Deputy Editor:
Eric N Taylor, MD, MSc, FASN
Literature review current through: Apr 2025. | This topic last updated: Feb 26, 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 HDF is not used in the United States due to regulatory limitations and the lack of commercially available HDF machines, but is common in Europe, Japan, and other countries.

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

BIOCHEMICAL EFFECTS — 

The purported benefits of convective therapies over conventional hemodialysis are attributed to the increased removal of larger molecules. Historically, the use of high-flux biocompatible membranes (which decreases cytokine release) [1,2] and ultrapure dialysate (which decreases cytokine release and introduces fewer impurities) [3,4] also were considered as potential advantages of convective therapies; however, high-flux membranes and ultrapure dialysate are now used routinely for conventional hemodialysis in resource-rich settings.

Solute clearance — By combining hemodialysis and hemofiltration, hemodiafiltration (HDF) leverages the enhanced larger solute clearance of hemofiltration, while also providing the high clearance of small solutes obtained with hemodialysis. (See "Technical aspects of hemodiafiltration", section on 'Principles of hemodiafiltration'.)

In hemodialysis, solutes are removed mostly by diffusion, a process whereby larger molecules move more slowly across the dialysis filter membrane than smaller molecules. As a result, hemodialysis clears smaller solutes more effectively than larger solutes, even if both are small enough to pass through the pores in the dialysis membrane unimpeded. By contrast, in hemofiltration, solutes are carried through the membrane pores by convection. If the solute can easily pass through the membrane pores, the rate of transfer by convection is independent of the molecular size. This enables higher clearances of larger solutes with hemofiltration compared with hemodialysis. 

Removal of specific molecules

●Urea – Small-molecule clearance is usually lower with hemofiltration as it is limited by the ultrafiltration volume when compared with conventional hemodialysis or HDF. By comparison, small-molecule removal is increased with the use of high-efficiency on-line HDF and can be similar or even higher than hemodialysis, depending on the volume of the substitution solution [5-7]. In the European Dialysis Outcomes and Practice Patterns Study (DOPPS), for example, patients on high-efficiency (15.0 to 24.9 L substitution fluid per session), thrice-weekly HDF had higher Kt/V urea levels than those on hemodialysis [6].

●Beta-2 microglobulin – A majority of studies have suggested better removal of beta-2 microglobulin with convective techniques as compared with conventional hemodialysis [8-15]. This has been further supported by two meta-analyses [16,17]. However, the increase in beta-2 microglobulin removal with HDF compared with current high-flux hemodialysis appears to be relatively small [18], and whether such increases translate into a clinical benefit for patients is not known.

●Phosphorus – The potential advantage of HDF over conventional hemodialysis for phosphate removal is uncertain [19]. However, kinetic models estimate that HDF at typical treatment settings removes about 10 percent more phosphate than conventional hemodialysis [20], and increased phosphorus control by convective techniques has been reported [21-24]. In one study, although urea and creatinine clearance was similar with HDF and hemodialysis, phosphate clearance was higher on HDF [23]. In a second report, phosphate removal increased when patients were converted from hemodialysis to HDF [21]. There was slow phosphate mobilization from tissue compartments as predialysis serum phosphorus levels did not change until a few months after the switch. In the randomized, crossover trial cited above, serum phosphorus levels were lower among patients treated with HDF compared with low-flux hemodialysis (4.6 versus 5 mg/dL, respectively), despite lower daily doses of the phosphate-binding agent, sevelamer [7]. Parathyroid hormone (PTH) levels were also shown to be lower among hemodiafiltration patients in this study (mean 202 versus 228 pg/mL in hemodialysis patients). However, since high-flux membranes are almost universally used on conventional hemodialysis today, it is unclear if the effect is due to the membrane characteristics or the use of convective techniques.

●Other molecules – Levels of homocysteine and complement D factor are decreased with hemofiltration [8,25]. By comparison, there are conflicting data concerning the effect of hemofiltration on levels of leptin and advanced glycation end products (AGEs) [8,25-28]. There is also evidence that convective therapies are associated with less oxidative stress, but no difference in inflammatory markers were found between HDF and low-flux hemodialysis [29,30]. Despite high large molecule removal by HDF, there is no significant effect on protein-bound toxin concentration [31,32]. Further studies are needed to determine whether changes in serum concentration or solute removal translate into improved clinical outcomes.

CLINICAL EFFECTS

Patient-centered outcomes

Mortality — Mortality data comparing convective therapies with hemodialysis are conflicting. Some but not all studies report that high-dose hemodiafiltration (HDF) compared with conventional hemodialysis may confer a mortality benefit in at least some patient subsets [6,33-49]. Five randomized trials have been published:

●The CONTRAST trial randomly assigned 714 patients to either HDF with an average substitution volume of approximately 19 L or low-flux hemodialysis over three years [37]. No differences in patient mortality rates were observed. A post-hoc analysis suggested decreased mortality with substitution volume more than 20 L (hazard ratio [HR] 0.61, 95% CI 0.38-0.98).

●The Turkish OL-HDF trial randomly assigned 782 patients to either HDF or high-flux hemodialysis over two years [46]. There were no between-group differences in all-cause or cardiovascular mortality. In a post-hoc analysis, substitution volumes of more than 17 L were associated with better cardiovascular and overall survival compared with high-flux hemodialysis (HR 0.70, 95% CI 0.46-1.08).

●The ESHOL trial randomly assigned 906 patients to either HDF with more than 20 L of convective volume per session or high-flux hemodialysis [41]. At a follow-up of three years, patients treated with on-line HDF had a 30 percent lower risk of all-cause mortality (HR 0.70, 95% CI 0.53-0.92), a 33 percent lower risk of cardiovascular mortality (HR 0.67, 95% CI 0.44-1.02), and a lower incidence of hypotension and rates of hospitalization.

●The FRENCHIE study randomly assigned 381 older adults (>65 years of age) to HDF or high-flux hemodialysis and found no difference in survival between the groups [50].

●The CONVINCE study was a pragmatic trial that randomly assigned 1360 patients to either high-dose HDF (convection volumes of at least 23 L per session) or high-flux hemodialysis [49]. At a median follow-up of 30 months, all-cause mortality was lower in the HDF group compared with the hemodialysis group (17 percent versus 22 percent; HR 0.77, 95% CI 0.65-0.93), though subgroup analyses suggested that the mortality benefit of HDF was limited to patients without preexisting cardiovascular disease or diabetes mellitus. Cause-specific mortality was a secondary outcome in this trial, and COVID-19 may have complicated determining cause of death; however, the mortality benefit conferred by HDF appeared larger for infection-related death than for cardiovascular death.

Meta-analyses of the five trials above [51,52] have reported that HDF compared with hemodialysis was associated with a lower risk of all-cause mortality (relative risk [RR] 0.84, 95% CI 0.74-0.95), a lower risk of death from cardiovascular causes (RR 0.78, 95% CI 0.64-0.96), and a lower risk of death from infection (RR 0.80, 95% CI 0.61-1.04) [52]. In addition, higher achieved convection volumes were associated with lower mortality in a graded fashion [52]. However, the results of these meta-analyses are limited by potential problems in the included trials:

●Trial findings may not be generalizable to the typical maintenance hemodialysis population [53]. For example, the study population in CONVINCE had a lower prevalence of key comorbid diagnoses such as diabetes mellitus (<40 percent) and a higher prevalence of permanent arteriovenous access (>85 percent) compared with what is generally seen in clinical practice.  

●In ESHOL and CONVINCE, the randomized groups were imbalanced. In ESHOL, the HDF group was younger, had a lower comorbidity index, and had a higher proportion of fistula compared with catheter use. In addition, patients who could not achieve a hemofiltration volume of more than 18 L were excluded after randomization; such patients may have had poor fistulas due to vascular disease. In CONVINCE, the HDF group at baseline had lower rates of cardiovascular disease, diabetes mellitus, and current smoking compared with the hemodialysis group.

●In the Turkish HDF study, the control patients were not treated with ultrapure dialysate.

●In CONTRAST and the Turkish trial, significant crossover and dropout rates could have introduced bias.

Previous meta-analyses that did not include CONVINCE suggested that HDF may have a larger effect on cardiovascular mortality than on all-cause mortality [9,16,17,54-56].

Hospitalization — Limited data describing hospitalization rates and length of stay with hemofiltration/HDF have been reported. One study that followed 45 patients for two years on HDF failed to demonstrate any difference in hospitalization rates as compared with over 300 patients treated with hemodialysis [34], while another year-long crossover study of 41 patients showed fewer (8 versus 17) hospitalizations on convective therapy as compared with hemodialysis [57]. In the Estudio de Supervivencia study de Hemodiafiltración Online (ESHOL) trial, hospitalization rates were lower in the HDF group compared with controls [41].

Quality of life — Compared with hemodialysis, quality of life (QOL) may be superior with convective therapies [25,38,58]:

●In one randomized, controlled trial, QOL based upon the Laupacis questionnaire improved on hemofiltration versus low-flux hemodialysis [25].

●In an analysis of data from the CONVINCE trial, health-related QOL as measured by the PROMIS-29 survey instrument declined for the entire study population, but the decline was slower in the HDF group compared with the high-flux hemodialysis group [59]. This difference was particularly notable for the domains of physical function, cognitive function, and social participation. However, it is possible that the lack of patient blinding in CONVINCE contributed to these results.

●In contrast to the findings of the two trials above, results from pre-CONVINCE systematic reviews have been less certain. In one meta-analysis, QOL appeared to be significantly improved in patients on HDF compared with those on hemodialysis when an unvalidated QOL tool was used but did not improve when validated QOL assessment tools were used [39]. Another meta-analysis found a significant improvement in social activity scores in patients on HDF, but did not find any improvement in fatigue or the physical component score of the Short Form Health Survey 36 (SF-36) [60].

Intermediate outcomes

Cardiovascular

●Hemodynamic stability – Improved hemodynamic tolerance may be an advantage of convective therapies over conventional hemodialysis. Many [61-65], but not all [34,66,67], studies have supported this view. Three meta-analyses and two trials have reported that convective therapies reduce intradialytic hypotension [9,16,17,50,68].

Potential mechanisms for improved hemodynamic stability include:

•Salt loading via substitution fluid administration (with a loss of relatively hypotonic fluid) [69].

•Decreased core body temperature (as a result of infusion of large amounts of fluid of lower temperature), leading to vasoconstriction [70,71].

•It has been suggested that ultrapure dialysate itself is associated with improved hemodynamic stability [72,73]. This may be due to reduced vasodilatation because of the lack of inflammation or exposure to pyrogens [72,73].

In summary, convective techniques may be associated with better intradialytic stability, although the benefit may not be due to convection itself.

●Hypertension – Although there were claims in the earlier literature of better blood pressure control with convective therapies [74,75], there are no convincing data from randomized, controlled studies that convective therapies offer better blood pressure control [25].

●Cardiac hypertrophy – There is conflicting evidence on the effect of convective therapies on the regression of left ventricular hypertrophy (LVH). In a multicenter, randomized, controlled trial, predilution hemofiltration (18 patients) resulted in greater regression of LVH compared with the control group (16 patients), dialyzed using low-flux hemodialysis [76]. In another randomized trial of patients on low-flux hemodialysis and predilution hemofiltration, there was no difference in cardiovascular parameters, including left ventricular mass index (LVMI), over one year [25]. However, daily HDF may be associated with regression of LVMI, suggesting a benefit with increased frequency rather than increased convection alone [35].

Hematological parameters — The effect of convection-based regimens on anemia has been variable. Several nonrandomized studies and one randomized trial found either improvement in hemoglobin or a decrease in erythropoietin (EPO) dose requirements on HDF [10,77-80]. By comparison, two randomized, controlled trials failed to demonstrate any improvements in these parameters with HDF [25,36].

Platelet activation, as measured by the expression of CD62p, was more pronounced and more protracted during hemodiafiltration than during low-flux hemodialysis in the Convective Transport Study (CONTRAST) [37,81]. It is unclear if this has potentially negative clinical effects.

Nutrition — Conflicting data exist concerning the relative effects of convective therapies on nutrition [25,36]. In one randomized, controlled study, there was an increase in lean body mass and body weight over one year in those undergoing hemofiltration as compared with no change in the group undergoing low-flux hemodialysis, although the difference was not statistically significant [25]. In another study, there was no difference in body weight, skin-fold thickness, or albumin between those undergoing low-flux hemodialysis and HDF [36]. In a third study, patients on HDF had preserved lean tissue mass and increased normalized protein nitrogen appearance compared with patients on high-flux hemodialysis [82]. Therefore, further studies are needed to demonstrate improvement in the nutritional status on convective therapies. No differences were found in micronutrient loss between HDF and hemodialysis [83]. Significant loss of vitamin C was reported on HDF [84].

Other outcomes

●Neuropathy – HDF has not been shown to improve neuropathy in patients with ESKD. In the FINESSE trial, which randomly assigned 124 patients on maintenance hemodialysis with neuropathy to either HDF or high-flux hemodialysis for 48 months, there was no difference in the progression of neuropathy between the two arms [40]. Convection volume in the HDF arm was a median of 24.7 L (interquartile range, 22.4 L to 26.5 L).

●Dialysis-related amyloidosis – Despite enhanced clearance of beta-2 microglobulin via hemofiltration/HDF, treatment with convective therapies has not been shown to reduce the incidence of dialysis-related amyloidosis (DRA) or complications associated with DRA (eg, carpal tunnel syndrome). (See 'Removal of specific molecules' above and "Dialysis-related amyloidosis".)

●Access patency – The effect of HDF on dialysis access patency is unknown. In a two-year observational study that compared 87 patients on HDF with 87 propensity-score matched patients on conventional hemodialysis, the patency rate of vascular access was higher in the HDF group (74.2 versus 47.7 percent) [85]. However, high-volume HDF generally requires a vascular access that can reliably achieve high blood flow rates (see "Prescribing chronic intermittent high-volume hemodiafiltration"). As such, it is possible that patients in the HDF group were selected for HDF, at least in part, because of the high quality of their vascular access.

COST — 

Although the cost of providing convective therapies has decreased with the availability of on-line substitution fluid production, hemodiafiltration (HDF) remains a more costly kidney replacement therapy than conventional high-flux hemodialysis due to the greater complexity of the therapy and higher cost of machines to deliver both diffusive and convective clearance. Several economic studies performed before the 2023 CONVINCE trial estimated the cost effectiveness of HDF compared with conventional hemodialysis and reported conflicting results [86-89]. In a cost-utility analysis based on CONVINCE, on-line HDF compared with conventional hemodialysis was associated with an increased cost of between €27,000 to €37,000 per quality-adjusted life-year (QALY) gained [90].

A significant challenge in interpreting HDF cost-effectiveness studies is how to generalize the results outside of the jurisdiction in which the study was conducted. For example, local and national regulatory requirements differ widely and may have substantial impact on the cost of HDF. Given that convective techniques require infusion of replacement fluid directly into the bloodstream, the extent of required sterility testing for microbial organisms, endotoxin, and biofilms may greatly influence the cost of setting up an HDF program [91]. Additionally, given that adding convective clearance to diffusion increases water use per treatment, utility costs per treatment are likely to be higher. Finally, the increased training of nurses and patient care technicians, and the increased effort from biomedical technicians would also need to be taken into account in estimating implementation costs. Increased payor reimbursement for HDF could help ameliorate some of these additional costs, although in many countries, including the United States, bundled payment systems do not currently include allowances for increased payments for convective therapies [92].

SUMMARY

●Overview – Hemodiafiltration (HDF) is a form of kidney replacement therapy 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. The purported benefits of convective therapies over conventional hemodialysis are attributed to the increased removal of larger molecules. (See 'Introduction' above and 'Biochemical effects' above.)

●Biochemical effects – Small-molecule clearance is usually lower with hemofiltration as it is limited by the ultrafiltration volume when compared with conventional hemodialysis or HDF. By comparison, small-molecule removal is increased with the use of high-efficiency on-line HDF and can be similar or even higher than hemodialysis, depending on the volume of the substitution solution. Kinetic models estimate that HDF at typical treatment settings removes about 10 percent more phosphate than conventional hemodialysis. (See 'Biochemical effects' above.)

●Clinical effects

•Patient-centered outcomes – Some but not all trial data suggest that high-dose HDF (eg, convection volumes ≥23 L per session) compared with conventional hemodialysis may confer a mortality benefit in at least some patient subsets. Further studies are needed to determine whether health related quality of life on HDF is superior to that on hemodialysis. (See 'Patient-centered outcomes' above.)

•Intermediate outcomes – HDF may mitigate intradialytic hурοtеոsiоո. Despite enhanced clearance of beta-2 microglobulin, treatment with convective therapies has not been shown to reduce the incidence of dialysis-related amyloidosis. (See 'Intermediate outcomes' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Andreas Pierratos, MD, FRCPC, who contributed to earlier versions of this topic review.

  1. Ghysen J, De Plaen JF, van Ypersele de Strihou C. The effect of membrane characteristics on tumour necrosis factor kinetics during haemodialysis. Nephrol Dial Transplant 1990; 5:270.
  2. Canivet E, Lavaud S, Wong T, et al. Cuprophane but not synthetic membrane induces increases in serum tumor necrosis factor-alpha levels during hemodialysis. Am J Kidney Dis 1994; 23:41.
  3. Schindler R, Lonnemann G, Schäffer J, et al. The effect of ultrafiltered dialysate on the cellular content of interleukin-1 receptor antagonist in patients on chronic hemodialysis. Nephron 1994; 68:229.
  4. Bommer J, Jaber BL. Ultrapure dialysate: facts and myths. Semin Dial 2006; 19:115.
  5. Canaud B, Bosc JY, Leblanc M, et al. Evaluation of high-flux hemodiafiltration efficiency using an on-line urea monitor. Am J Kidney Dis 1998; 31:74.
  6. Canaud B, Bragg-Gresham JL, Marshall MR, et al. Mortality risk for patients receiving hemodiafiltration versus hemodialysis: European results from the DOPPS. Kidney Int 2006; 69:2087.
  7. Pedrini LA, De Cristofaro V, Comelli M, et al. Long-term effects of high-efficiency on-line haemodiafiltration on uraemic toxicity. A multicentre prospective randomized study. Nephrol Dial Transplant 2011; 26:2617.
  8. Ward RA, Schmidt B, Hullin J, et al. A comparison of on-line hemodiafiltration and high-flux hemodialysis: a prospective clinical study. J Am Soc Nephrol 2000; 11:2344.
  9. Susantitaphong P, Siribamrungwong M, Jaber BL. Convective therapies versus low-flux hemodialysis for chronic kidney failure: a meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2013; 28:2859.
  10. Maduell F, del Pozo C, Garcia H, et al. Change from conventional haemodiafiltration to on-line haemodiafiltration. Nephrol Dial Transplant 1999; 14:1202.
  11. Canaud B, Assounga A, Kerr P, et al. Failure of a daily haemofiltration programme using a highly permeable membrane to return beta 2-microglobulin concentrations to normal in haemodialysis patients. Nephrol Dial Transplant 1992; 7:924.
  12. Shinzato T, Kobayakawa H, Maeda K. Comparison of various treatment modes in terms of beta 2-microglobulin removal: hemodialysis, hemofiltration, and push/pull HDF. Artif Organs 1989; 13:66.
  13. Wizemann V, Külz M, Techert F, Nederlof B. Efficacy of haemodiafiltration. Nephrol Dial Transplant 2001; 16 Suppl 4:27.
  14. Lornoy W, Becaus I, Billiouw JM, et al. Remarkable removal of beta-2-microglobulin by on-line hemodiafiltration. Am J Nephrol 1998; 18:105.
  15. Maduell F, Navarro V, Cruz MC, et al. Osteocalcin and myoglobin removal in on-line hemodiafiltration versus low- and high-flux hemodialysis. Am J Kidney Dis 2002; 40:582.
  16. Wang AY, Ninomiya T, Al-Kahwa A, et al. Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: a systematic review and meta-analysis of randomized trials. Am J Kidney Dis 2014; 63:968.
  17. Nistor I, Palmer SC, Craig JC, et al. Convective versus diffusive dialysis therapies for chronic kidney failure: an updated systematic review of randomized controlled trials. Am J Kidney Dis 2014; 63:954.
  18. Ward RA, Daugirdas JT. Kinetics of β -2-Microglobulin with Hemodiafiltration and High-Flux Hemodialysis. Clin J Am Soc Nephrol 2024; 19:869.
  19. Locatelli F, Carfagna F, Del Vecchio L, La Milia V. Haemodialysis or haemodiafiltration: that is the question. Nephrol Dial Transplant 2018; 33:1896.
  20. Daugirdas JT. Comparison of measured vs kinetic-model predicted phosphate removal during hemodialysis and hemodiafiltration. Nephrol Dial Transplant 2022; 37:2522.
  21. Minutolo R, Bellizzi V, Cioffi M, et al. Postdialytic rebound of serum phosphorus: pathogenetic and clinical insights. J Am Soc Nephrol 2002; 13:1046.
  22. Davenport A, Gardner C, Delaney M, Pan Thames Renal Audit Group. The effect of dialysis modality on phosphate control : haemodialysis compared to haemodiafiltration. The Pan Thames Renal Audit. Nephrol Dial Transplant 2010; 25:897.
  23. Zehnder C, Gutzwiller JP, Renggli K. Hemodiafiltration--a new treatment option for hyperphosphatemia in hemodialysis patients. Clin Nephrol 1999; 52:152.
  24. Penne EL, van der Weerd NC, van den Dorpel MA, et al. Short-term effects of online hemodiafiltration on phosphate control: a result from the randomized controlled Convective Transport Study (CONTRAST). Am J Kidney Dis 2010; 55:77.
  25. Beerenhout CH, Luik AJ, Jeuken-Mertens SG, et al. Pre-dilution on-line haemofiltration vs low-flux haemodialysis: a randomized prospective study. Nephrol Dial Transplant 2005; 20:1155.
  26. Widjaja A, Kielstein JT, Horn R, et al. Free serum leptin but not bound leptin concentrations are elevated in patients with end-stage renal disease. Nephrol Dial Transplant 2000; 15:846.
  27. Gerdemann A, Wagner Z, Solf A, et al. Plasma levels of advanced glycation end products during haemodialysis, haemodiafiltration and haemofiltration: potential importance of dialysate quality. Nephrol Dial Transplant 2002; 17:1045.
  28. Lin CL, Huang CC, Yu CC, et al. Reduction of advanced glycation end product levels by on-line hemodiafiltration in long-term hemodialysis patients. Am J Kidney Dis 2003; 42:524.
  29. Vaslaki LR, Berta K, Major L, et al. On-line hemodiafiltration does not induce inflammatory response in end-stage renal disease patients: results from a multicenter cross-over study. Artif Organs 2005; 29:406.
  30. Calò LA, Naso A, Carraro G, et al. Effect of haemodiafiltration with online regeneration of ultrafiltrate on oxidative stress in dialysis patients. Nephrol Dial Transplant 2007; 22:1413.
  31. Snauwaert E, Van Biesen W, Raes A, et al. Haemodiafiltration does not lower protein-bound uraemic toxin levels compared with haemodialysis in a paediatric population. Nephrol Dial Transplant 2020; 35:648.
  32. van Gelder MK, Middel IR, Vernooij RWM, et al. Protein-Bound Uremic Toxins in Hemodialysis Patients Relate to Residual Kidney Function, Are Not Influenced by Convective Transport, and Do Not Relate to Outcome. Toxins (Basel) 2020; 12.
  33. Canaud B, Barbieri C, Marcelli D, et al. Optimal convection volume for improving patient outcomes in an international incident dialysis cohort treated with online hemodiafiltration. Kidney Int 2015; 88:1108.
  34. 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.
  35. Rabindranath KS, Strippoli GF, Daly C, et al. Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2006; :CD006258.
  36. Wizemann V, Lotz C, Techert F, Uthoff S. On-line haemodiafiltration versus low-flux haemodialysis. A prospective randomized study. Nephrol Dial Transplant 2000; 15 Suppl 1:43.
  37. Grooteman MP, van den Dorpel MA, Bots ML, et al. Effect of online hemodiafiltration on all-cause mortality and cardiovascular outcomes. J Am Soc Nephrol 2012; 23:1087.
  38. Lin CL, Huang CC, Chang CT, et al. Clinical improvement by increased frequency of on-line hemodialfiltration. Ren Fail 2001; 23:193.
  39. Rabindranath KS, Strippoli GF, Roderick P, et al. Comparison of hemodialysis, hemofiltration, and acetate-free biofiltration for ESRD: systematic review. Am J Kidney Dis 2005; 45:437.
  40. Kang A, Arnold R, Gallagher M, et al. Effect of Hemodiafiltration on the Progression of Neuropathy with Kidney Failure: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:1365.
  41. Maduell F, Moreso F, Pons M, et al. High-efficiency postdilution online hemodiafiltration reduces all-cause mortality in hemodialysis patients. J Am Soc Nephrol 2013; 24:487.
  42. Teo KK, Basile C, Ulan RA, et al. Comparison of hemodialysis and hypertonic hemodiafiltration on cardiac function [corrected]. Kidney Int 1987; 32:399.
  43. Santoro A, Mancini E, Bolzani R, et al. The effect of on-line high-flux hemofiltration versus low-flux hemodialysis on mortality in chronic kidney failure: a small randomized controlled trial. Am J Kidney Dis 2008; 52:507.
  44. Vilar E, Fry AC, Wellsted D, et al. Long-term outcomes in online hemodiafiltration and high-flux hemodialysis: a comparative analysis. Clin J Am Soc Nephrol 2009; 4:1944.
  45. Kuhlmann MK. On-line hemodiafiltration: not a self-fulfilling prophecy. J Am Soc Nephrol 2012; 23:974.
  46. Ok E, Asci G, Toz H, et al. Mortality and cardiovascular events in online haemodiafiltration (OL-HDF) compared with high-flux dialysis: results from the Turkish OL-HDF Study. Nephrol Dial Transplant 2013; 28:192.
  47. Blankestijn PJ. Haemodiafiltration: becoming the new standard? Nephrol Dial Transplant 2013; 28:1.
  48. Canaud B, Bayh I, Marcelli D, et al. Improved survival of incident patients with high-volume haemodiafiltration: a propensity-matched cohort study with inverse probability of censoring weighting. Nephron 2015; 129:179.
  49. Blankestijn PJ, Vernooij RWM, Hockham C, et al. Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure. N Engl J Med 2023; 389:700.
  50. Morena M, Jaussent A, Chalabi L, et al. Treatment tolerance and patient-reported outcomes favor online hemodiafiltration compared to high-flux hemodialysis in the elderly. Kidney Int 2017; 91:1495.
  51. Guimarães MGM, Tapioca FPM, Dos Santos NR, et al. Hemodiafiltration versus Hemodialysis in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis. Kidney Med 2024; 6:100829.
  52. Vernooij RWM, Hockham C, Strippoli G, et al. Haemodiafiltration versus haemodialysis for kidney failure: an individual patient data meta-analysis of randomised controlled trials. Lancet 2024.
  53. Ranchin B, Shroff R. Haemodiafiltration improves survival in patients receiving dialysis. Lancet 2024.
  54. Susantitaphong P, Jaber BL. Understanding discordant meta-analyses of convective dialytic therapies for chronic kidney failure. Am J Kidney Dis 2014; 63:888.
  55. Nistor I, Palmer SC, Craig JC, et al. Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2015; :CD006258.
  56. Mostovaya IM, Blankestijn PJ, Bots ML, et al. Clinical evidence on hemodiafiltration: a systematic review and a meta-analysis. Semin Dial 2014; 27:119.
  57. Verzetti G, Navino C, Bolzani R, et al. Acetate-free biofiltration versus bicarbonate haemodialysis in the treatment of patients with diabetic nephropathy: a cross-over multicentric study. Nephrol Dial Transplant 1998; 13:955.
  58. O'Loughlin JA, Bruder JM, Lysaght MJ. Degradation of low molecular weight uremic solutes by oral delivery of encapsulated enzymes. ASAIO J 2004; 50:253.
  59. Rose M, Fischer FH, Liegl G, et al. The CONVINCE randomized trial found positive effects on quality of life for patients with chronic kidney disease treated with hemodiafiltration. Kidney Int 2024; 106:961.
  60. Suwabe T, Barrera-Flores FJ, Rodriguez-Gutierrez R, et al. Effect of online hemodiafiltration compared with hemodialysis on quality of life in patients with ESRD: A systematic review and meta-analysis of randomized trials. PLoS One 2018; 13:e0205037.
  61. Altieri P, Sorba GB, Bolasco PG, et al. On-line predilution hemofiltration versus ultrapure high-flux hemodialysis: a multicenter prospective study in 23 patients. Sardinian Collaborative Study Group of On-Line Hemofiltration. Blood Purif 1997; 15:169.
  62. Locatelli F, Altieri P, Andrulli S, et al. Hemofiltration and hemodiafiltration reduce intradialytic hypotension in ESRD. J Am Soc Nephrol 2010; 21:1798.
  63. Altieri P, Sorba G, Bolasco P, et al. Predilution haemofiltration--the Second Sardinian Multicentre Study: comparisons between haemofiltration and haemodialysis during identical Kt/V and session times in a long-term cross-over study. Nephrol Dial Transplant 2001; 16:1207.
  64. Donauer J, Schweiger C, Rumberger B, et al. Reduction of hypotensive side effects during online-haemodiafiltration and low temperature haemodialysis. Nephrol Dial Transplant 2003; 18:1616.
  65. Mion M, Kerr PG, Argiles A, et al. Haemodiafiltration in high-cardiovascular-risk patients. Nephrol Dial Transplant 1992; 7:453.
  66. Karamperis N, Jensen D, Sloth E, Jensen JD. Comparison of predilution hemodiafiltration and low-flux hemodialysis at temperature-controlled conditions using high calcium-ion concentration in the replacement and dialysis fluid. Clin Nephrol 2007; 67:230.
  67. Pinney JH, Oates T, Davenport A. Haemodiafiltration does not reduce the frequency of intradialytic hypotensive episodes when compared to cooled high-flux haemodialysis. Nephron Clin Pract 2011; 119:c138.
  68. Rootjes PA, Chaara S, de Roij van Zuijdewijn CLM, et al. High-Volume Hemodiafiltration and Cool Hemodialysis Have a Beneficial Effect on Intradialytic Hemodynamics: A Randomized Cross-Over Trial of Four Intermittent Dialysis Strategies. Kidney Int Rep 2022; 7:1980.
  69. Di Filippo S, Manzoni C, Andrulli S, et al. Sodium removal during pre-dilution haemofiltration. Nephrol Dial Transplant 2003; 18 Suppl 7:vii31.
  70. Di Filippo S, Manzoni C, Andrulli S, et al. Sodium removal during pre-dilution haemofiltration. Nephrol Dial Transplant 2003; 18 Suppl 7:vii31.
  71. Karamperis N, Sloth E, Jensen JD. Predilution hemodiafiltration displays no hemodynamic advantage over low-flux hemodialysis under matched conditions. Kidney Int 2005; 67:1601.
  72. Kjellstrand CM, Blagg CR, Twardowski ZJ, Bower J. Cardiovascular stability (CVI) during daily hemodialysis (DHD) - Relative influence of dialysis purity, clearance and ultrafiltration speed - Experience with the Aksys PHD system. ASAIO J 2004; 50:177.
  73. Kjellstrand C, Blagg C, Odar-Cederlof I, et al. Daily hemodialysis (DHD) and ultrapure dialysis (UPH) synergistically improve patient well-being (WB) and cardiovascular stability (CVS). Hemodial Int 2007; 11:104.
  74. Schünemann B, Girndt J, Quellhorst E. Hemofiltration as a treatment for "dialysis-resistant" hypertension and hypotensive hyperhydration. J Dial 1977; 1:575.
  75. Kishimoto T, Yamagami S, Tanaka H, et al. Superiority of hemofiltration to hemodialysis for treatment of chronic renal failure: comparative studies between hemofiltration and hemodialysis on dialysis disequilibrium syndrome. Artif Organs 1980; 4:86.
  76. Alvestrand A, Ledebo I, Hagerman I, et al. Left ventricular hypertrophy in incident dialysis patients randomized to treatment with hemofiltration or hemodialysis: results from the ProFil study. Blood Purif 2011; 32:21.
  77. Bonforte G, Grillo P, Zerbi S, Surian M. Improvement of anemia in hemodialysis patients treated by hemodiafiltration with high-volume on-line-prepared substitution fluid. Blood Purif 2002; 20:357.
  78. Lin CL, Huang CC, Yu CC, et al. Improved iron utilization and reduced erythropoietin resistance by on-line hemodiafiltration. Blood Purif 2002; 20:349.
  79. Vaslaki L, Major L, Berta K, et al. On-line haemodiafiltration versus haemodialysis: stable haematocrit with less erythropoietin and improvement of other relevant blood parameters. Blood Purif 2006; 24:163.
  80. Pedrini LA, Comelli M, Ruggiero P, et al. Mixed hemodiafiltration reduces erythropoiesis stimulating agents requirement in dialysis patients: a prospective randomized study. J Nephrol 2020; 33:1037.
  81. Penne EL, Blankestijn PJ, Bots ML, et al. Resolving controversies regarding hemodiafiltration versus hemodialysis: the Dutch Convective Transport Study. Semin Dial 2005; 18:47.
  82. Molina P, Vizcaíno B, Molina MD, et al. The effect of high-volume online haemodiafiltration on nutritional status and body composition: the ProtEin Stores prEservaTion (PESET) study. Nephrol Dial Transplant 2018; 33:1223.
  83. Cross J, Davenport A. Does online hemodiafiltration lead to reduction in trace elements and vitamins? Hemodial Int 2011; 15:509.
  84. Morena M, Cristol JP, Bosc JY, et al. Convective and diffusive losses of vitamin C during haemodiafiltration session: a contributive factor to oxidative stress in haemodialysis patients. Nephrol Dial Transplant 2002; 17:422.
  85. Yoshida M, Maeoka Y, Takahashi A, et al. Effect of Haemodiafiltration Versus Haemodialysis on Vascular Access Patency when Starting Haemodialysis. Nephrol Dial Transplant 2025.
  86. 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.
  87. Mazairac AH, Blankestijn PJ, Grooteman MP, et al. The cost-utility of haemodiafiltration versus haemodialysis in the Convective Transport Study. Nephrol Dial Transplant 2013; 28:1865.
  88. Ramponi F, Ronco C, Mason G, et al. Cost-effectiveness analysis of online hemodiafiltration versus high-flux hemodialysis. Clinicoecon Outcomes Res 2016; 8:531.
  89. Takura T, Kawanishi H, Minakuchi J, et al. Cost-effectiveness analysis of on-line hemodiafiltration in Japan. Blood Purif 2013; 35 Suppl 1:85.
  90. Schouten AEM, Fischer F, Blankestijn PJ, et al. A health economic evaluation of the multinational, randomized controlled CONVINCE trial: cost-utility of high-dose online hemodiafiltration compared to high-flux hemodialysis. Kidney Int 2025; 107:728.
  91. Ward RA, Vienken J, Silverstein DM, et al. Regulatory Considerations for Hemodiafiltration in the United States. Clin J Am Soc Nephrol 2018; 13:1444.
  92. Emrani Z, Amiresmaili M, Daroudi R, et al. Payment systems for dialysis and their effects: a scoping review. BMC Health Serv Res 2023; 23:45.
Topic 1937 Version 33.0

References

1 : The effect of membrane characteristics on tumour necrosis factor kinetics during haemodialysis.

2 : Cuprophane but not synthetic membrane induces increases in serum tumor necrosis factor-alpha levels during hemodialysis.

3 : The effect of ultrafiltered dialysate on the cellular content of interleukin-1 receptor antagonist in patients on chronic hemodialysis.

4 : Ultrapure dialysate: facts and myths.

5 : Evaluation of high-flux hemodiafiltration efficiency using an on-line urea monitor.

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

7 : Long-term effects of high-efficiency on-line haemodiafiltration on uraemic toxicity. A multicentre prospective randomized study.

8 : A comparison of on-line hemodiafiltration and high-flux hemodialysis: a prospective clinical study.

9 : Convective therapies versus low-flux hemodialysis for chronic kidney failure: a meta-analysis of randomized controlled trials.

10 : Change from conventional haemodiafiltration to on-line haemodiafiltration.

11 : Failure of a daily haemofiltration programme using a highly permeable membrane to return beta 2-microglobulin concentrations to normal in haemodialysis patients.

12 : Comparison of various treatment modes in terms of beta 2-microglobulin removal: hemodialysis, hemofiltration, and push/pull HDF.

13 : Efficacy of haemodiafiltration.

14 : Remarkable removal of beta-2-microglobulin by on-line hemodiafiltration.

15 : Osteocalcin and myoglobin removal in on-line hemodiafiltration versus low- and high-flux hemodialysis.

16 : Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: a systematic review and meta-analysis of randomized trials.

17 : Convective versus diffusive dialysis therapies for chronic kidney failure: an updated systematic review of randomized controlled trials.

18 : Kinetics ofβ-2-Microglobulin with Hemodiafiltration and High-Flux Hemodialysis.

19 : Haemodialysis or haemodiafiltration: that is the question.

20 : Comparison of measured vs kinetic-model predicted phosphate removal during hemodialysis and hemodiafiltration.

21 : Postdialytic rebound of serum phosphorus: pathogenetic and clinical insights.

22 : The effect of dialysis modality on phosphate control : haemodialysis compared to haemodiafiltration. The Pan Thames Renal Audit.

23 : Hemodiafiltration--a new treatment option for hyperphosphatemia in hemodialysis patients.

24 : Short-term effects of online hemodiafiltration on phosphate control: a result from the randomized controlled Convective Transport Study (CONTRAST).

25 : Pre-dilution on-line haemofiltration vs low-flux haemodialysis: a randomized prospective study.

26 : Free serum leptin but not bound leptin concentrations are elevated in patients with end-stage renal disease.

27 : Plasma levels of advanced glycation end products during haemodialysis, haemodiafiltration and haemofiltration: potential importance of dialysate quality.

28 : Reduction of advanced glycation end product levels by on-line hemodiafiltration in long-term hemodialysis patients.

29 : On-line hemodiafiltration does not induce inflammatory response in end-stage renal disease patients: results from a multicenter cross-over study.

30 : Effect of haemodiafiltration with online regeneration of ultrafiltrate on oxidative stress in dialysis patients.

31 : Haemodiafiltration does not lower protein-bound uraemic toxin levels compared with haemodialysis in a paediatric population.

32 : Protein-Bound Uremic Toxins in Hemodialysis Patients Relate to Residual Kidney Function, Are Not Influenced by Convective Transport, and Do Not Relate to Outcome.

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

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

35 : Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease.

36 : On-line haemodiafiltration versus low-flux haemodialysis. A prospective randomized study.

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

38 : Clinical improvement by increased frequency of on-line hemodialfiltration.

39 : Comparison of hemodialysis, hemofiltration, and acetate-free biofiltration for ESRD: systematic review.

40 : Effect of Hemodiafiltration on the Progression of Neuropathy with Kidney Failure: A Randomized Controlled Trial.

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

42 : Comparison of hemodialysis and hypertonic hemodiafiltration on cardiac function [corrected].

43 : The effect of on-line high-flux hemofiltration versus low-flux hemodialysis on mortality in chronic kidney failure: a small randomized controlled trial.

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

45 : On-line hemodiafiltration: not a self-fulfilling prophecy.

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

47 : Haemodiafiltration: becoming the new standard?

48 : Improved survival of incident patients with high-volume haemodiafiltration: a propensity-matched cohort study with inverse probability of censoring weighting.

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

50 : Treatment tolerance and patient-reported outcomes favor online hemodiafiltration compared to high-flux hemodialysis in the elderly.

51 : Hemodiafiltration versus Hemodialysis in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis.

52 : Haemodiafiltration versus haemodialysis for kidney failure: an individual patient data meta-analysis of randomised controlled trials.

53 : Haemodiafiltration improves survival in patients receiving dialysis.

54 : Understanding discordant meta-analyses of convective dialytic therapies for chronic kidney failure.

55 : Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease.

56 : Clinical evidence on hemodiafiltration: a systematic review and a meta-analysis.

57 : Acetate-free biofiltration versus bicarbonate haemodialysis in the treatment of patients with diabetic nephropathy: a cross-over multicentric study.

58 : Degradation of low molecular weight uremic solutes by oral delivery of encapsulated enzymes.

59 : The CONVINCE randomized trial found positive effects on quality of life for patients with chronic kidney disease treated with hemodiafiltration.

60 : Effect of online hemodiafiltration compared with hemodialysis on quality of life in patients with ESRD: A systematic review and meta-analysis of randomized trials.

61 : On-line predilution hemofiltration versus ultrapure high-flux hemodialysis: a multicenter prospective study in 23 patients. Sardinian Collaborative Study Group of On-Line Hemofiltration.

62 : Hemofiltration and hemodiafiltration reduce intradialytic hypotension in ESRD.

63 : Predilution haemofiltration--the Second Sardinian Multicentre Study: comparisons between haemofiltration and haemodialysis during identical Kt/V and session times in a long-term cross-over study.

64 : Reduction of hypotensive side effects during online-haemodiafiltration and low temperature haemodialysis.

65 : Haemodiafiltration in high-cardiovascular-risk patients.

66 : Comparison of predilution hemodiafiltration and low-flux hemodialysis at temperature-controlled conditions using high calcium-ion concentration in the replacement and dialysis fluid.

67 : Haemodiafiltration does not reduce the frequency of intradialytic hypotensive episodes when compared to cooled high-flux haemodialysis.

68 : High-Volume Hemodiafiltration and Cool Hemodialysis Have a Beneficial Effect on Intradialytic Hemodynamics: A Randomized Cross-Over Trial of Four Intermittent Dialysis Strategies.

69 : Sodium removal during pre-dilution haemofiltration.

70 : Sodium removal during pre-dilution haemofiltration.

71 : Predilution hemodiafiltration displays no hemodynamic advantage over low-flux hemodialysis under matched conditions.

72 : Cardiovascular stability (CVI) during daily hemodialysis (DHD) - Relative influence of dialysis purity, clearance and ultrafiltration speed - Experience with the Aksys PHD system

73 : Daily hemodialysis (DHD) and ultrapure dialysis (UPH) synergistically improve patient well-being (WB) and cardiovascular stability (CVS)

74 : Hemofiltration as a treatment for "dialysis-resistant" hypertension and hypotensive hyperhydration.

75 : Superiority of hemofiltration to hemodialysis for treatment of chronic renal failure: comparative studies between hemofiltration and hemodialysis on dialysis disequilibrium syndrome.

76 : Left ventricular hypertrophy in incident dialysis patients randomized to treatment with hemofiltration or hemodialysis: results from the ProFil study.

77 : Improvement of anemia in hemodialysis patients treated by hemodiafiltration with high-volume on-line-prepared substitution fluid.

78 : Improved iron utilization and reduced erythropoietin resistance by on-line hemodiafiltration.

79 : On-line haemodiafiltration versus haemodialysis: stable haematocrit with less erythropoietin and improvement of other relevant blood parameters.

80 : Mixed hemodiafiltration reduces erythropoiesis stimulating agents requirement in dialysis patients: a prospective randomized study.

81 : Resolving controversies regarding hemodiafiltration versus hemodialysis: the Dutch Convective Transport Study.

82 : The effect of high-volume online haemodiafiltration on nutritional status and body composition: the ProtEin Stores prEservaTion (PESET) study.

83 : Does online hemodiafiltration lead to reduction in trace elements and vitamins?

84 : Convective and diffusive losses of vitamin C during haemodiafiltration session: a contributive factor to oxidative stress in haemodialysis patients.

85 : Effect of Haemodiafiltration Versus Haemodialysis on Vascular Access Patency when Starting Haemodialysis.

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

87 : The cost-utility of haemodiafiltration versus haemodialysis in the Convective Transport Study.

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

89 : Cost-effectiveness analysis of on-line hemodiafiltration in Japan.

90 : A health economic evaluation of the multinational, randomized controlled CONVINCE trial: cost-utility of high-dose online hemodiafiltration compared to high-flux hemodialysis.

91 : Regulatory Considerations for Hemodiafiltration in the United States.

92 : Payment systems for dialysis and their effects: a scoping review.