Update on Clinical Evidence Supporting Hemodiafiltration

Abstract

The aim of this chapter is to define hemodiafiltration target efficiency, to clarify the concept of “optimal convective dose,” and to facilitate hemodiafiltration (HDF) implementation in clinical practice by addressing the need for the establishment of best clinical practices for HDF. The approach taken was to conduct a comprehensive summary of clinical evidence supporting HDF. Convective dose is the total ultrafil‐ tered volume and is complementary to diffusive dose (urea Kt/V) as a dose‐depend‐ ent parameter. It can be quantified and adjusted to patient characteristics. Factors affecting convective dose are discussed: patient characteristics, prescription‐depend‐ ent factors, and technical and machine‐dependent factors. The key issue of HDF prescription and implementation of best practices is addressed as are intermediary and endpoint clinical outcomes. The main messages are as follows: (1) HDF is safe and effective provided that best clinical practices are followed and the right convective dose is delivered; (2) HDF is easy to perform with new technology; and (3) depending on the convection volume, HDF reduces all‐cause and cardiovascular mortality. Open challenges remain, namely, the implementation of best practices to (a) achieve optimal convection volume, (b) define patient subsets that would benefit more from HDF, and (c) evaluate new tools that fine‐tune HDF prescription according to individual patient needs.