The rationale and clinical potential of on‐line hemodiafiltration as renal replacement therapy

Abstract

On‐line hemodiafiltration (ol‐HDF) was developed in the 1980s in response to the unmet medical needs observed with conventional low‐ and high‐flux hemodialysis. Firstly, the limited overall efficacy of conventional HD treatment programs as compared to native kidney function has been consistently documented over the broad MW spectrum of uremic toxins as well as fluid volume and hemodynamic control. Secondly, the unphysiological profile of intermittent treatment leading to repetitive dialysis‐induced hemodynamic stress is now a well‐recognized component of cardiovascular disease and end organ damage. Thirdly, the bioincompatibility of patient‐dialysis system leading to dialysis‐induced biological reactions also identified as contributing to dialytic morbidity and mortality. To overcome these limitations and pitfalls, alternative convective‐based therapies (hemofiltration and hemodiafiltration), using higher hemoincompatible membranes and ultrapure dialysis fluid, were proposed as a solution to enhance and enlarge MW spectrum of uremic compounds cleared and to reduce dialysis‐patient biological interactions. In this context, online HDF appeared soon as the best viable and efficient renal replacement modality to cover these needs. Clinical development and implementation of ol‐HDF showed also that dialytic convective dose matters with a threshold point (23 L/1.73 m2 in postdilution mode) to observe clinical benefits and outcomes improvements.

Rationale for a New Classification of Solutes of Interest in Chronic Kidney Disease and Hemodialysis

“…Albumin losses in the dialysate in HF HD were less than 1 g and around 1.5-2.5 g with either HF hemodiafiltration or MCO HD. Likely, the higher removal of albumin does not negatively affect outcomes because trials comparing HD versus HF hemodiafiltration did not demonstrate worst outcomes with latter [57,58].…”

Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path

“…The use of on-line hemodiafiltration (OL-HDF) overcomes the technical challenges of bagged replacement dialysate and reduces costs [ 223 ]. Compared with high-flux HD, it can more effectively remove uremic toxins with a broader range of molecular weights [ 224 ] and reduce all-cause and CV mortality, and is associated with a better clinical prognosis [ 225 ]. However, some studies have concluded that this dialysis modality is not significantly different from other modalities [ 226 ].…”

Advancing high-volume hemodiafiltration: from concept to CONVINCE

“…Moreover, through the utilization of ultrapure dialysis fluid and a high-flux synthetic membrane, hemodiafiltration (HDF) globally improves the hemocompatibility of the system and reduces inflammation. This method significantly bridges the gap between conventional hemodialysis and native kidney function in clearing larger molecular-weight uremic toxins 3 .…”