Kidney Week Educational Symposia-Considerations for Incorporating Hemodiafiltration into Dialysis Care

Video Transcription

Video Summary

The symposium introduces growing global adoption of hemodiafiltration (HDF) and its emerging availability in the United States following recent FDA clearances for Fresenius 5008X systems, with broader implementation expected. Speakers frame HDF as an “upgrade” to conventional hemodialysis (HD) by adding substantial convective clearance to diffusive clearance, improving removal of “middle molecules” that do not clear well by diffusion alone.<br /><br />Dr. Damian Ashby explains membrane pore mechanics and the middle-molecule hypothesis (e.g., beta-2 microglobulin and dialysis amyloidosis) and reviews clinical trial evidence. High-flux membranes increased permeability but limited convection volumes, while HDF can raise convection to ~20+ liters per session. Major trials showed mixed results (CONTRAST and Turkish study neutral; ESHOL positive), likely influenced by achieved convection volumes and study design. Individual patient data meta-analyses suggest better outcomes at higher convection volumes (e.g., >23 L). The newer CONVINCE trial showed a significant mortality reduction (~23%) and modest quality-of-life benefits, with generally good tolerability and possibly fewer intradialytic symptoms.<br /><br />Dr. Francisco Maduell focuses on practical implementation: HDF has no formal contraindications, should start early (including incident patients), and should not shorten treatment time (recommend ≥12 hours/week). Key requirements include certified machines, ultrapure dialysate with rigorous water/dialysate monitoring, and high blood flow to achieve target convection (commonly total convective volume ~23 L/session). Fistulas are preferred, but catheters are not a barrier if blood flow and/or treatment time are adequate. Post-dilution HDF and automated substitution are favored; medium cut-off dialyzers should be avoided in HDF due to albumin loss risk. Audience discussion covers patient selection (possibly greatest benefit in lower-risk patients), feasibility in older units, cost considerations, and dosing with more frequent or incremental dialysis.

Asset Subtitle

Moderator(s): Matthew Rivara

Presentation(s):

Introduction - Matthew Rivara
Theoretical and Scientific Rationale for Hemodiafiltration - Damien Ashby
Practical Considerations for Incorporating Hemodiafiltration into Routine Dialysis Care - Francisco Maduell

Support is provided by an educational grant from Fresenius Medical Care.

Meta Tag

Date 11/7/2025

Pathway 1 Dialysis

Session ID 520816

Keywords

hemodiafiltration (HDF)

conventional hemodialysis (HD)

convective clearance

middle molecule removal

Fresenius 5008X FDA clearance

high convection volume (≥23 L/session)

CONVINCE trial mortality reduction

ultrapure dialysate and water quality monitoring

post-dilution HDF with automated substitution

medium cut-off dialyzer albumin loss risk