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. 2025 Aug 1;40(8):1590-1614.
doi: 10.1093/ndt/gfaf024.

Haemodiafiltration versus high-flux haemodialysis-a Consensus Statement from the EuDial Working Group of the ERA

Yuri Battaglia  1   2 , Rukshana Shroff  3 , Björn Meijers  4 , Ionut Nistor  5 , Gaetano Alfano  6 , Casper Franssen  7 , Valerie Luyckx  8 , Vassilios Liakopoulos  9 , Alessandro Mantovani  10 , Federica Baciga  1   2 , Federica Caccia  1 , Claudia Momentè  1 , Andrew Davenport  11 , Peter J Blankestijn  12 , Adrian Covic  13 , Christian Combe  14 , Carlo Basile  15
Affiliations

Haemodiafiltration versus high-flux haemodialysis-a Consensus Statement from the EuDial Working Group of the ERA

Yuri Battaglia et al. Nephrol Dial Transplant. .

Abstract

Haemodialysis (HD) is a life-saving therapy for individuals with kidney failure. Post-filter haemodiafiltration (HDF) and high-flux HD are the most widely used treatment modalities. To date, five randomized controlled trials (RCTs) have been performed that compare all-cause and cardiovascular (CV) mortality between HDF and low- or high-flux HD in adults receiving maintenance dialysis for at least 1 year. RCTs, meta-analyses and pooled individual patient data analyses have been published on this topic. However, all of them are limited by the heterogeneity of inclusion criteria and significant methodological shortcomings, including informative selection bias and the exclusion of poorly performing patients from the HDF arm after randomization. Given this background, the European Dialysis Working Group of the European Renal Association presents a Consensus Statement on HDF and high-flux HD, addressing three key outcomes: survival, health-related quality of life, and biochemical endpoints. A separate section is dedicated to paediatric patients. We searched five large electronic databases to identify parallel or cross-over RCTs comparing HDF with high-flux HD on pre-defined outcome measures. Using a mini-Delphi method, we developed 22 key consensus points by combining meta-analyses, clinical experience, and expert opinion. They aim to inform and assist in decision making and are not intended to define a standard of care. The key summary point is that HDF appears to be associated with improved overall and CV survival, provided high convection volumes are achieved. The generalizability of these findings to the entire dialysis population depends on the patient's overall health and requires further study.

Keywords: all-cause mortality; convection volume; haemodiafiltration; haemodialysis; kidney failure.

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Conflict of interest statement

R.S. discloses research grants from Fresenius Medical Care and Vitaflo, consulting fees from Astra Zeneca, and speaker honoraria from Fresenius Medical Care and Amgen; B.M. is a senior clinical investigator of the Fonds Wetenschappelijk Onderzoek (grant 1800820 N) and received support from KU Leuven via grants 3M190551 and C14/21/103. He received speaker and/or consultancy fees from Baxter, Nipro, Fresenius; I.N. discloses speaker honoraria from Fresenius KABI and Astra Zeneca; A.D. received a travel grant from Nipro Corporation, Japan, and speaker honoraria from Fresenius Medical Care; Y.B. discloses speaker honoraria from Astra Zeneca; C.C. received consultancy fees from Rhythm and Maze Therapeutics, and travel support from Amgen and Sanofi; and the other authors declare no conflict of interest.

Figures

Figure 1:
Figure 1:
Schematic representation of technical differences between haemodialysis and haemodiafiltration.
Figure 2:
Figure 2:
Summary of the results of the literature search and study selection (PRISMA Diagram) for the following outcomes: all-cause mortality, cardiovascular mortality, SCD, intradialytic hypotension, hospitalizations, and infection rates.
Figure 3:
Figure 3:
Summary of the results of the literature search and study selection (PRISMA Diagram) for QoL outcomes.
Figure 4:
Figure 4:
Summary of the results of the literature search and study selection (PRISMA Diagram) for the following outcomes: biochemical data and clearance of uraemic toxins.
Figure 5:
Figure 5:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on all-cause mortality. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 6:
Figure 6:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on cardiovascular mortality. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 7:
Figure 7:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on infection-related mortality. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 8:
Figure 8:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on pre-dialysis serum β2-microglobulin (β2M) levels. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 9:
Figure 9:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on pre-dialysis serum phosphate levels. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 10:
Figure 10:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on pre-dialysis serum albumin levels. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 11:
Figure 11:
Forest plot and pooled estimates of the effects of HDF vs high-flux HD on pre-dialysis serum CRP levels. n/N, numbers of patients/population; WMD, weighted mean differences; W, weight.
Figure 12:
Figure 12:
Summary of the results of the literature search and study selection (PRISMA Diagram) for paediatric studies.
See this image and copyright information in PMC

References

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