High-volume online hemodiafiltration versus high-flux hemodialysis: a short review of recent evidence and a discussion on clinical implementation

Abstract

Online hemodiafiltration (HDF) has received significant attention as a potentially superior dialysis modality compared to conventional high-flux hemodialysis for patients with end-stage kidney disease. The CONVINCE (CONvective VERSus diffusive dialysis in patients with End-stage kidney disease) trial, subsequent meta-analyses, and observational studies indicate that high-dose HDF (≥23 L convection per session) is associated with improved survival outcomes, particularly through reductions in cardiovascular and possibly also infection-related mortality. Additionally, emerging evidence suggests modest but meaningful benefits in health-related quality of life and symptom control. This comment synthesizes the current literature (2022-2025), highlighting clinical outcomes, patient-centered metrics, feasibility, cost-effectiveness, personalized treatment considerations, and implications for clinical practice. Additionally, practical prescription guidance is provided to assist nephrologists in achieving optimal convection volumes and clinical outcomes in routine clinical practice.