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# Hemodiafiltration's backers say the US question is now how, not whether
- URL: https://nephspace.com/hdf-review-jasn/
- Published: 2026-10-02T00:31:00.000Z
- Updated: 2026-10-04T19:23:27.000Z
- Description: Authors of the main hemodiafiltration trials explain how to prescribe high-volume HDF and predict it will likely become the global standard. Most of them have ties to HDF machine makers.
- Author: Dr Wael Hussein
- Tags: Dialysis, #story, #has-audio, #in-center-dialysis, #review, #full-story, Stories

### What it covers

Online hemodiafiltration (HDF) is established in many regions. In the US it is just getting started. The review says the FDA approved an HDF-capable dialysis system in 2024 and that broad US rollout has begun. This invited JASN review is a practical manual for units about to switch. The corresponding author, Blankestijn, led the CONVINCE trial. It is a narrative review with no new data and no systematic search.

On benefit, the authors summarize randomized trials, an individual-patient meta-analysis and real-world cohorts: high-volume HDF lowers all-cause mortality and hospitalization compared with high-flux HD. They state these as conclusions and do not repeat the effect sizes.

### Key points

- The dose of HDF is convective volume. The usual high-volume target is at least 23 L per session, three times a week. Newer analyses suggest "more is better" along a continuum. Lower volumes are not harmful, just less helpful.
- Blood flow is the main lever: 350 to 450 mL/min, with 15-gauge or larger needles. CONVINCE averaged 369 mL/min.
- A catheter is not a contraindication. About 13% of CONVINCE participants had a tunneled catheter, though the target is harder to reach.
- Use a dialyzer of at least 2.0 m², but fix blood flow first. About 3.5 to 4 hours, three times a week, is enough. Do not shorten sessions because Kt/V went up.
- Watch bicarbonate in the first months. Track beta-2 microglobulin along with Kt/V. Expect slightly more loss of amino acids, water-soluble vitamins and trace elements.
- US patients are larger and older, with shorter sessions. At a blood flow near 400 mL/min they reach about 27 L per session, roughly 23 L once scaled to body surface area.

### Why it matters

For US units weighing a switch, this review is a practical how-to guide. Its take on medium cutoff dialyzers is brief. They raise middle-molecule removal without substitution fluid, but evidence on survival and patient-centered outcomes is much thinner than for high-volume HDF. The head-to-head trial, MOTheR (Theranova versus online HDF), was presented in June 2026\. The authors decline to interpret it until it is published.

### Caveats

The authors include investigators from the main trials they summarize, and there is no risk-of-bias assessment. Several supporting real-world studies, including the claim of about 20% fewer hospitalizations, come from Fresenius-linked datasets. The authors say plainly that protection of residual kidney function has not been adequately tested. The review does not name the US machine, its maker or its price.

Industry ties: 7 of the 10 authors have ties to HDF machine makers (Fresenius or B. Braun), including one Fresenius employee and one emeritus Fresenius medical officer. One author has also received honoraria from Nipro.

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**The source:** Blankestijn PJ, Roos S, Barth C, Bots ML, Cromm K, Davenport A, Hegbrant J, Strippoli G, Vernooij RWM, Canaud B. Hemodiafiltration: Clinical Practice of Today and a Look into the Future. J Am Soc Nephrol. Published online ahead of print September 22, 2026\. doi:10.1681/ASN.0000001282 [Read the original](https://doi.org/10.1681/ASN.0000001282?ref=nephspace.com)

**🎧 Listen:** [Weekly · Oct 2](https://nephspace.com/weekly-oct-2/), from 01:10; also in [Deep Dive · Two Roads](https://nephspace.com/two-roads/), from 02:47.

*Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our* [*disclaimer*](https://nephspace.com/disclaimer/) *and* [*disclosures*](https://nephspace.com/disclosures/)*. Spotted an error?* [*Tell us*](mailto:hello@nephspace.com?subject=Correction)*.*