Does online high-volume hemodiafiltration offer greater efficiency and sustainability compared to high-flux hemodialysis? A detailed simulation analysis anchored in real-world data

Abstract

Abstract Recent findings, including the CONVINCE study report, suggests the superiority of high-volume hemodiafiltration over high-flux hemodialysis in improving patients’ outcomes. Despite positive patient outcomes, concerns have arisen about the potential negative environmental impact of high-volume hemodiafiltration, as it may lead to increased water and dialysis fluid consumption and higher waste production. In this manuscript, we address the environmental impact of high-volume HDF, focusing on three key factors: water treatment consumption, dialysis fluid consumption, and solute efficiency markers of HD and HDF. By optimizing HDF prescription through adjustments in operational capabilities, such as reducing the QD/QB ratio to 1,2 rather than 1,5 and incorporating automated ultrafiltration and substitution control, it has been demonstrated that HDF delivers a higher dialysis dose for small and middle-molecule uremic compounds with the same dialysis fluid consumption and at equal dialysis doses dialysis fluid consumption is reduced. This finding is supported by real-world data from 26 031 patients who underwent high-volume postdilution hemodiafiltration at a reduced dialysis flow (550 ml/min) and achieved an effective OCMKt/V of 1.70. In addition, simulation modeling calculations, using blood extraction coefficient, dialysate saturation coefficient, and solute clearances with urea (small MW) and ß2M (middle MW), consistently show postdilution HDF's superiority to HD. This holds true even with a significant reduction in dialysis flow down to 440 ml/min reflecting QD/QB ratio of 1,2. Postdilution HDF generates high ultrafiltrate flow (up to 35% of blood flow), delivering saturated ultrafiltrate to the lower solute concentration containing effluent dialysate, thus enhancing solute clearance which opens the way to reduce the dialysis flow. In conclusion, our analysis, combining simulation and real-world data, suggests that postdilution HDF could be a more environmentally friendly treatment option compared to conventional hemodialysis. Additionally, automated user-friendly functions that minimize dialysis fluid use, can further strengthen this environmental benefit while enhancing efficiency.