Hemodiafiltration: Clinical Practice of Today and a Look into the Future

Hemodiafiltration (HDF) with online production of substitution fluid has emerged as kidney replacement therapy and is increasingly adopted worldwide. Recent randomized controlled trials, individual participant data meta-analyses, and large real-world studies have demonstrated that high-volume HDF improves clinical outcomes compared with conventional high-flux hemodialysis (HD), including reduction in all-cause mortality and hospitalization. Importantly, these benefits appear dose-dependent, with achieved convective volume serving as a modifiable treatment target. Beyond survival, data suggest advantages in patient reported outcomes and evidence for cost-effectiveness. This review provides a practical overview of contemporary HDF delivery, focusing on the prescription variables that determine treatment performance, including vascular access, blood flow rate, filtration fraction, treatment time, dialyzer characteristics, and machine technology. Current evidence suggests that high-volume post-dilution HDF can be achieved safely and reproducibly in routine clinical practice using standard thrice-weekly treatment schedules and contemporary dialysis platforms. Monitoring should extend beyond conventional small-solute clearance metrics to include indicators of middle-molecule removal and patient-centered outcomes. Future developments are expected to move HDF from a uniform prescription strategy towards a more individualized approach. Emerging data support refinement of convection-volume targets according to patient characteristics and treatment response, while incorporation of patient-reported outcomes and predictive models may facilitate precision-based therapy. Advances in automation, digital monitoring, biosensors, and artificial intelligence are most likely to further optimize treatment delivery and personalization. Although implementation requires investment in infrastructure, training, and quality assurance, growing evidence suggests that these costs may be offset by improved clinical outcomes, reduced healthcare utilization, and enhanced sustainability. Collectively, current evidence supports high-volume HDF as among the most effective dialysis modality currently available and it is likely to become the global standard for kidney replacement therapy.