High-Volume Hemodiafiltration Versus High-Flux Hemodialysis: A Narrative Review for the Clinician.

End-stage kidney disease (ESKD) management presents a significant challenge, with increasing patient burden, escalating costs, and unmet needs in improving survival and quality of life. High-volume hemodiafiltration has been found to offer enhanced solute clearance, improved inflammatory marker profiles, and better patient-centered outcomes in multiple trials compared with high-flux hemodialysis. Recent data also confirm a survival advantage compared to standard high-flux hemodialysis. We compiled a narrative review for the clinician illustrating evidence supporting the comparative performance of high-volume hemodiafiltration with conventional high-flux hemodialysis in ESKD management. Data on intermediary outcomes including biochemical and clinical benefits, as well as patient-centered outcomes and all-cause and cardiovascular death data from prospective randomized trials, their meta-analyses, and real-world cohort studies were reviewed and summarized. Randomized studies in adults have found that high-volume hemodiafiltration demonstrates superior outcomes, with a 23% improvement in survival rates when achieving convective volumes ≥23 L/session, enhanced removal of uremic toxins, reduced inflammation, and better patient-reported outcomes. Cohort studies in pediatric populations find associations with improvements in growth, cognitive development, and cardiovascular health. Hemodiafiltration appears to be cost-effective when accounting for extended life expectancy and improved quality of life, although the existing data are limited to European geographies. Hemodiafiltration offers enhanced survival, a reduced treatment burden, and improved quality of life for ESKD patients. Given the existing data of superiority versus high-flux hemodialysis, it is plausible that hemodiafiltration will become the standard of care.