[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-456057-105":59,"doc-detail-456057-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","hemodiafiltration-should-be-the-primary-in-center-kidney-replacement-modality-in-eskd-commentary","Hemodiafiltration Should Be the Primary In-Center Kidney Replacement Modality in ESKD - Commentary","","Commentary argues for prioritizing high volume hemodiafiltration (HVHDF) as the primary in-center kidney replacement modality for ESKD while addressing counterpoints. It contrasts conventional 3–4 hour hemodialysis and discusses how longer, at least 4-hour, sessions may improve ultrafiltration and removal of middle molecules. It weighs requests for broader HVHDF study against observational outcomes and CONVINCE patient-reported measures favoring HVHDF. The piece also evaluates water and cost considerations and outlines practical implementation barriers in the U.S.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/hemodiafiltration-should-be-the-primary-in-center-kidney-replacement-modality-in-eskd-commentary/456057/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/hemodiafiltration-should-be-the-primary-in-center-kidney-replacement-modality-in-eskd-commentary/456057.png","ImageObject",300,407,{"name":92,"@type":93},"Terk","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":19},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Why does the commentary support HVHDF as a primary in-center modality for ESKD?","Question",{"text":112,"@type":113},"It argues that HVHDF can improve outcomes versus conventional hemodialysis, and cites evidence including CONVINCE patient-reported outcome measures showing HVHDF superiority in several domains.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What is the counterargument about dialysis session duration?",{"text":117,"@type":113},"It states an alternative approach is performing at least 4-hour hemodialysis to reduce ultrafiltration rates and increase removal of smaller middle molecules, though longer treatments can affect satisfaction, staffing, and facility expenses.",{"name":119,"@type":110,"acceptedAnswer":120},"What implementation barriers are described for switching to HVHDF?",{"text":121,"@type":113},"The commentary highlights the challenge of determining conversion costs to HVHDF, balancing investment in equipment and dialyzers against Medicare reimbursement, plus added uncertainty from growth of Medicare Advantage plans.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},456057,1791421729,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":19,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24,"preview_page_count":4},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Hemodiafiltration Should Be the Primary In-Center Kidney Replacement Modality in ESKD: Commentary  \nThomas A. Golper   \nKidney360 6: 1655–1656, 2025. doi: [https://doi.org/10.34067/KID.0000000847](https://doi.org/10.34067/KID.0000000847)  \nBernard Canaud and I met in Montpellier, France, in 1990 as he and Charles Mion were essentially creating online hemodiafiltration (HDF) . I was influenced by Karl Koch, Stanley Shaldon, Charles Dinarello, Nathan Levin, Dick Ward, Alfred Cheung, and others regarding the effect of water quality on hemodialysis outcomes, and the Montpellier approach regarding dialysis water quality was novel. The dialysis facility Medical Director is responsible for the quality of the dialysis (e.g., water quality) but also must be a wise steward of resources such as dialyzer reuse, staffing ratios, conversion from high-flux hemodialysis to high volume HDF (HVHDF, which means convective volumes per session of $23 L) . Thus, the quality and cost of dialysis-like care has been my interest for decades and influences these remarks. As my third commentary in high impact journals regarding HDF in the United States,1,2 I am attempting a point-counterpoint approach to the positions taken by Canaud versus Sharma and Lin.3,4  \nOutcomes and Costs  \nCanaud mentions that 3–4-hour conventional hemodialysis sessions are associated with inferior outcomes; hence, we need improvement, and HVHDF may be a solution.3 I counter with the simple argument that we should strive to perform at least 4-hour hemodialysis sessions to achieve two goals: slower ultrafiltration rates and greater removal of smaller middle molecules. Longer treatments decrease patient satisfaction, require more staff time, and increase facility expenses. However, no new equipment or techniques are needed. Is that an acceptable compromise?  \nSharma and Lin request a study of HVHDF in diverse populations before its broad implementation.4 I think that would be a waste of limited resources (see below) . The findings of Dialysis Outcomes and Practice Patterns Study, an observational study with limited diversity, suggest that  \npatients exposed to longer duration hemodialysis sessions (versus shorter) have better outcomes.5 Canaud cites the patient-reported outcome measures data of the Comparison of High-Dose Hemodiafiltration with High-Flux Hemodialysis (CONVINCE) study that shows that in several domains, HVHDF was superior to high-flux hemodialysis.6 The suggestion to increase time on high-flux hemodialysis and patient dissatisfaction with that must be addressed in the context of the CONVINCE study patientreported outcome measures results. This looks to favor HVHDF.  \nCost-effectiveness was argued in the context of water usage.7 These are the only data suggesting that less water is used in HDF. Hemodialysis does require a lot of water, but the quantity of water used as dialysate and/or substitution fluid is far less than reverse osmosis (RO) rejected water necessary for either hemodialysis or HDF. In the United States, I am not aware of any jurisdiction that allows RO rejected water to re-enter the community's processed water system. That is a larger “waste” of water than that needed for dialysate or substitution fluid. The spent dialysate goes down a similar drain as the rejected RO water. Both HVHDF and hemodialysis will have RO rejected water in similar amounts that will not be locally recycled.8  \nImplementation Barriers  \nBy April 2025, Fresenius had not yet determined the cost of conversion to HVHDF from high-flux hemodialysis in its US facilities. This is a complex process of balancing the investment costs of converting to the 5008X machines and the FX CorAL dialyzers versus the fixed payment from Medicare. Furthermore, the growth of Medicare Advantage plans onto the dialysis sector increases uncertainty for facility payments. The facility payment from commercial  \nVanderbilt University Medical Center, Nashville, Tennessee and Larner College of Medicine, University of Vermo","cbCaiqjgAXtdn0iV","https://ap.wps.com/l/cbCaiqjgAXtdn0iV","pdf",211683,"English","# Outcomes and Costs\n## Implementation Barriers\n## Other Issues","[{\"question\":\"Why does the commentary support HVHDF as a primary in-center modality for ESKD?\",\"answer\":\"It argues that HVHDF can improve outcomes versus conventional hemodialysis, and cites evidence including CONVINCE patient-reported outcome measures showing HVHDF superiority in several domains.\"},{\"question\":\"What is the counterargument about dialysis session duration?\",\"answer\":\"It states an alternative approach is performing at least 4-hour hemodialysis to reduce ultrafiltration rates and increase removal of smaller middle molecules, though longer treatments can affect satisfaction, staffing, and facility expenses.\"},{\"question\":\"What implementation barriers are described for switching to HVHDF?\",\"answer\":\"The commentary highlights the challenge of determining conversion costs to HVHDF, balancing investment in equipment and dialyzers against Medicare reimbursement, plus added uncertainty from growth of Medicare Advantage plans.\"}]","Hemodiafiltration Should Be the Primary In-Center Kidney Replacement Modality in ESKD - Commentary | PDF",1790745029]