Content uploaded by Francisco Maduell
Author content
All content in this area was uploaded by Francisco Maduell on Sep 16, 2015
Content may be subject to copyright.
E-Mail karger@karger.com
Review
Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
Is There an ‘Optimal Dose’ of
Hemodiafiltration?
FranciscoMaduell
Department of Nephrology and Renal Transplantation, Hospital Clínic Barcelona, Barcelona , Spain
volume higher than 23 liters/session. There is insufficient
scientific evidence to recommend that the convective dose
should be normalized to body size.
© 2015 S. Karger AG, Basel
Introduction
Despite continuous improvement in hemodialysis
(HD) devices, membrane biocompatibility and dialysate
purification, mortality among these patients remains un-
acceptably high
[1] . HD is based on the capacity of mole-
cules to diffuse across a semipermeable membrane, which
allows adequate clearance of low-molecular-weight parti-
Key Words
Convective therapies · Infusion flow · Mortality · Online
hemodiafiltration
Abstract
Background: Retrospective randomized clinical studies
have shown that online hemodiafiltration (OL-HDF) is asso-
ciated with a lower risk reduction of mortality than standard
hemodialysis. Summary: In all of these large randomized
studies, the convective volume seemed to be an important
issue, but the optimal OL-HDF dose has not yet been de-
fined. This article, to make a EUDIAL working group position,
reviews the association between survival and convective
volume, the minimum recommended replacement volume,
the importance of the infusion flow rate, and the main limit-
ing factors in achieving a high convective volume. Finally,
the article discusses whether the convective dose should be
normalized to body size. Key Messages: At present, there is
sufficient scientific evidence to indicate that OL-HDF treat-
ment reduces mortality risk and that it should be the first-
line option in hemodialysis patients. It seems reasonable to
recommend that patients should receive the highest pos-
sible convective dose and that the largest possible blood
flow should be used to obtain the highest possible infusion
flow rate. Based on the results of secondary analyses of the
main clinical trials, the current recommendation of the op-
timal dose of OL-HDF, in the postdilutional mode and on a
thrice-weekly treatment schedule, would be a convective
Published online: September 8, 2015
Francisco Maduell, MD
Servicio de Nefrología y Trasplante Renal, Hospital Clínic Barcelona
c/Villarroel 170
ES–08006 Barcelona (Spain)
E-Mail fmaduell @ clinic.ub.es
© 2015 S. Karger AG, Basel
0253–5068/15/0405–0017$39.50/0
www.karger.com/bpu
Francisco Maduell
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
Maduell
Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
18
cles. High-flux membranes were introduced many years
ago to increase the clearance of middle-large molecules.
The anticipated advantages of high-flux (HF-HD) over
low-flux HD (LF-HD) were not confirmed in the HEMO
study
[2] . Subsequently, the results of the MPO study [3]
showed that HF-HD is associated with better survival in
patients with hypoalbuminemia and diabetes mellitus.
European best practice guidelines [4] suggested that
the use of high-flux membranes should be considered to
delay the long-term complications of HD (dialysis-relat-
ed amyloidosis, hyperphosphatemia, cardiovascular risk
and anemia). To exploit the high permeability of high-
flux membranes, convective therapies should be consid-
ered.
High-volume online hemodiafiltration (OL-HDF)
marks a new step toward native kidney blood purifi-
cation. These techniques offer more effective uremic
substance removal over a wider range of molecular sizes
than other dialysis modalities, which has been associated
with potential clinical advantages
[5] . The DOPPS study
showed a mortality risk reduction of 35% in patients
treated with high-efficiency HDF compared with those
treated with LF-HD or HF-HD
[6] . These results were
confirmed in another noncontrolled study conducted in
4 European countries
[7] , in the RISCAVID trial [8] and
in a comparative long-term outcome analysis
[9] .
During the last few years, three large, prospective, ran-
domized clinical trials (RCTs) have been conducted in
distinct European countries to compare survival out-
comes in prevalent patients receiving conventional HD
and OL-HDF. The CONTRAST study randomized 714
patients to LF-HD or OL-HDF; at the end of the study,
the two groups showed no difference in survival
[10] .
Similarly, in the Turkish HDF study, 782 patients were
randomized to HF-HD or OL-HDF and the outcome was
not affected by treatment allocation
[11] . Finally, in Cata-
lonia (Spain), the ESHOL study randomized 906 patients
to HF-HD or OL-HDF
[12] . In this clinical trial, alloca-
tion to OL-HDF was associated with a 30% reduction in
all-cause mortality.
EUDIAL Working Group Position
The European Dialysis (EUDIAL) working group was
created in 2010 by the European Renal Association-Eu-
ropean Dialysis and Transplant Association (ERA-ED-
TA) to review HDF therapies.
In the first paper
[13] , the EUDIAL group revised the
definition of HDF as the blood clearance treatment that
combines diffusive and convective transport using a high-
flux dialyzer with an ultrafiltration coefficient higher
than 20 ml/mm Hg/h/m
2 , a sieving coefficient for β
2 -
microglobulin greater than 0.6 and a percentage of effec-
tive convective transport greater than 20% of the total
processed blood. Convection volume was defined as the
total ultrafiltration volume obtained over the entire HDF
session, the sum of the replacement volume and the in-
tradialytic weight loss achieved. In postdilution HDF, the
effective convection volume will be equal to the total vol-
ume ultrafiltered but, in pre-, mid- or mixed dilution, the
ultrafiltration volume must be adjusted for a dilution fac-
tor which is calculated as the total plasma water volume
processed divided by the plasma water plus upstream in-
fused fluid. To date, all large RCTs with mortality as the
end point have been conducted with the postdilution
mode.
Meta-Analyses and Incident Patient Studies
Two recent meta-analyses, including all three above-
mentioned RCTs, have confirmed that OL-HDF decreas-
es overall and cardiovascular mortality. In a meta-analy-
sis by Nistor et al.
[14] , OL-HDF was associated with a
13% reduction in all-cause mortality (not statically sig-
nificant) and a 25% reduction in cardiovascular mortali-
ty. Similarly, in a EUDIAL systematic review and meta-
analysis
[15] , OL-HDF reduced the all-cause and cardio-
vascular mortality risk by 16 and 27%, respectively.
Three incident patient studies have recently been pub-
lished. In an epidemiological cohort study in 442 incident
HD patients in 3 countries (Bosnia and Herzegovina, Ser-
bia and Slovenia), Imamovic et al.
[16] observed that
high-volume OL-HDF (>20.4 liters replacement volume/
session) was associated with improved survival compared
with high-flux dialysis (hazard rate, HR, 0.29; confidence
interval, CI, 0.13–0.68). Siriopol et al.
[17] evaluated an
incident cohort in a retrospective analysis of the Roma-
nian dialyzed population from the EUCLID database. Af-
ter propensity score matching, 265 HDF-treated patients
were matched to 530 HD-treated patients; OL-HDF was
associated with improved survival (HR 0.24; CI 0.13–
0.46). Canaud et al.
[18] recruited 4,876 incident patients
from a study population extracted from a database of pa-
tients on dialysis treatment in 369 NephroCare centers
throughout 12 European countries. After propensity
score matching, 795 high-volume HDF-treated patients
(>21 liters replacement volume/session) were matched to
795 high-flux HD-treated patients, and inverse probabil-
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
Optimal Convective Dose Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
19
ity of censoring weighting was applied to reduce bias by
indication and consider modality crossover. Again, high-
volume OL-HDF was associated with improved survival
(HR 0.50; CI 0.37–0.68).
Association between Survival and Convective
Volume
In all of these large, randomized studies, the convec-
tive volume seemed to be an important issue. A post hoc
analysis of the CONTRAST study showed that mortality
was considerably lower in the group of patients with the
highest delivered convection volume (upper tertile >21.95
liters) than in patients randomized to LF-HD, with a 39%
mortality risk reduction in patients receiving high con-
vection volumes
[10] .
In a Turkish study
[11] , the median value of the sub-
stitution volume in the OL-HDF group was 17.4 liters. In
a secondary analysis that stratified patients according to
this threshold, those in the low-efficiency OL-HDF group
were more likely to have diabetes, higher phosphate lev-
els, lower albumin levels and higher hemoglobin levels
compared with the high-efficiency OL-HDF and HF-HD
groups. Treatment with high-efficiency OL-HDF was as-
sociated with a 46% risk reduction for overall mortality
and a 69% risk reduction for cardiovascular mortality.
In post hoc analyses of the ESHOL study [12] , mortal-
ity in the intermediate tertile (23.1–25.4 liters/session) and
upper tertile (>25.4 liters/session) was significantly lower
than that in patients randomized to HD, with a 40 and 45%
risk reduction for overall mortality, respectively. In this
secondary analysis, those patients in the highest convective
volume tertile group were younger, with a lower Charlson
comorbidity index and lower percentage of catheter.
In the EUDIAL meta-analysis [15] , evidence was ob-
tained supporting a dose-response relationship between
the magnitude of the convection volume and mortality
risk: the larger the convection volume, the better the out-
come.
What Is the Threshold Convective Volume for
Increasing Survival?
The results of post hoc analyses of all three RCTs pro-
vide evidence of the need to deliver high convection vol-
umes to reduce all-cause mortality and indicate that this
treatment modality could modify patient survival when a
sufficient convective volume is reached.
Based on the results of secondary analyses of the main
clinical trials, the current recommendation for high-vol-
ume OL-HDF would be >23 liters/session of convective
volume. However, because this recommendation is based
on secondary analyses, there could be a selection bias. Pa-
tients with greater convective volume are those with bet-
ter overall health status, and have good vascular access
and less diabetes and cardiovascular disease. In the ab-
sence of more conclusive scientific evidence, this recom-
mendation seems reasonable and affordable but requires
confirmation in future clinical trials.
In a recent retrospective observational study
[19] , ex-
tracted from a database of patients on OL-HDF treatment
throughout 8 European countries, 2,293 incident patients
constituted the basis for subsequent determination of the
convection volume threshold above which survival was
increased. The lowest (54.6 liters/week) and highest (64.8
liters/week) achieved tertiles of average convection vol-
ume were used to define the two populations. After pro-
pensity score matching, 204 patients per group were com-
pared, and the highest convective group was associated
with a significantly higher survival ratio of 3.42 (1.68–
6.98). In the overall study population, the cubic spline
modeling approach showed that the minimum threshold
convection volume delivered during OL-HDF therapy
above which a patient would show a survival benefit was
56.8 liters/week (19 liters/session). The optimal convec-
tion dose was between 56.8 and 75 liters/week (19–25
liters/session).
What Is More Important, the Convective Volume or
the Infusion Flow Rate?
The convective dose not only depends on the overall
convective volume achieved, but also on the infusion
flow rate (Q
i ). In a previous study [20] , we found that
conversion from 4–5 h thrice weekly OL-HDF to 7–8 h
every other day with OL-HDF showed different patterns
of solute removal, which were related to dialysis time,
convective volume and/or Q
i . In a subsequent study
[21] , we evaluated experimentally and mathematically
how treatment time (4 vs. 8 h) and Q
i (50 vs. 100 ml/
min) affect different molecular weight solute removal.
Patients with dialysis time 4 h and Q
i 100 ml/min ob-
tained a similar convective volume as those with dialysis
time 8 h and Q
i 50 ml/min ( fig.1 ). The results obtained
confirm the impact of dialysis duration on the removal
of urea and creatinine, while the impact on Q
i was clear-
ly shown for high-molecular-weight molecules (myo-
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
Maduell
Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
20
globin and prolactin). For β
2 -microglobulin, both fac-
tors enhance the removal efficiency of the dialyzer
( fig.1 ).
Tattersall and Ward [13] , on behalf of the EUDIAL
group, link convective efficiency as a percentage of total
processed blood (greater than 20%). Chapdelaine et al.
[22] , also on behalf of the EUDIAL group, proposed a frac-
tion filtration (FF) formula for clinical utilization, in which
FF is equal to a percentage of convection flow rate (substi-
tution flow rate + ultrafiltration flow rate) over blood flow
(Q
b ). Initial prescriptions of OL-HDF recommended FF
between 25 and 30%, and values of up to 30% have been
obtained using new software with automatic infusion flow.
Because the strict definition of FF is the ratio of the ultra-
filtration rate to the plasma water flow rate, which depends
on hematocrit and protocrit, FF or infusion flow varies by
these individual viscosity characteristics.
Should the Convective Dose Be Normalized to Body
Size?
At present, there are insufficient data or studies to rec-
ommend that the convective dose should be expressed
normalized to body size. Post hoc analyses of the ESHOL
study evaluated the association between convective vol-
ume per session in comparison with convective volume
per square meter of body surface area (BSA) and convec-
tive volume per body mass index. In all tertiles with high-
er convective volume per session, convective volumes re-
lated to body mass index and BSA were associated with a
45, 34 and 38% risk reduction for overall mortality, re-
spectively
[12] .
A study examining the optimal convection volume for
improving patient outcomes in an international incident
dialysis cohort treated with OL-HDF
[19] expressed the
4 h Qi 50
11.7
21.1 22.7
43.1
4 h Qi 100 8 h Qi 50 8 h Qi 100
0
a
10
20
30
40
50
Replacement fluid (liters)
*
*
n.s.
Fig. 1. Convective volume ( a ) and solute
reduction ratio (
b ) for each treatment type.
* p < 0.01 with respect to all others.
0
b
10
20
30
40
50
60
70
80
90
100
Solute reduction ratio (%)
4 h Qi 50 4 h Qi 100 8 h Qi 50 8 h Qi 100
72.2
72.8
88.8
89.7
Urea
(60 Da)
65.7
67.1
79.4
80.4
Creatinine
(113 Da)
69.9
77.9
82.6
86.7
DŽ2-Microglobulin
(11,800 Da)
34.7
55.5
46
64.6
Myoglobin
(17,200 Da)
28.9
45.5
32.8
50
Prolactin
(23,000 Da)
1.1
12.7
5.7
14.8
į1-Microglobulin
(33,000 Da)
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
Optimal Convective Dose Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
21
convective dose as liters per week per square meter BSA
and reported that the minimum threshold convection
volume conferring a survival benefit was 32.7 liters/week/
m
2 BSA. The optimal convection dose was between 32.7
and 45 liters/week/m
2 BSA.
Main Limiting Factors in Achieving High Convective
Volume or Q
i
Hemoconcentration
The main patient-related factors determining higher
blood viscosity are hematocrit and protocrit. An inverse
relationship between hematocrit levels and convective
volume has been observed; however, a direct correlation
with albumin was found
[23, 24] . Apparently, a higher
value of albumin facilitates greater vascular refilling.
Vascular Access
Probably the most important patient-related factor is
vascular access. A native fistula is the best option for all
HD modalities as well as for OL-HDF. However, the use
of a native fistula or graft has decreased due to greater
patient age and the increased prevalence of cardiovascu-
lar disease and diabetes. For this reason, the use of per-
manent tunneled catheters has increased in the last few
years. Catheter use leads to a lower Q
b and convective
volume. In a multicenter study, only a third of the pa-
tients with a catheter achieved a minimum of 21 liters of
the replacement target volume
[24] . It is important to
consider that, in patients with a catheter, the dialysis du-
ration should be increased to achieve an adequate dialy-
sis dose (by an additional 30 min if the catheter is used in
a normal position and by 1 h if it is in reversed position)
[25] . Therefore, catheter use should not be seen as an ob-
stacle for HDF, but increasing dialysis duration must be
considered.
Blood Flow
The main limiting factor for Q
i is Q b . In postdilution
mode, the maximum recommended infusion flow is 33%
of the Q
b value. Although OL-HDF can be performed
with all Q
b values, a prescription of Q
b between 350 and
500 ml/min allows a Q
i of between 80 and 160 ml/min.
Achieving adequate convective volumes may be difficult
in patients with limited Q
b (patients with catheters or
malfunctioning vascular access). However, prescription
of Q
b is more a matter of treatment policy in each dialysis
unit than of the characteristics of the patients themselves
[26] .
Table 1. Recommendations to obtain the optimal HDF dose
Prescription Recommendation
Vascular access Fistula or graft
Catheter
First option
Increase dialysis duration
Qb350 – 500 ml/min Maximum possible
Dialysate flow 400 – 500 ml/min +
infusion flow rate
No influence on convective dose
Infusion flow rate 25 – 33% of the Qb
90 – 160 ml/min
Maximum possible
Dialysis duration 4.0 – 5.0 h/session Maximum possible
Convective volume (replacement
volume + intradialytic weight loss)
>23 liters/session Maximum possible
Percentage effective convective
volume of the blood processed
25 – 30% Maximum possible
Dialyzer High-flux membrane
KUF >40 ml/h/mm Hg
SC for β2-microglobulin >0.6
Avoid membranes with high
adsorption capacity, i.e. PMMA
KUF = Ultrafiltration coefficient; SC = sieving coefficient; PMMA = polymethyl methacrylate.
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
Maduell
Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
22
Dialysate Flow
Dialysate flow has no influence on convective dose. A
recent study analyzed 59 patients who all received 5 ses-
sions in which only dialysate flow was varied (300, 400,
500, 600 and 700 ml/min) and found that the convective
volume achieved was similar in all situations. Urea clear-
ance was slightly increased with a higher dialysate flow
and was unchanged in medium and large molecules
[27] .
Dialysis Machine
The development of new dialysis machines that allow
an automatic Q
i in order to maximize the convective vol-
ume have reduced the risk of hemoconcentration and
have increased convective volume. Using the GAMBRO
AK 200 machine, Panichi et al.
[28] compared standard
volume control with automatized control transmem-
brane pressure (ULTRAcontrol module to adjust the re-
placement rate) and showed that automatized control
transmembrane pressure increased replacement volume
by 20%. After the 5008 CorDiax monitor software was
updated by an internal algorithm, the machine adjusts the
Q
i to the highest possible volume at each moment. This
change of software resulted in a 15% increase in the total
convective volume
[29] .
Dialyzer
As mentioned above, OL-HDF needs high-flux dialyz-
ers. The incorporation of a new generation of dialyzers
with higher sieving properties for larger solutes and opti-
mized hollow-fiber dimensions significantly improved the
efficiency of removal of large uremic toxins
[30] . Current-
ly, dialyzers are available with large convective capacity,
with ultrafiltration coefficients between 40 and 100 ml/h/
mm Hg. This means that a transmembrane pressure of 200
mm Hg allows a Q
i of 133–333 ml/min, which is much
higher than those that can currently be used. Therefore,
dialyzers with an ultrafiltration coefficient >45 ml/h/mm
Hg are not a limiting factor for convective volume, and the
differences obtained in purification capacity would be
minimal. Thus, again it can be seen that the Q
i -limiting
factor mainly lies in the Q
b (25–33%). Therefore, the max-
imum use of dialyzers will be achieved with the maximum
Q
b . Membranes with a high adsorption capacity, such as
polymethyl methacrylate, limit convection and therefore
the convective volume target would not be reached.
Dialysis Duration
An increase in the dialysis duration will always be a
valid alternative to increase convective volume and there-
fore to reach the desired minimum convective volume.
The main recommendations for the optimal convec-
tive dose are summarized in table1 .
Conclusions
There is sufficient scientific evidence to indicate that
OL-HDF treatment reduces mortality risk and should
be the first-line option in HD patients. It seems reason-
able to recommend that patients should receive the
highest possible convective dose. The convective target
volume should therefore be the maximum possible for
the individual characteristics and parameters of each di-
alysis patient. Because we cannot act on individual pa-
tient characteristics, such as hematocrit, total protein or
vascular access, it is always advisable to use the largest
Q
b possible to obtain the highest Q
i possible. Catheter
use should not be seen as an obstacle to HDF but in-
creasing dialysis duration must be considered. Latest-
generation dialysis machines offer automated infusion
systems that maximize the convective dose with the
highest Q
i and with minimal hemoconcentration com-
plications.
It seems reasonable to maintain a minimum convec-
tive dose recommendation while awaiting confirmation
in future studies. Based on the results of secondary anal-
yses of the main clinical trials and considering that there
could be a selection bias, the current recommendation
of the optimal OL-HDF dose, in the postdilutional mode
and on a thrice-weekly treatment schedule, would be a
convective volume higher than 23 liters/session. There
is insufficient evidence to recommend that the convec-
tive dose should be normalized to body size, although it
has been suggested that convective dose should be ad-
justed to BSA.
Disclosure Statement
The author received lecture fees from Amgen, Baxter, Bellco,
Fresenius and Nipro.
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
Optimal Convective Dose Blood Purif 2015;40(suppl 1):17–23
DOI: 10.1159/000437409
23
References
1 Renal replacement therapy in Europe: a sum-
mary of the 2011 ERA-EDTA Registry An-
nual Report. Clin Kidney J 2014;
7: 227–238.
2 Eknoyan G, Beck GJ, Cheung AK, et al: Effect
of dialysis dose and membrane flux in main-
tenance and hemodialysis. N Engl J Med 2002;
347: 2010–2019.
3 Locatelli F, Martin-Malo A, Hannedouche T,
et al: Effect of membrane permeability on sur-
vival of hemodialysis patients. J Am Soc
Nephrol 2009;
20: 645–654.
4 Tattersall J, Canaud B, Heimburger O, Pedri-
ni L, Schneditz D, Van Biesen W; European
Renal Best Practice Advisory Board: High-
flux or low-flux dialysis: a position statement
following publication of the Membrane Per-
meability Outcome study. Nephrol Dial
Transplant 2010;
25: 1230–1232.
5 Maduell F: Hemodiafiltration. Hemodial Int
2005;
9: 47–55.
6 Canaud B, Bragg-Gresham JL, Marshall MR,
et al: Mortality risk for patients receiving he-
modiafiltration versus hemodialysis: Europe-
an results from the DOPPS. Kidney Int 2006;
69: 2087–2093.
7 Jirka T, Cesare S, Di Benedetto, et al: Mortal-
ity risk for patients receiving hemodiafiltra-
tion versus hemodialysis. Kidney Int 2006;
70:
1524–1525.
8 Panichi V, Rizza GM, Paoletti S, et al: Chron-
ic inflammation and mortality in haemodialy-
sis: effect of different replacement therapies.
Results from the RISCAVID study. Nephrol
Dial Transplant 2008;
23: 2337–2343.
9 Vilar E, Fry AC, Wellsted D, Tattersall JE,
Greenwood RN, Farrington K: Long-term
outcomes in online hemodiafiltration and
high flux hemodialysis: a comparative analy-
sis. Clin J Am Soc Nephrol 2009;
4: 1944–1953.
10 Grooteman MPC, van den Dorpel MA, Bots
ML, et al: Effect of online hemodiafiltration
on all-cause mortality and cardiovascular
outcomes. J Am Soc Nephrol 2012;
23: 1083–
1096.
11 Ok E, Asci G, Toz H, et al: Mortality and car-
diovascular events in online-hemodiafiltra-
tion (OL-HDF) compared with high-flux
dialysis: results from the Turkish Online
Haemodiafiltration Study. Nephrol Dial
Transplant 2013;
28: 192–202.
12 Maduell F, Moreso F, Pons M, et al: High-ef-
ficiency postdilution online hemodiafiltra-
tion reduces all-cause mortality in hemodial-
ysis patients. J Am Soc Nephrol 2013;
24: 487–
497.
13 Tattersall JE, Ward RA; EUDIAL group: On-
line haemodiafiltration: definition, dose
quantification and safety revisited. Nephrol
Dial Transplant 2013;
28: 542–550.
14 Nistor I, Palmer SC, Craig JC, et al: Convec-
tive versus diffusive dialysis therapies for
chronic kidney failure: an update systematic
review of randomized controlled trials. Am J
Kidney Dis 2014;
63: 954–967.
15 Mostovaya I, Blankestijn PJ, Bots ML, et al;
EUDIAL group: Clinical evidence on hemo-
diafiltration: a systematic review and a meta-
analysis. Semin Dial 2014;
27: 119–127.
16 Imamovic G, Hrvacevic R, Kapun S, Marcelli
D, Bayh I, Grassmann A, Scatizzi L, Maslovar-
ic J, Canaud B: Survival of incident patients on
high-volume online hemodiafiltration com-
pared to low-volume online hemodiafiltra-
tion and high-flux hemodialysis. Int Urol
Nephrol 2014;
46: 1191–1200.
17 Siriopol D, Canaud B, Stuard S, Mircescu G,
Nistor I, Covic A: New insights into the effect
of haemodiafiltration on mortality: the Ro-
manian experience. Nephrol Dial Transplant
2015;
30: 294–301.
18 Canaud B, Bayh I, Marcelli D, Ponce P, Me-
rello JI, Gurevich K, Ladanyi E, Ok E, Imam-
ovic G, Grassmann A, Scatizzi L, Gatti E: Im-
proved survival of incident patients with
high-volume haemodiafiltration: a propensi-
ty-matched cohort study with inverse proba-
bility of censoring weighting. Nephron 2015;
129: 179–188.
19 Canaud B, Barbieri C, Marcelli D, Bellocchio
F, Bowry S, Mari F, Amato C, Gatti E: Optimal
convection volume for improving patient
outcomes in an international incident dialysis
cohort treated with online hemodiafiltration.
Kidney Int 2015, Epub ahead of print.
20 Maduell F, Arias M, Durán CE, Vera M, Font-
seré N, Azqueta M, Rico N, Pérez N, Sentis A,
Elena M, Rodriguez N, Arcal C, Bergadá E,
Cases A, Bedini JL, Campistol JM: Nocturnal,
every-other-day, online haemodiafiltration:
an effective therapeutic alternative. Nephrol
Dial Transplant 2012;
27: 1619–1631.
21 Maduell F, Sanchez J, Net M, Gomez M, Gon-
zalez JM, Arias-Guillen M, Rodriguez N, Rico
N, Campistol JM: Mathematical modeling of
different molecule removal on on-line hae-
modiafiltration: influence of dialysis duration
and infusion flow. Blood Purif 2015;
39: 288–
296.
22 Chapdelaine I, de Roij van Zuijdewijn CL,
Mostovaya IM, Lévesque R, Davenport A,
Blankestijn PJ, Wanner C, Nubé MJ, Groote-
man MP; EUDIAL group: Optimization of
the convection volume in online post-dilu-
tion haemodiafiltration: practical and techni-
cal issues. Clin Kidney J 2015;
8: 191–198.
23 Penne EL, van der Weerd NC, Bots ML, van
den Dorpel MA, Grooteman MP, Lévesque R,
Nubé MJ, Ter Wee PM, Blankestijn PJ; CON-
TRAST investigators: Patient- and treatment-
related determinants of convective volume in
post-dilution haemodiafiltration in clinical
practice. Nephrol Dial Transplant 2009;
24:
3493–3499.
24 Marcelli D, Scholz C, Ponce P, Sousa T, Kop-
perschmidt P, Grassmann A, Pinto B, Canaud
B: High-volume postdilution hemodiafiltra-
tion is a feasible option in routine clinical
practice. Artif Organs 2015;
39: 142–149.
25 Maduell F, Vera M, Arias M, Fontseré N, Blas-
co M, Serra N, Bergadá E, Cases A, Campistol
JM: How much should dialysis time be in-
creased when catheters are used? Nefrologia
2008;
28: 633–636.
26 Chapdelaine I, Mostovaya IM, Blankestijn P,
Bots ML, van den Dorpel MA, Lévesque R, et
al: Treatment policy rather than patient char-
acteristics determines convection volume in
online post-dilution hemodiafiltration. Blood
Purif 2014;
37: 229–237.
27 Maduell F, Ojeda R, Arias-Guillén M, Fontseré
N, Vera M, Rodríguez N, Gómez M, Rodas L,
Bazan G, Jiménez-Hernández M, Piñeiro G,
Rico N: Optimizing dialysate flow in on-line
hemodiafiltration. Nefrologia 2015, in press.
28 Panichi V, De Ferrari G, Saffioti S, Sidoti A,
Biagioli M, Bianchi S, Imperiali P, Gabbrielli
C, Conti P, Patrone P, Falqui V, Rombolà G,
Mura C, Icardi A, Mulas D, Rosati A, Santori
F, Mannarino A, Tomei V, Bertucci A, Steck-
iph D, Palla R: Divert to ULTRA: differences
in infused volumes and clearance in two on-
line hemodiafiltration treatments. Int J Artif
Organs 2012;
35: 435–343.
29 Maduell F, Rodríguez N, Sahdalá L, Coronel
D, Arias Guillén M, Ojeda R, Vera M, Font-
seré N, Cases A, Campistol JM: Impact of the
5008 monitor software update on total con-
vective volume. Nefrologia 2014;
34: 599–604.
30 Maduell F, Arias-Guillen M, Fontseré N, Oje-
da R, Rico N, Vera M, Elena M, Bedini JL,
Wieneke P, Campistol JM: Elimination of
large uremic toxins by a dialyzer specifically
designed for high-volume convective thera-
pies. Blood Purif 2014;
37: 125–130.
Downloaded by:
Universitat de Barcelona
198.143.45.1 - 9/16/2015 11:12:54 AM
