Dialysis adequacy today: a European perspective

The need to improve haemodialysis (HD) therapies and to reduce cardiovascular and all-cause mortality frequently encountered by dialysis patients has been recognized and addressed for many years. A number of approaches, including increasing the frequency versus duration of treatment, have been proposed and debated in terms of their clinical efficacy and economic feasibility. Future prescription of dialysis to an expanding end-stage chronic kidney disease (CKD-5D) population needs a re-evaluation of existing practices while maintaining the emphasis on patient well-being both in the short and in the long term. Efficient cleansing of the blood of all relevant uraemic toxins, including fluid and salt overload, remains the fundamental objective of all dialysis therapies. Simultaneously, metabolic disorders (e.g. anaemia, mineral bone disease, oxidative stress) that accompany renal failure need to be corrected also as part of the delivery of dialysis therapy itself. Usage of high-flux membranes that enable small and large uraemic toxins to be eliminated from the blood is the first prerequisite towards the aforementioned goals. Application of convective therapies [(online-haemodiafiltration (OL-HDF)] further enhances the detoxification effects of high-flux haemodialysis (HF-HD). However, despite an extended clinical experience with both HF-HD and OL-HDF spanning more than two decades, a more widespread prescription of convective treatment modalities awaits more conclusive evidence from large-scale prospective randomized controlled trials. In this review, we present a European perspective on the need to implement optimal dialysis and to improve it by adopting high convective therapies and to discuss whether inertia to implement these practice patterns may deprive patients of significantly improved well-being and survival.