Advancing high-volume hemodiafiltration: from concept to CONVINCE

Conventional kidney replacement therapy (KRT) for end-stage kidney disease (ESKD) is associated with unmet medical needs, limited efficiency, poor patient outcomes, perception, and high costs.Advancements, including synthetic high-flux membranes, better-designed dialyzers, smart hemodialysis machines, and ultrapure dialysis fluid, have improved outcomes, but challenges persist.Online hemodiafiltration allows for tailored convective doses, which can enhance the removal of uremic toxins, particularly those in the middle and large molecular weight range.This approach has been consistently associated with improved intermediary outcomes and potentially better patient outcomes, although the latter remains under debate.Several cohort and interventional studies, including individual patient data meta-analysis, have suggested the superiority of high-volume HDF to high-flux hemodialysis in reducing mortality.The CONVINCE trial, supported by HORIZON 2020, demonstrated a 23% reduction in all-cause mortality with hemodiafiltration, representing a milestone study in the KRT field.While secondary outcomes show promise, further analysis is needed.Overall, hemodiafiltration marks a significant advancement in KRT, with the potential to shift the treatment paradigm in kidney patient care.In this special issue, a comprehensive review retraces the long journey of hemodiafiltration from concept to the achievement of CONVINCE and provides clues for successful implementation.