Revisiting the hemodiafiltration with endogenous reinfusion: what is its merit in clinical practice? A narrative review

INTRODUCTION: Despite significant advancements in medical and technical aspects in the field of dialytic renal replacement therapies, morbidity and mortality are extremely high among patients with end-stage renal disease (ESRD), and most interventional studies yielded unsatisfactory outcomes. Hemodiafiltration with endogenous reinfusion (HFR) emerges as a distinctive blood purification technique characterized by a dual-chamber dialyzer and a resin adsorption filter core, integrating the mechanisms of diffusion, convection, and adsorption within a single therapeutic framework. DISCUSSION: Current evidence suggests that, in addition to its capacity for the removal of uremic toxins, HFR could also be effective in ameliorating the inflammatory states and oxidative stress among the dialysis population; however, the existing evidence is limited by small sample sizes and short follow-up periods. Nevertheless, in clinical practice, several challenges associated with HFR in clinical practice necessitate immediate consideration. These challenges include the technical specifications of dialyzers, the impact on micronutrient levels, and the requirement for a broader scope of clinical indications. The present review elucidates the technical aspects of HFR and summarizes our perspectives on the contentious issues pertaining to its clinical application. Finally, we offer insights into future clinical trials exploring more specific indications for the utilization of HFR. CONCLUSIONS: Future studies should be adequately powered, prospective, multi-center, randomized controlled trials with robust clinical endpoints to address the identified challenges associated with HFR, thereby optimizing its therapeutic role in the management of ESRD.