Although evidence indicates that HVHDF improves patient outcomes, concerns remain regarding its cost-effectiveness and environmental sustainability compared to HD.<\/p>\n
Although the initial investment in HVHDF infrastructure may seem significant, it is important to consider the long-term benefits, such as improved quality of care, increased survival, and more efficient resource utilization, which can help to offset these potential upfront costs gradually.<\/em><\/p>\n HVHDF addresses critical clinical and financial challenges, meeting the expectations of multiple stakeholders, including patients, physicians, healthcare providers, and funders (5).<\/p>\n Health economic outcome studies comparing HVHDF and traditional HD could provide valuable insights into its sustainability.<\/p>\n Schouten et al. have executed a comprehensive cost-utility evaluation of HVHDF compared to high-flux HD ESKD patients (302). The trial examined the impact of HDF on survival rates and HRQoL, taking into account economic implications from both short-term (two-year) and long-term (lifetime) perspectives. The financial assessment was based on data from the CONVINCE trial and existing literature. The study considered both direct healthcare costs, such as dialysis sessions and hospitalizations, and indirect costs, including productivity losses and informal caregiving.<\/p>\n Given the established superiority of HVHDF in reducing mortality, the investigators sought to determine whether these clinical benefits justify the increased costs associated with its implementation<\/em>.<\/p>\n Conducted across 61 centers in eight European countries, the trial randomized 1,360 adult patients undergoing HD for at least three months. Patients were allocated either to high-dose HDF or to continue receiving conventional high-flux HD. The study followed them for at least two years, gathering data on healthcare costs, quality-adjusted life years (QALYs), and broader economic implications. The main results of the trial demonstrated a substantial survival advantage for patients treated with HDF, with a 23% lower risk of all-cause mortality compared to those treated with HD. The cost-utility analysis employed a Markov cohort model to assess outcomes over both a two-year and lifetime horizon, revealing that HDF led to an incremental cost per QALY of \u20ac31,898\u2013\u20ac37,344 over two years and \u20ac27,068\u2013\u20ac36,751 over a lifetime. These variations reflect differences in dialysis staff costs across different scenarios.<\/p>\n While HDF was associated with greater overall costs due to increased life expectancy and the corresponding need for additional dialysis sessions, sensitivity analyses indicated that at a willingness-to-pay threshold of \u20ac50,000 per QALY, the probability of its cost-effectiveness surpassed 90%. When intervention costs in additional life years were excluded, which lowered the economic burden of longer survival, the incremental cost-effectiveness ratio decreased significantly to \u20ac13,231 per QALY.<\/strong><\/p>\n A key driver of cost differences was the expense of dialysis disposables, as well as increased water and electricity consumption in HDF. However, these costs were partially offset by reduced medication use and potential improvements in patient HRQoL. Hospitalization costs were slightly higher in the HDF group, though the study acknowledged that more detailed analyses are needed to explore the causes of these admissions. This analysis highlighted variations in cost structures across countries, and the authors recommended that healthcare organizations tailor findings to local economic conditions. The results emphasize the need to integrate clinical effectiveness with economic viability in treatment decisions, particularly in resource-intensive areas like dialysis care. Ultimately, the CONVINCE trial presents a compelling case for HDF as a cost-effective therapy for ESKD.<\/p>\n While requiring greater initial resource allocation, its demonstrated survival benefits, coupled with favorable cost-per-QALY ratios, suggest that high-dose HDF represents a valuable investment in patient care (302)<\/strong>.<\/p>\n Shroff and the EuDial Working Group have raised concerns about the sustainability and environmental impact of HVHDF, given its larger infusion volume requirements compared to conventional high-flux HD, speculating that the associated costs may outweigh the benefits (303). Conversely, Canaud et al., analyzing real-world data from over 26,000 patients treated in FME EMEA clinics, along with simulation modeling, demonstrated that optimally prescribed post-dilution online HDF is more environmentally friendly compared to high-flux HD (29).<\/strong> By reducing the dialysate flow rate to 430 mL\/min (reflecting a Qd : Qb ratio 1.2, instead of 1.4 or 1.5) and integrating automated ultrafiltration and substitution control, post-dilution HVHDF achieves a higher dialysis dose for both small- and middle-molecule uremic toxins while reducing the dialysis fluid consumption compared to standard HD (29). These findings highlight the potential of HVHDF as a more sustainable and resource-efficient dialysis modality while maintaining superior treatment efficacy (29). HVHDF enhances solute clearance across all molecular weights and significantly reduces water and dialysate consumption by enabling lower dialysate flow rates without compromising clearance efficiency (29).<\/p>\n Post-dilution HVHDF uses ultrapure dialysate more efficiently than traditional HD or other HDF modalities (29). It increases the clearance of middle molecules, improves quality of life, and reduces hospital admissions and lengths of stay (304). These reductions in hospitalizations lead to cost savings for healthcare systems. Enhanced removal of uremic toxins also decreases the need for supportive medications, such as phosphate binders and erythropoiesis-stimulating agents. Furthermore, HVHDF minimizes saline usage for system priming and rinsing, reducing plastic waste and associated costs. Replacing disposable components with recyclable or reusable alternatives can further mitigate plastic waste.<\/p>\n Dialysis machines capable of online sterile fluid generation can minimize reliance on saline and substitution fluid packaging, lowering the energy consumption and CO2<\/sub> emissions associated with their production and transportation. Improved patient quality of life and social impact can also increase patient productivity.<\/p>\n Optimally prescribed post-dilution online HVHDF emerges as a sustainable and effective therapy, balancing clinical excellence with environmental responsibility (305, 306).<\/p>\n HDF addresses the ecological challenges of traditional dialysis by reducing water and saline usage, minimizing plastic waste, and decreasing the carbon footprint.<\/p>\n With improved patient outcomes and long-term cost savings, HVHDF represents a forward-looking approach to KRT, benefiting patients, healthcare systems, and the environment.<\/p>\n <\/p>\n","protected":false},"featured_media":0,"template":"","format":"standard","meta":{"_acf_changed":false},"categories":[128],"tags":[250],"language":[41],"articles":[215],"class_list":["post-8493","article","type-article","status-publish","format-standard","hentry","category-articles","tag-handbook-hdf","language-english","articles-hemodiafiltration","entry","no-media"],"acf":[],"yoast_head":"\n