This review provides a detailed analysis of hemodiafiltration (HDF), its progress from an emerging technique to a potential conventional treatment for chronic hemodialysis patients, and its current status. The article covers advances, methodologies, and clinical benefits of HDF, spe-cifically focusing on its impact on cardiovascular health, survival rates, and overall well-being. The text also addresses concerns about the safety of HDF and provides evidence to dispel worries re-lated to the elimination of beneficial substances and infection risks. Additionally, the article ex-plores the potential implications of expanded hemodialysis (HDx) as an alternative to HDF, its classification, safety profile, and an ongoing trial assessing its non-inferiority to HDF. Supported by evidence from randomized controlled trials and observational studies, the review emphasizes the superiority of HDF as a hemodialysis modality, advocating for its positioning as the gold standard in treatment. However, it acknowledges the need for extensive research to define the role of HDx in comprehensive treatment approaches for individuals undergoing dialysis. The synthesis of current knowledge underscores the importance of ongoing exploration and research to refine hemodialysis practices for optimal patient outcomes.

The choice of dialysate buffer in hemodialysis is crucial, with acetate being widely used despite complications. Citrate has emerged as an alternative due to its favorable effects, yet concerns persist about its impact on calcium and magnesium levels. This study investigates the influence of citrate dialysate (CD) with and without additional magnesium supplementation on CKD-MBD biomarkers and assesses their ability to chelate divalent metals compared to acetate dialysates (AD). A prospective crossover study was conducted in a single center, involving patients on thrice-weekly online hemodiafiltration (HDF). Four dialysates were compared: two acetate-based and two citrate-based. Various biochemical parameters were monitored before and after each dialysis session. Seventy-two HDF sessions were performed in eighteen patients. CD showed stability in iPTH levels and reduced post-dialysis total calcium, with no significant increase in adverse events. Magnesium supplementation with CD prevented hypomagnesemia. However, no significant differences among dialysates were observed in the chelation of other divalent metals. Citrate dialysates, particularly with higher magnesium concentrations, offer promising benefits, including prevention of hypomagnesemia and stabilization of CKD-MBD parameters, suggesting citrate as a viable alternative to acetate. Further studies are warranted to elucidate long-term outcomes and optimize dialysate formulations.

Background: Chronic kidney disease (CKD) is a significant cardiovascular (CV) risk factor, with dialysis-dependent CKD (DD-CKD) patients facing high mortality rates. Hypercholesterolemia is another crucial CV risk factor, typically managed with lipid-lowering therapy, though its efficacy in DD-CKD remains uncertain. Evidence shows mixed results regarding the benefits of statins in these patients. Citrate-based dialysates are known to reduce inflammatory biomarkers compared to acetate-based ones, potentially impacting lipid profiles and immune responses. This study aimed to determine the effects of citrate versus acetate dialysate on lipid profiles and immunophenotypes in DD-CKD patients. Methods: This unicentric, cross-over, prospective study included 21 hemodialysis patients (10 males, 11 females, average age 62.25 years). Each patient underwent 24 dialysis sessions (12 with each dialysate) and acted as their own control. Lipid profiles, immunological parameters, and nutritional and inflammatory markers were measured before the last session with each dialysate. Results: Compared to acetate dialysate (AD), citrate dialysate (CD) resulted in significantly higher LDL (75.71 vs. 67.05 mg/dL, p=0.042) and HDL (51.19 vs. 47.14 mg/dL, p=0.013), and lower TG (97.86 vs. 110.38 mg/dL, p=0.046). CD also led to higher NK cells (19.24 vs. 16.95%, p=0.035), higher complement C3 levels (115.14 vs. 107.81 mg/dL, p=0.009) and lower CD3+ CD8+ and CD16+56+ lymphocytes. Finally, total lymphocytes were lower with AD than with CD. We found no difference in predialysis nutritional nor inflammatory parameters (IL-6 and hs-CRP) except for ESR, which was higher when subjects used CD than AD. Conclusion: There are significant differences in lipid and immunophenotypic profiles that should increase the CV risk of patients who use CD. However, numerous studies have shown no differences, or even a benefit in mortality in certain HD subpopulations that use CD. Further studies are needed to understand if the observed changes may be counterbalanced by other mechanisms potentially provided by citrate (e.g., reducing vascular calcification).