**6. Conclusion**

Anticoagulation must be a major consideration for any extracorporeal dialysis therapy. Many patients on home haemodialysis manage well with the administration anticoagulation, and unfractionated heparin and low molecular weight heparin are in common use. These strategies can also be used in HDF and should not pose a barrier to home HDF use. HDF may allow dialysis without anticoagulation through the use of pre‐dilution HDF. This may be particularly

Today's dialysis technology enables HDF to be delivered in the home setting safely with the production of ultra‐pure dialysate and detection of venous dislodgement. There is a growing experience of centres using this technology [94] with a positive experience. Further details on optimal heparinization regimes, water quality variability and its surveillance in home HDF are necessary to define best clinical practice. It is likely that new technology coupled with increasing HDF uptake in dialysis centres will lead on to increasing use of HDF at

Haemodialysis treatment in general is very costly, and in the United Kingdom, 1–2% of the National Health Service budget is spent on renal care with only 0.05% with ESRF [95]. After consumables, a large proportion of the cost is made up of direct nursing care and transportation [96] (both of which are considerably less in home haemodialysis). Home haemodialysis has been estimated to cost over a third less than hospital‐based haemodialysis in the United Kingdom [96] and frequent home haemodialysis has been shown to offer a cost saving in both

In addition to the reduced transport and nursing costs, savings are also offered from a reduction in hospital admissions [37] and a reduction in medication costs (particularly

The initial setup costs of home haemodialysis are high due to the cost of training, the equipment and installation. These initial costs are usually paid back by 14 months after which savings occur [99], making home haemodialysis an attractive option not only from the clinical benefits

Costs of high‐flux dialysers have also reduced considerably over time and high‐flux haemo‐ dialysis is now the common standard care. A UK Study looked at the costs of 34 patients switching to OL‐HDF and 44 who remained on high‐flux HD. The cost of the treatment was either more expensive or cheaper depending on the choice of blood lines. There was a cost saving in the OL‐HDF group in terms of phosphate binders. Lebourg et al. [81] looked at >28,000 dialysis treatments in a single centre and once again HDF was found to be either cheaper or more costly (-€1.29 to +€4.58 per session) depending on treatment variables selected. It is clear that from a cost perspective, there is little difference between HDF and

helpful in patients with prolonged bleeding or intolerances to anticoagulation.

home.

112 Advances in Hemodiafiltration

**5.2. Economic impact of HD and HDF**

Canada and Australia too [97].

but also from the cost‐saving aspect.

phosphate binders) [98].

high‐flux HD.

Home haemodialysis provides a convenient and clinically effective way of providing both frequent and extended haemodialysis treatment. Although the hard outcome data for survival from prospective randomized trials are lacking, it is unlikely that a larger, adequately powered trial with sufficient follow‐up time will be feasible and the answer may need to come from registry data. It is also time to look beyond urea clearance and towards markers, such as convective volume and β‐trace protein, as this may pave the way to further improve haemo‐ dialysis care in the future.

However, it is clear that there are a number of clinical benefits from more frequent and extended haemodialysis and aside from this, home haemodialysis is a treatment preferred by many patients if choices are given [100] and a treatment that is associated with an increased satisfaction [101].

HDF is also a feasible treatment in the home setting and is already in use. There is growing evidence from randomized trials that dialysis patient outcomes may be improved by high‐ frequency HD and by using HDF with high convective volumes. Combining increased fre‐ quency HD with convective treatment would give patients the benefits of both small and middle MW clearance without additional patient burden or cost implications. This may pave the way to further improved patient outcomes; however, further randomized clinical studies will be needed for a more definitive answer.
