**10. Conclusion**

The second meta-analysis comprised seven RCTs with a total of 569 participants who met the eligibility criteria [21]. This analysis demonstrated that after 48 h of treatment, significantly higher amounts of weight loss and fluid removal were observed in the UF group compared with the diuretic group. Serum creatinine levels and changes in creatinine were found to be similar. There was no difference in all-cause mortality and all-cause rehospitalizations. In addition to these results, the authors noted that there were only minor differences between the UF and control groups in the incidence of adverse events, such as infections, anemia, hemor‐

UF recommendations for HF from the 2013 guideline by the American College of Cardiology Foundation/American Heart Association Task Force [64] are shown in **Table 1**, along with recommendations from the Canadian Cardiovascular Society [65] and the European Society

alleviate congestive symptoms and fluid weight.

**Table 1.** Recommendations and guidelines for the use of hemodiafiltration in patients with congestive heart failure.

Controversy still exists regarding the efficacy of HDF reported in clinical trial results to restore diuretic responsiveness in patients with CHF. The studies evaluating HDF showed consider‐ able heterogeneity in terms of (1) study population, (2) causes of acute decompensation, (3) indications and protocols used for the prescription of HDF, (4) the "standard management" used in the control arm, and (5) end points. Marenzi et al. recommended using HDF as a complementary intervention along with diuretics rather than solely as an alternative inter‐ vention in patients with ADHF [52]. Moreover, HDF should probably be prescribed on an individual basis in diuretic-resistant patients to achieve safe decongestion. From a financial

responding to medical therapy."

in diuretic-resistant patients"

resistant to diuretics."

**9. HDF challenges and cost-effectiveness**

"Ultrafiltration may be considered for patients with obvious volume overload to

"Venovenous ultrafiltration may be of benefit in relieving congestion particularly

"Venovenous isolated ultrafiltration is sometimes used to remove fluid in patients with heart failure, although it is usually reserved for those unresponsive or

Ultrafiltration may be considered for patients with refractory congestion not

rhage, progressive HF, and other cardiac disorders (**Figure 2**).

of Cardiology [66].

68 Advances in Hemodiafiltration

[64]

(2012)[65]

(2012)[66]

American College of Cardiology/ American Heart Association (2013)

Canadian Cardiovascular Society

European Society of Cardiology

**Reference Guidelines**

**8. Recommendations for the use of HDF in clinical practice**

In patients with ADHF, decongestion is a major treatment goal. HDF techniques seem to be an effective tool for removal of fluid, but more robust studies are required to clarify the benefits of HDF and to characterize the group of patients who would benefit most from using it over standard diuretic therapy. Despite recent studies, crucial clinical questions are left unan‐ swered. It is nonetheless apparent that HDF is an effective treatment strategy that should be used only for a selected group of suitable patients and performed by skilled professionals. The next research step for UF should not involve evaluating its effectiveness over that of diuretics; rather, it is more important to identify the patients who best respond to this technique to help restore their diuretic responsiveness.
