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

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 standpoint, expenditures associated with HDF usage are still a major concern. Although initially these expenditures were considered non-prohibitive, a decision-model analysis has since found HDF to be expensive from a societal and hospital perspective. Nonetheless, for a Medicare payer, HDF can be cost-effective if existing nephrology resources such as dialysis machines, disposable supplies, and nursing staff are used as alternatives [67].
