Haemodialysis

The population undergoing haemodialysis continues to expand, with an increasing prevalence of elderly dependent patients including those aged >80 years. Despite major advances in technology, long-term clinical outcomes are disappointing, even in low-risk patients. Current definitions of adequacy of dialysis, based on urea clearance, need to be broadened to encompass parameters including middle molecule clearance, salt and water balance, and patient symptoms and well-being. Haemodiafiltration provides improved middle molecule clearance over haemodialysis, with some evidence of improved survival. There is a trend towards individualizing the haemodialysis dose to meet the patient's needs. Patients with significant residual kidney function may require less dialysis. For others without residual kidney function, more frequent treatments can be necessary to adequately control uraemia and volume status, and improve survival. Home-based treatment can facilitate more frequent treatments for some patients, although centre-based therapy remains the default for most.