Haemodialysis

End-stage kidney disease affects around 1 in 1000 people in the UK, well over a third of whom are treated with haemodialysis. The population undergoing haemodialysis continues to expand, with an increasing prevalence of elderly dependent patients. Despite major advances in technology, long-term clinical outcomes are suboptimal, even in low-risk patients. Poor outcomes are driven by high rates of cardiovascular disease and infection. Current definitions of dialysis adequacy, based on urea clearance, should be broadened to encompass parameters including middle molecule clearance, salt and water balance, and patient-reported outcomes. 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 a person's needs. Patients with significant residual kidney function may require less dialysis. For others without residual kidney function, more frequent treatments can help to control uraemia and volume status, and improve survival. Home-based treatment can facilitate more frequent treatments without the requirement to travel to a dialysis unit for some patients, although centre-based therapy remains the default for most.