Short-term efficacy and safety of hemodialysis using super high-flux dialyzers compared with online hemodiafiltration: a cross-sectional study in Vietnam

Short-term efficacy and safety of hemodialysis using super high-flux dialyzers compared with online hemodiafiltration: a cross-sectional study in Vietnam | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short-term efficacy and safety of hemodialysis using super high-flux dialyzers compared with online hemodiafiltration: a cross-sectional study in Vietnam Thanh Cong Nguyen, Hong Vu Le Thi, Phu Quoc Nguyen, Hoai Vy Nguyen Thi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8307919/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Online hemodiafiltration (OL-HDF) enhances removal of middle-molecule uremic toxins but requires ultrapure water systems and specialized equipment, limiting uptake in many low- and middle-income countries. Super high-flux (SHF) dialyzers have been proposed as a pragmatic alternative to improve permeability and remove larger solutes using standard hemodialysis machines, yet no evaluation has been conducted in Vietnam. Our study aimed to compare the short-term efficacy and safety of HD using SHF dialyzers (SHF-HD) with post-dilution OL-HDF in a real-world Vietnamese tertiary center. Methods: This cross-sectional study enrolled 30 patients receiving maintenance dialysis at People’s Hospital 115 (Ho Chi Minh City, Vietnam). Among those, fifteen patients received SHF-HD and fifteen received OL-HDF. A single 240-minute session was examined per patient. Blood samples were drawn pre- and post-dialysis to measure urea, β₂-microglobulin, parathyroid hormone, interleukin-6, leptin, albumin, and C-reactive protein concentration. Reduction ratios for middle molecules were hematocrit-corrected. Results: Baseline demographics, comorbidities, and biochemical parameters were comparable between groups. Both pre- and post-dialysis concentrations of solutes showed no significant differences between modalities. Reduction ratios of middle-molecule toxins showed no significant differences between SHF-HD and OL-HDF, including β₂-microglobulin (65.05% vs. 68.20%, p = 0.561), parathyroid hormone (66.32% vs. 63.57%, p = 0.803), interleukin-6 (23.62% vs. 21.20%, p = 0.213), and leptin (41.08% vs. 36.36%, p = 0.678). Albumin changes were minimal in both groups (− 0.40 ± 0.68 vs. −0.44 ± 1.32 g/L, p = 0.911), and C-reactive protein remained stable. Across all 30 treatment sessions, no intradialytic complications were observed. Conclusions: In this first Vietnamese evaluation, SHF-HD provided short-term removal of middle-molecule solutes comparable to OL-HDF, with minimal albumin loss, stable inflammatory markers, and no adverse events. Larger longitudinal studies are warranted to determine whether the observed biochemical equivalence translates into long-term clinical benefits. Super high-flux dialyzer online hemodiafiltration middle molecules β₂-microglobulin interleukin-6 hemodialysis Vietnam Figures Figure 1 Figure 2 Background Hemodialysis (HD) has progressed remarkably over the past five decades and has become the most widely used form of kidney replacement therapy worldwide. Ideally, treatment should remove small solutes such as urea and creatinine as well as middle and protein-bound molecules implicated in inflammation, oxidative stress, and cardiovascular disease, while maintaining intradialytic safety and comfort. The modern classification of uremic toxins highlights that many clinically relevant solutes - β₂-microglobulin (B2M), cytokines, and advanced glycation products - fall beyond the diffusion range of conventional membranes ( 1 ). International guidelines have therefore expanded dialysis adequacy from urea kinetics alone to include middle-molecule removal and patient-centered outcomes ( 2 ). OL-HDF was introduced to augment conventional high-flux HD through convective transport, enhancing the clearance of solutes above 15–25 kDa. Large multicenter trials, including the CONVINCE trial ( 3 ), the ESHOL study ( 4 ), and the recent individual-patient review and meta-analysis of randomized controlled trials ( 5 , 6 ), demonstrated consistent survival benefits for high-volume OL-HDF compared with high-flux HD, following a dose–response relationship with convective volume. A 2021 consensus by the ERA Dialysis Working Group concluded that HDF is associated with improved overall and cardiovascular survival, provided that convection volumes are sufficiently high ( 7 ). Despite its proven efficacy, routine implementation of OL-HDF is restricted in many low- and middle-income countries (LMICs) because of the need for ultrapure water, online substitution monitoring, and rigorous fluid-quality control ( 8 ). On the other hand, SHF dialyzers have emerged as a pragmatic dialysis method to extend the removal of middle-large molecules besides OL-HDF, or serve as an alternative option where OL-HDF cannot be universally implemented. These membranes widen pore-size distribution and optimize fiber geometry to enhance middle-molecule permeability with acceptable albumin loss. Randomized trials in Thailand have shown that SHF-HD can achieve short-term removal of protein-bound and middle-molecule toxins comparable to post-dilution high-volume OL-HDF ( 9 – 11 ). Observational data from Japan indicate that SHF-HD yields survival outcomes equivalent to OL-HDF when albumin leakage is matched ( 12 ), and the 2024 registry analyses from the Japanese Society for Dialysis Therapy provided robust epidemiological evidence that use of type V dialyzer – or super high-flux dialyzer – correlates with better survival ( 13 ). Similar trends are observed with newer medium-cutoff (MCO) membranes, which extend permeability to larger middle molecules while maintaining albumin safety ( 14 – 16 ). Together, these findings suggest that optimized diffusive clearance may narrow the performance gap with convective therapy. The consensus so far is that if SHF-HD can remove middle molecules to the same degree as HDF, it should in theory confer similar benefits, but this has not been definitively proven, especially in low-resource countries. In Vietnam, where dialysis resources are stretched and OL-HDF is not yet widespread, nephrologists have innovated within HD programs. Nguyen Huu Dung and colleagues adopted a practical strategy by incorporating hemoperfusion into routine HD, aiming to mimic the toxin removal benefit of OL-HDF ( 17 ). Their pilot study reported a noticeable reduction in cardiovascular mortality with the HD plus hemoperfusion approach, suggesting that better removal of middle molecules may translate into meaningful clinical benefit even when resources are limited. Removing solutes is only part of what makes a dialysis technique clinically meaningful. Any modality that claims to be “advanced” must also be judged on safety, tolerability, and overall biocompatibility, since intradialytic complications remain a practical concern for both clinicians and patients. SHF dialyzers, for instance, have not been shown to have higher rates of hypotension compared with other membranes. Albumin handling is another crucial issue. These super-permeable membranes still need to retain albumin effectively; otherwise, they risk exacerbating malnutrition and worsening long-term outcomes. High-volume HDF inevitably loses a few grams of albumin per session, which is generally acceptable but still worth monitoring. In a crossover randomized trial from Thailand, Tiranathanagul and colleagues found that patients tolerated both HDF and SHF-HD used alongside hemoperfusion, without differences in intradialytic events, reinforcing the idea that these modalities can be used safely when properly implemented ( 10 ). Serum albumin level remained unchanged after an 8-week study period, despite the observation of greater albumin in dialysate during combination of SHF and hemoperfusion dialysis than during HDF. Vietnam’s dialysis system reflects these global contrasts. Maintenance hemodialysis has expanded quickly across the country, yet the use of OL-HDF remains modest. Cost constraints, machine limitations, and the demanding requirements for water quality control all contribute to this slow uptake, leaving many centers reliant on conventional high-flux HD despite interest in more advanced modalities ( 8 , 18 – 20 ). Although SHF-HD has been used abroad for more than a decade, its introduction into Vietnam is recent, and it is quickly becoming a practical bridge toward more modern dialysis care. When looking across the international literature, a fairly consistent pattern emerges: both OL-HDF and SHF-HD tend to outperform conventional high-flux HD in clearing middle-molecule toxins. Yet nearly all of these data come from non-Vietnamese cohorts, which leaves several questions unanswered for local practice. No published study has evaluated SHF-HD in Vietnamese patients or directly compared it with OL-HDF in this context. That gap matters. Differences in diet, body size, and center-level treatment protocols could influence how well SHF membranes perform, and we do not know whether safety profiles regarding blood pressure stability, electrolyte handling, or albumin loss hold true in Vietnamese settings. These gaps create the small but important space that our study steps into. In short, Vietnam needs evidence generated within its own dialysis units to determine whether adopting SHF-HD is both feasible and beneficial. Our work contributes to that effort by examining SHF-HD in real-world Vietnamese patients and comparing its performance with OL-HDF for the first time. We hypothesized that SHF-HD would provide comparable short-term solute removal and safety profile to OL-HDF, thereby establishing a basis for future multicenter studies and guiding modality selection in resource-limited dialysis settings. Methods Study design This cross-sectional study was conducted at the Dialysis Unit of People’s Hospital 115, Ho Chi Minh City, Vietnam, between July and September 2025. The study was carried out under real-world clinical conditions at one of the largest tertiary renal centers in southern Vietnam, which manages a high-volume population of patients with end-stage kidney disease (ESKD). All participants received verbal and written explanations and provided written informed consent before enrollment. Ethical conduct followed the principles of the Declaration of Helsinki. The protocol was approved by the Institutional Review Board of People’s Hospital 115 (Approval No. 2497/QĐ-BVND115; registration CS/15/25/46). This study was not registered on ClinicalTrials.gov because it was not an interventional trial. Because this study was designed as a cross-sectional, exploratory analysis conducted within a fixed period and a defined dialysis population, no formal sample size calculation was performed. The number of participants was determined by the availability of eligible patients meeting inclusion criteria. Convenience sampling was applied among patients who met criteria and consented within the study timeframe. Participants A total of thirty ESKD patients undergoing HD were included, of that fifteen were treated with SHF-HD, and fifteen were treated with OL-HDF. Inclusion criteria : Adults aged ≥ 18 years with ESKD Receiving stable maintenance HD for at least three months with a thrice-weekly dialysis schedule. Prescription of either SHF-HD or post-dilution OL-HDF. Use an arteriovenous fistula, arteriovenous graft or tunneled cuffed catheter as vascular access. Exclusion criteria : Inadequate blood flow rate (< 250 mL/min for OL-HDF or 100 mL/24 albumin Presence of severe acute illness Outcome The primary outcome was the short-term efficacy of SHF-HD, assessed by reduction ratio (RR) of middle molecules after dialysis, compared with OL-HDF. Secondary outcomes comprised intradialytic complications and post-dialysis changes in serum albumin and CRP, representing treatment safety and biocompatibility, and were likewise compared with OL-HDF. Data collection and laboratory measurements In Vietnam, the indication of OL-HDF and HD using SHF dialyzers follows the criteria established by the Ministry of Health (Official Decision No. 3365/QĐ-BYT) ( 21 ). Patients are eligible for OL-HDF when presenting with any of the following conditions: hyperphosphatemia-related disorders, malnutrition, anemia with poor response to erythropoietin, uremic pruritus, infection-related complications, amyloidosis, cardiovascular or neurological complications related to ESKD, refractory hypertension, or in acute emergencies requiring cytokine removal when conventional hemodialysis is insufficient. The indication of hemodialysis using SHF dialyzers is similar to those for conventional low-flux and high-flux dialyzers. At the Dialysis Unit of People’s Hospital 115, treatment modality assignment adheres to both national and institutional policies. Patients are prescribed OL-HDF if they meet the national criteria. The use of SHF dialyzer is indicated for patients who meet the criteria for OL-HDF but are unable to undergo the procedure due to specific limitations such as: patient’s refusal, financial constraints, poor vascular access, or failure to achieve the sufficient Qb required for HDF. The decision to use SHF dialyzer therefore represents a technical and pragmatic institution, aimed at enhancing the middle molecule clearance in patients who cannot access OL-HDF, while maintaining the same clinical indication framework defined by the Vietnam’s Ministry of Health. Dialysis was performed using Fresenius dialysis machines (Fresenius Medical Care, Germany) model 4008S for SHF-HD and 5008S for OL-HDF, both were connected to a two-stage reverse osmosis system with DIASAFEⓇ plus filters (Fresenius Medical Care, Germany) to ensure water purity. SHF sessions used Elisio-17HX or Elisio-19HX dialyzers (Nipro Corporation, Japan). OL-HDF was delivered in post-dilution mode. All treatments used dialysate flow rate of 500 mililiters per minute and a treatment duration of 240 minutes dialysis session. All participants received bicarbonate-based dialysate, and dialyzers were single-use during sampling to eliminate reuse bias. For each patient, venous blood sample was drawn immediately before and after a single 240-minute dialysis session using a slow-flow technique following the 2015 KDOQI guideline ( 2 ) to prevent access-related fluctuations. Main biochemical molecules included B2M, interleukin-6 (IL6), parathyroid hormone (PTH), leptin, albumin, and CRP. The corrected reduction ratio was calculated following the hematocrit-corrected formula according to Daniel Schneditz et al. ( 22 ), applied for PTH, β2MG, IL6 and Leptin: $$\:RR\:\left(corrected,\:\%\right)=\left(1-\frac{\:{H}_{0}\left(1\:-\:{H}_{1}\right){C}_{1}}{{H}_{1}\left(1-\:{H}_{0}\right){C}_{0}}\right)*100\%$$ The reduction ratio of Urea and Phosphate using the following formula: $$\:RR\left(\%\right)=\left(1-\:\frac{{C}_{1}}{{C}_{0}}\right)*100\%$$ H 0 and C 0 represent for the hematocrit and solute concentration from the blood line of pre-dialyzer at time 0 minute. H 1 and C 1 denote the hematocrit and solute concentration from the blood line of pre-dialyzer at time 240 minutes. Statistical Analysis All data were analyzed using R Console v4.5.1, Microsoft Excel, and Word 2021 for data handling and reporting. Data normality was evaluated with the Shapiro-Wilk test. Continuous variables were presented as mean ± SD if normally distributed, or median [IQR] otherwise. Independent samples were compared using Welch’s t-test or Mann-Whitney U test, while paired data were analyzed with the paired t-test or Wilcoxon signed-rank test. We treated p values below 0.05 as statistically significant. To explore how the biochemical and clinical measures related to one another, we carried out a correlation analysis. Variables that followed a normal distribution were examined using Pearson coefficients, whereas those that did not were assessed with Spearman’s rank method. This approach allowed us to capture both linear relationships and those that were less strictly proportional. Correlation strength was interpreted as follows: very weak (|r| < 0.20), weak (0.20 ≤ |r| < 0.40), moderate (0.40 ≤ |r| < 0.60), strong (0.60 ≤ |r| < 0.80), and very strong (|r| ≥ 0.80). Results Baseline characteristics A total of 30 ESKD patients undergoing maintenance HD who met the study criteria were enrolled. Of these, 15 patients were treated with SHF-HD (SHF group) and 15 patients received OL-HDF (HDF group). Across the study population, 46.8% were male, and the median age was 48.0 [39.0–58.9] years. Blood pressure, BMI, and dialysis vintage have no statistically significant differences between the two groups. Hypertension and Diabetes Mellitus were the two most common comorbidities, accounting for 73.3% and 53.5% of all participants, respectively. Further details are provided in Table 1 . Table 1 Characteristic of study population Characteristic Total (n = 30) HDF (n = 15) SHF (n = 15) p -value Male, n (%) 14 (46.7) 8 (53.5) 6 (40.0) — Age (years, median [IQR]) 48.0 [39.0-58.9] 39.0 [36.5–51.5] 54.0 [45.0–61.0] 0.054 BMI (kg/m², median [IQR]) 22.5 [19.3–24.8] 22.8 [21.7–24.2] 19.8 [18.1–24.7] 0.290 Systolic BP (mmHg, median [IQR]) 125.0 [120.0-140.0] 120.0 [110.0-135.0] 130.0 [120.0-140.0] 0.169 Diastolic BP (mmHg, median [IQR]) 70.0 [62.5–80.0] 70.0 [60.0–80.0] 70.0 [70.0–80.0] 0.468 Dialysis vintage (months, median [IQR]) 37.0 [29.8–49.8] 43.2 [30.5–61.0] 37.0 [30.5–43.5] 0.253 AVF as vascular access, n (%) 29 (96.7) 15 (100) 14 (93.3) — Hypertension, n (%) 22 (73.3) 11 (73.3) 11 (73.3) — Diabetes, n (%) 16 (53.3) 7 (46.7) 9 (60.0) — CVD, n (%) 1 (3.3) 1 (6.7) 0 (0.0) — History of kidney transplantation, n (%) 1 (3.3) 1 (6.7) 0 (0.0) — Dialysis parameters and baseline biochemical markers The Qb in the HDF group was significantly higher than that in the SHF group (p = 0.008). Other treatment session parameters were similar between the two groups. At the baseline, there were no statistically significant differences in any laboratory marker concentrations between the HDF group and the SHF group. Details of all biochemical marker concentrations and dialysis parameters are presented in Table 2 . Table 2 Basline dialysis and laboratory parameters of study population Parameter HDF (n = 15) SHF (n = 15) p -value Blood flow rate (Qb, mL/min, mean ± SD) 270.00 ± 22.04 240.00 ± 23.60 0.008 Substitution flow rate (mL/min, mean ± SD) 71.60 ± 5.81 — — Convective volume (L/session, mean ± SD) 17.20 ± 1.44 — — UF volume (L, median [IQR]) 3.00 [3.00–4.00] 4.00 [2.75–4.00] 0.692 Kt/V (median [IQR]) 1.43 [1.33–1.60] 1.37 [1.34–1.48] 0.836 Hemoglobin (Hb, g/dL, mean ± SD) 10.78 ± 1.60 10.72 ± 1.22 0.909 Urea (mmol/L, mean ± SD) 30.82 ± 7.60 34.11 ± 7.52 0.243 Creatinine (µmol/L, mean ± SD) 1123.11 ± 264.01 1209.02 ± 308.95 0.420 Albumin (g/L, mean ± SD) 36.13 ± 2.04 37.18 ± 1.59 0.128 CRP (mg/L, mean ± SD) 10.86 ± 2.52 11.06 ± 3.13 0.843 Calcium (Ca, mmol/L, median [IQR]) 2.5 [2.2–2.5] 2.4 [2.2–2.6] 0.917 Phospho (P, mmol/L, median [IQR]) 2.50 [2.2–2.8] 2.11 [1.9–2.4] 0.078 PTH (pg/mL, median [IQR]) 1.0 [0.6–1.5] 1.1 [0.7–1.8] 0.431 B2M (mg/L, median [IQR]) 23.2 [22.1–25.5] 22.9 [21.8–25.7] 0.967 IL6 (pg/mL, median [IQR]) 10.3 [7.3–11.8] 9.2 [6.3–10.4] 0.340 Leptin (ng/mL, median [IQR]) 14.3 [3.8–22.5] 5.9 [3.2–16.4] 0.443 The heatmap illustrates the correlations among pre-dialysis biochemical markers. B2M showed a positive correlation with both IL6 and leptin, with moderate correlation strength (r = 0.51, p = 0.004; and r = 0.41, p = 0.025, respectively). IL6 also demonstrated a positive, moderate correlation with CRP (r = 0.5, p = 0.005), and leptin also showed the a moderate correlation with calcium (r = 0.43, p = 0.017). Other marker pairs showed only weak and non-significant correlation. Further information on correlation matrix is shown in Fig. 1 . Dialysis Efficacy Table 3 Post-dialysis laboratory parameters Marker HDF (n = 15) SHF (n = 15) p -value Hemoglobin (Hb, g/dL, mean ± SD) 11.27 ± 1.73 11.53 ± 1.97 0.704 Urea (mmol/L, mean ± SD) 8.78 ± 2.91 9.88 ± 3.48 0.356 Creatinine (µmol/L, mean ± SD) 465.17 ± 131.37 465.59 ± 157.87 0.994 Albumin (g/L, mean ± SD) 35.69 ± 2.07 36.78 ± 1.57 0.115 CRP (mg/L, mean ± SD) 11.02 ± 2.18 10.58 ± 2.30 0.601 Calcium (Ca, mmol/L, median [IQR]) 2.84 [2.59–3.17] 2.89 [2.74–2.98] 1.000 Phospho (P, mmol/L, median [IQR]) 1.61 [0.94–1.79] 1.12 [0.85–1.41] 0.290 PTH (pg/mL, median [IQR]) 0.44 [0.15–0.62] 0.35 [0.13–1.11] 0.678 B2M (mg/L, median [IQR]) 8.72 [6.89–9.14] 7.82 [6.77–9.31] 0.934 IL6 (pg/mL, median [IQR]) 7.72 [6.51–9.41] 6.11 [4.72–7.87] 0.229 Leptin (ng/mL, median [IQR]) 7.04 [1.88–10.73] 3.07 [1.62–10.11] 0.561 Regarding the clearance of middle-molecular-weight uremic toxins and cytokines after a single dialysis session, both modalities demonstrated equivalent performance. The median RRs of all evaluated middle molecules were not significantly different in the SHF group compared with the HDF group, including phospho (51.71% [31.91–53.75] vs. 39.52% [30.02–58.86]; p = 0.901), PTH (66.32% [34.87–82.56] vs. 63.57% [49.41–79.22]; p = 0.803), B2M (65.05% [61.61–68.39] vs. 68.20% [63.86–67.68]; p = 0.561), leptin (41.08% [34.25–49.39] vs. 36.36% [34.25–49.39]; p = 0.678), and IL6 (23.62% [20.26–30.72] vs. 21.20% [14.76–24.90]; p = 0.213), as illustrated in Fig. 1 . Safety profile In the SHF group, the mean change in serum albumin and CRP after treatment was − 0.40 ± 0.68 g/L and − 0.48 ± 2.63 mg/L, respectively. In comparison to the HDF group, there were no significant differences in either albumin (-0.44 ± 1.32 g/L, p = 0.911) or CRP (0.16 ± 2.32 mg/L, p = 0.356), as illustrated in Fig. 2 . Throughout all thirty treatment sessions, there were no intradialytic complications in either patient group, including intradialytic hemodynamic instability, cardiac arrhythmias, dialyzer allergic reactions, dialysis disequilibrium syndrome, gastrointestinal syndromes, muscle cramps, and dialyzer rupture. Discussion Existing evidence on SHF or expanded HD largely originates from high-income countries (Japan, Europe) or upper-middle-income settings such as Thailand. To our knowledge, this study is the first to investigate the use of SHF dialyzers in Vietnam, and one of the first from any LMICs, to evaluate the efficacy and safety profile compared with OL-HDF. In this light, it is noteworthy that the SHF dialyzer in our study achieved middle molecules reduction comparable to OL-HDF. The primary endpoint, B2M, cytokines, and peptide hormones reduction did not differ significantly between modalities, as expected in four-hour treatment with both groups. Albumin declined insignificantly following SHF-HD and nonsignificantly to OL-HDF, and CRP did not alter in either group. None of the acute safety events were observed. Our findings are in line with prior controlled studies in which SHF-HD achieved comparable clearance of solutes and middle molecules to high-volume OL-HDF, without acute safety concerns ( 9 , 11 , 12 , 16 ). B2M is a surrogate for middle molecules and is the basis for dialyzer flux classification in Japan. Over 90% of Japanese HD patients have been treated with type IV/V high-performance membranes for over a decade, which has been associated with lower B2M levels and a decline in amyloidosis complications. Notably, a 2024 Japanese Society for Dialysis Therapy registry study found that the use of type V dialyzers with B2M clearance ≥ 70 mL/min was independently associated with improved 2-year survival, with adjusted HR 0.86 (95% CI, 0.80–0.92, p < 0.0001) vs. standard HF membranes ( 13 ). For instance, recent studies in Thailand demonstrated that thrice-weekly SHF-HD eliminates middle molecules and protein-bound toxins as effectively as post-dilution OL-HDF. In one such trial, RRs for indoxyl sulfate and B2M in the SHF-HD group were statistically indistinguishable from those on high-volume OL-HDF with the convective volume achieved 24–26 liters per session ( 9 ). We also measured IL6 and leptin as markers of larger uremic toxins. Both showed a 20%-40% reduction per session with no differences between modalities. These larger cytokines and adipokines are poorly removed by diffusion alone, but HDF can remove some through convection. The efficacy is probably supported by the membrane properties of SHF dialyzers. Larger and more uniformly distributed pores increase the sieving coefficient for middle molecules while maintaining a cutoff below albumin’s molecular size. In the dialyzer, the secondary flows and Taylor dispersion have contributed to the amplification of the mass transfer beyond pure diffusion at higher rates of blood flow, which is sometimes called internal convection. All these phenomena, along with the long fibres and the optimised packing of fibres, can increase the transport of larger solutes, which can be transported without the presence of a substitution fluid supplied externally. Some studies even suggest that “expanded HD” with novel membranes might exceed OL-HDF in removing the largest solutes: for example, certain SHF or MCO dialyzers have shown higher clearance of cytokines than OL-HDF ( 11 ). Another important dimension is biocompatibility and inflammation. Persistent low-grade inflammation in dialysis patients has long been tied to their high burden of cardiovascular disease. OL-HDF might attenuate this inflammation over time by two mechanisms: the requirement for ultrapure dialysate reduces exposure to endotoxins, and convective transport can remove some cytokines. In the short term, however, we observed no significant difference in inflammatory markers between SHF-HD and OL-HDF. This suggests that both modalities were similarly biocompatible in our setting with real-world dialysis fluid quality in both arms and modern synthetic membranes. Panichi et al. observed that switching from standard HD to HDF led to significant reductions in CRP and IL6 levels over 4 months, whereas reverting to conventional HD caused these markers to rise again ( 23 ). In our comparison, we did not detect any short-term difference in inflammatory markers between SHF-HD and OL-HDF, which is reasonable given that acute inflammatory shifts rarely emerge within a single session. Even so, membrane design may matter more than the modality alone. Recent work with vitamin E–coated SHF dialyzers is a good example. In a randomized study, the vitamin E-coated membrane achieved middle-molecule clearance similar as an MCO dialyzer, yet it also lowered oxidative and inflammatory biomarkers ( 24 ). Findings like these hint that incremental refinements in membrane biocompatibility might influence the inflammatory response, although whether these effects persist or translate into clinical benefit remains uncertain. Across the 30 sessions we followed, no intradialytic complications occurred, not even the small issues that sometimes surface when membranes are changed. This pattern is similar to the experience reported by Tiranathanagul and colleagues in Thailand, where patients tolerated SHF-HD just as well as OL-HDF and showed no rise in hypotension or other symptoms over their eight-week crossover periods ( 10 ). Taken together, these findings support the view that well-designed high-flux membranes can offer HDF-like clearance while remaining safe and comfortable for patients in the short term, although longer-term effects still need clearer evidence. Our study has several limitations. The most obvious is the small sample. With only fifteen patients in each group, our ability to detect very small differences was inevitably limited. Even so, the overlap in almost every measured parameter was striking, and that consistency gives at least some confidence that the patterns we observed were not simply noise. Another limitation involves the blood-flow rates. Both groups operated at lower Qb than what is typically reported in larger trials ( 9 , 11 , 16 ), sometimes because of protocol constraints and sometimes because of patient factors that restricted achievable flow. This makes comparison with other studies a little tricky, and it raises the possibility that some performance differences could be masked by lower baseline flow. Lower blood-flow rates often limit the convective volume that HDF can generate, and this can blunt the clinical advantages it would otherwise offer. That concern was relevant in our setting. Although the HDF group in our study operated at a higher Qb than the SHF group, about 270 compared with 240 mL per minute, the SHF treatments still matched HDF in terms of toxin removal. This outcome is striking because, at least in theory, the lower Qb should have placed SHF-HD at a disadvantage. Yet we did not see any meaningful reduction in clearance. It raises the possibility that membrane performance in SHF-HD may compensate for modest flow limitations, although we cannot say how far this effect extends beyond the short-term observations we captured. Third, our study did not measure albumin concentration in the dialysate or ultrafiltrate, so we could not directly quantify albumin loss through the dialyzer. We did observe that serum albumin levels after treatment were unchanged in both groups, which is an encouraging indirect indicator that albumin loss was minimal. Furthermore, the mean albumin decreases during SHF-HD (−0.40 g/L) was virtually identical to that during OL-HDF (−0.44 g/L). In OL-HDF, a small amount of albumin, typically 1–3 g per session, is known to be lost into the discarded ultrafiltration fluid. It stands to reason that SHF dialyzers might allow a similar scale of loss. Evidence from other studies supports this: a crossover trial by Tiranathanagul et al. noted slightly higher albumin leakage into dialysate with SHF-HD compared to HDF, but importantly no significant drop in patients’ serum albumin over 8 weeks of treatment ( 10 ). Likewise, long-term observational work from Thailand found that 15 months on SHF-HD did not lead to hypoalbuminemia; mean serum albumin remained approximately 4.0 g/dL, unchanged from baseline ( 9 ). Still, we acknowledge that without direct measurement, we cannot definitively state the grams of albumin lost in SHF-HD. And finally, because our work was limited to a short observational window, we were not able to examine outcomes that unfold slowly, such as survival, cardiovascular events, or changes in quality of life. That is a real constraint, and it leaves open questions that a longer study would be better suited to answer. Even so, it does not undermine the central pattern we observed: over the short term, SHF-HD performed on par with OL-HDF in both solute clearance and safety. If anything, these limitations simply point toward the next steps, inviting larger and longer studies to determine whether the short-term equivalence we found holds up when patients are followed over months or years. These results are best interpreted within the context of routine dialysis practice in settings where OL-HDF is not yet widely available, as is still the case in many centers in Vietnam. Conventional high-flux HD remains highly effective for the removal of small solutes, yet its limited capacity for middle-molecule clearance continues to be a concern given the established links between these toxins and complications such as dialysis-related amyloidosis, chronic inflammation, and cardiovascular disease. OL-HDF offers a more efficient solution for this problem, but its broader implementation is constrained by the need for ultrapure water systems, compatible machines, and higher operational costs. Against this background, SHF membranes represent a technically simpler approach that can be readily applied on standard HD platforms and may enhance middle-molecule removal under everyday clinical conditions. From a physiological standpoint, our findings are consistent with the growing body of work supporting the concept of “expanded HD,” in which enhanced diffusive transport and internal convection achieved by SHF or MCO membranes can approach the biochemical clearance profile of post-dilution OL-HDF. Nevertheless, the present study was designed to capture only short-term biochemical and safety outcomes, and any inference beyond acute solute removal would go beyond what our data can reliably support. While SHF-HD may therefore be considered a pragmatic option in centers where OL-HDF cannot be routinely implemented, its influence on longer-term outcomes such as survival, cardiovascular events, or hospitalization cannot be addressed by this study. Importantly, we observed no acute safety concerns, including hemodynamic instability or meaningful albumin loss, which supports the short-term tolerability of SHF-HD in a real-world clinical setting. Whether this favorable short-term biochemical and safety profile translates into sustained clinical benefit will require confirmation in larger studies with longitudinal follow-up. Conclusions In this cross-sectional study conducted under routine clinical conditions in Vietnam, SHF-HD achieved short-term removal of small and middle-molecule solutes comparable to OL-HDF, with minimal changes in serum albumin, stable inflammatory markers, and no intradialytic adverse events. These findings indicate that, in the short term, SHF-HD can provide a biochemical performance similar to OL-HDF in everyday practice. However, given the limited sample size and single-session design, no conclusions can be drawn regarding long-term clinical outcomes. Larger, prospective studies with extended follow-up are needed to clarify the sustained efficacy and safety of SHF-HD in comparison with OL-HDF. Abbreviations AVF Arteriovenous fistula B2M β₂-microglobulin BMI Body mass index BP Blood pressure CRP C-reactive protein CVD Cardiovascular diseases ESKD End-stage kidney disease HD Hemodialysis HDF Hemodiafiltration IL6 Interleukin-6 KDOQI Kidney Disease Outcomes Quality Initiative Kt/V Dialysis clearance normalized to volume distribution of urea LMICs Low- and middle-income countries MCO Medium cut-off (membrane) OL-HDF Online hemodiafiltration PTH Parathyroid hormone Qb Blood flow rate RR Reduction ratio SHF Super high-flux SHF-HD Hemodialysis using super high-flux dialyzer UF Ultrafiltration Declarations Ethics approval and consent to participate: All participants received verbal and written explanations and provided written informed consent before enrollment. Ethical conduct followed the principles of the Declaration of Helsinki. The protocol was approved by the Institutional Review Board of People’s Hospital 115 (Approval No. 2497/QĐ-BVND115; registration CS/15/25/46). This study was not registered on ClinicalTrials.gov because it was not an interventional trial. Consent for publication: All authors have reviewed and approved the final manuscript and consent to its publication. This manuscript does not contain any individual person’s identifiable data. Availability of data and materials: Due to institutional policies and patient confidentiality regulations at People’s Hospital 115, the datasets generated and/or analyzed during the current study are not publicly available. Data may be made available upon reasonable request and with approval from the hospital’s Institutional Review Board and corresponding author. Competing interests: Thanh Cong Nguyen received financial support from Nipro Corporation (Japan) as speaker honoraria to present the findings of this study at the 5th National Dialysis Conference (2025) of the Vietnam Dialysis Association. All other authors declare no competing interests. Funding: This study was partially supported by Nipro Corporation (Japan), including provision of dialyzers for patients and partial financial support for laboratory testing and research materials. The funder had no role in study design, patient recruitment, dialysis procedures, laboratory measurements, data analysis, interpretation of findings, manuscript writing, or the decision to submit the article for publication. The authors are fully responsible for the content and editorial decisions. The funder had no influence on scientific conclusions or publication decisions. Authors’ contributions: Thanh Cong Nguyen conceived and designed the study, supervised dialysis procedures, coordinated data and laboratory work, performed the analyses, interpreted the results, prepared and reviewed the manuscript for scientific accuracy as corresponding author. Van Song Tran and Hong Vu Le Thi provided clinical supervision, project management, and contributed to manuscript review. Hoai Vy Nguyen Thi assisted with patient recruitment, data collection, sample handling, monitoring of dialysis sessions, and manuscript editing. Phu Quoc Nguyen supported data collection, helped with statistical analysis, and reviewed the manuscript for technical accuracy. Ngoc Tran Le Nguyen assisted with patient recruitment, data collection, laboratory coordination. All authors read and approved the final manuscript and meet the ICMJE authorship criteria. Acknowledgements: We are deeply grateful to Assoc. Prof. Le Viet Thang, MD, PhD (Division of Nephrology and Dialysis, Vietnam Military Medical University), whose insightful comments and critical suggestions strengthened the scientific quality of this manuscript. We also thank Phung Huy Hoang, MD (Department of Cardiac Arrhythmias, People’s Hospital 115) and Phan Ngoc Phuong Thao, MD (Division of Infectious Diseases, Pham Ngoc Thach University of Medicine), for their technical support during data analysis. We acknowledge Pham Hoang Lam, along with Nguyen Ba Hai, Nguyen Truc, Nguyen Manh Hung, Nguyen Van Thao, Phan Thanh Nam, and all staff from the Nephrology and Transplant Immunology Department, the hospital laboratory teams, and collaborating units for their continued assistance during the project. Finally, we thank Nipro Corporation (Japan) for providing partial financial and material support for this study. References Rosner MH, Reis T, Husain-Syed F, Vanholder R, Hutchison C, Stenvinkel P, et al. Classification of Uremic Toxins and Their Role in Kidney Failure. Clin J Am Soc Nephrol CJASN. 2021;16(12):1918–28. Daugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Suri RS, et al. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis. 2015;66(5):884–930. Blankestijn PJ, Vernooij RWM, Hockham C, Strippoli GFM, Canaud B, Hegbrant J, et al. Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure. N Engl J Med. 2023;389(8):700–9. Maduell F, Moreso F, Pons M, Ramos R, Mora-Macià J, Carreras J, et al. High-Efficiency Postdilution Online Hemodiafiltration Reduces All-Cause Mortality in Hemodialysis Patients. J Am Soc Nephrol. 2013;24(3):487. Vernooij RWM, Hockham C, Strippoli G, Green S, Hegbrant J, Davenport A, et al. Haemodiafiltration versus haemodialysis for kidney failure: an individual patient data meta-analysis of randomised controlled trials. The Lancet. 2024;404(10464):1742–9. Canaud B, Strippoli G, Davenport A. High-Volume Hemodiafiltration Versus High-Flux Hemodialysis: A Narrative Review for the Clinician. J Clin Med. 2025;14(8):2614. Battaglia Y, Shroff R, Meijers B, Nistor I, Alfano G, Franssen C, et al. Haemodiafiltration versus high-flux haemodialysis—a Consensus Statement from the EuDial Working Group of the ERA. Nephrol Dial Transplant. 2025;40(8):1590–614. Bello AK, Okpechi IG, Levin A, Ye F, Saad S, Zaidi D. ISN–Global Kidney Health Atlas: A report by the International Society of Nephrology: An Assessment of Global Kidney Health Care Status focussing on Capacity, Availability, Accessibility, Affordability and Outcomes of Kidney Disease. [Internet]. International Society of Nephrology; 2023. Available from: Thammathiwat T, Tiranathanagul K, Limjariyakul M, Chariyavilaskul P, Takkavatakarn K, Susantitaphong P, et al. Super high-flux hemodialysis provides comparable effectiveness with high‐volume postdilution online hemodiafiltration in removing protein‐bound and middle‐molecule uremic toxins: A prospective cross‐over randomized controlled trial. Ther Apher Dial. 2021;25(1):73–81. Tiranathanagul K, Khemnark N, Takkavatakarn K, Limjariyakul M, Mahatanan N, Chariyavilaskul P, et al. Comparative efficacy between hemodialysis using super high-flux dialyzer with hemoperfusion and high-volume postdilution online hemodiafiltration in removing protein bound and middle molecule uremic toxins: A cross-over randomized controlled trial. Artif Organs. 2022;46(5):775–85. Lukkanalikitkul E, Kidkaem H, Phonrat M, Prathompong P, Anutrakulchai S. A randomized trial comparing medium cut-off membrane dialyzers with online hemodiafiltration for uremic toxins clearance in hemodialysis patients. Sci Rep. 2025;15(1):5467. Okada K, Tashiro M, Michiwaki H, Inoue T, Shima H, Minakuchi J, et al. Comparison of survival for super high-flux hemodialysis (SHF-HD) with high albumin leakage versus online hemodiafiltration or SHF-HD with low albumin leakage: the SUPERB study. Ren Replace Ther. 2023 July 6;9(1):32. Abe M, Kikuchi K, Kanda E, Wada A, Nakai S, Hanafusa N. Super high-flux dialyzers improve survival in patients on hemodialysis: a cohort study of the Japanese Society for Dialysis Therapy (JSDT) Renal Data Registry. Ren Replace Ther. 2024;10(1):50. Weiner DE, Falzon L, Skoufos L, Bernardo A, Beck W, Xiao M, et al. Efficacy and Safety of Expanded Hemodialysis with the Theranova 400 Dialyzer: A Randomized Controlled Trial. Clin J Am Soc Nephrol. 2020 Sept;15(9):1310. Lim JH, Park Y, Yook JM, Choi SY, Jung HY, Choi JY, et al. Randomized controlled trial of medium cut-off versus high-flux dialyzers on quality of life outcomes in maintenance hemodialysis patients. Sci Rep. 2020;10(1):7780. Belmouaz M, Goussard G, Joly F, Sibille A, Martin C, Betous T, et al. Comparison of High-Flux, Super High-Flux, Medium Cut-Off Hemodialysis and Online Hemodiafiltration on the Removal of Uremic Toxins. Blood Purif. 2023;52(3):309–18. Nguyen Huu D, Dao Bui Quy Q, Nguyen Thi Thu H, Phan The C, Nguyen Thi Hong Q, Nguyen Duc L, et al. A Combination of Hemodialysis with Hemoperfusion Helped to Reduce the Cardiovascular-Related Mortality Rate after a 3-Year Follow-Up: A Pilot Study in Vietnam. Blood Purif. 2020 July 2;50(1):65–72. Hyodo T, Fukagawa M, Hirawa N, Isaka Y, Nakamoto H, Van Bui P, et al. Present status of renal replacement therapy in Asian countries as of 2017: Vietnam, Myanmar, and Cambodia. Ren Replace Ther. 2020;6(1):65. Pham Van B, Vo Duc C. Global Dialysis Perspective: Vietnam. Kidney360. 2020 July 21;1(9):974–6. Tran PQ, Nguyen NTY, Nguyen B, Bui QTH. Quality of life assessment in patients on chronic dialysis: Comparison between haemodialysis and peritoneal dialysis at a national hospital in Vietnam. Trop Med Int Health. 2022;27(2):199–206. Văn Thuấn Trần, Anh Đức Hà, Gia Tuyển Đỗ, Tam Võ, Việt Thắng Lê, et al. Guideline on Technical Procedures in Nephrology and Urology - Volume 1.1. Vietnam’s Ministry of Health; 2025. Schneditz D, Putz-Bankuti C, Ribitsch W, Schilcher G. Correction of plasma concentrations for effects of hemoconcentration or hemodilution. ASAIO J Am Soc Artif Intern Organs 1992. 2012;58(2):160–2. Panichi V, Manca-Rizza G, Paoletti S, Taccola D, Consani C, Filippi C, et al. Effects on inflammatory and nutritional markers of haemodiafiltration with online regeneration of ultrafiltrate (HFR) vs online haemodiafiltration: a cross-over randomized multicentre trial. Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc - Eur Ren Assoc. 2006;21(3):756–62. Belmouaz M, Cogne E, Joly F, Duthe F, Desport E, Martin C, et al. Effects of super high-flux vitamin E–coated and medium cut-off dialyzers on uremic toxins removal and biocompatibility: the E-FLUX randomized controlled study. Clin Kidney J. 2025;18(5): sfaf106. Additional Declarations Competing interest reported. - Thanh Cong Nguyen received financial support from Nipro Corporation (Japan) as speaker honoraria to present the findings of this study at the 5th National Dialysis Conference (2025) of the Vietnam Dialysis Association. All other authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8307919","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558889796,"identity":"749bd705-8df2-4569-ac7a-b9a7ad935a0c","order_by":0,"name":"Thanh Cong 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07:12:55","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115673,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8307919/v1/4e07381e96369b00f7d14016.html"},{"id":98377383,"identity":"2d2593d5-c626-4c12-a1aa-73d50a7bd476","added_by":"auto","created_at":"2025-12-17 07:12:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69267,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of solutes clearance between SHF group and HDF group\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSafety profile\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8307919/v1/74889a06ebb549c1f95ad283.png"},{"id":98439262,"identity":"9f340a1d-cfbb-4689-9ff5-f016bb6ff38d","added_by":"auto","created_at":"2025-12-17 17:01:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57437,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of changes in serum albumin and CRP concentrations between SHF and HDF groups\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8307919/v1/fff945fd19f3474c0ad5051d.png"},{"id":100040226,"identity":"83bd6fee-964b-492b-ac56-6ffd7b2cb70a","added_by":"auto","created_at":"2026-01-12 10:54:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":818470,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8307919/v1/1dd2277a-a11f-43c2-a2e5-3399c77dd3e1.pdf"}],"financialInterests":"Competing interest reported. -\tThanh Cong Nguyen received financial support from Nipro Corporation (Japan) as speaker honoraria to present the findings of this study at the 5th National Dialysis Conference (2025) of the Vietnam Dialysis Association.\n-\tAll other authors declare no competing interests.","formattedTitle":"Short-term efficacy and safety of hemodialysis using super high-flux dialyzers compared with online hemodiafiltration: a cross-sectional study in Vietnam","fulltext":[{"header":"Background","content":"\u003cp\u003eHemodialysis (HD) has progressed remarkably over the past five decades and has become the most widely used form of kidney replacement therapy worldwide. Ideally, treatment should remove small solutes such as urea and creatinine as well as middle and protein-bound molecules implicated in inflammation, oxidative stress, and cardiovascular disease, while maintaining intradialytic safety and comfort. The modern classification of uremic toxins highlights that many clinically relevant solutes - β₂-microglobulin (B2M), cytokines, and advanced glycation products - fall beyond the diffusion range of conventional membranes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). International guidelines have therefore expanded dialysis adequacy from urea kinetics alone to include middle-molecule removal and patient-centered outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOL-HDF was introduced to augment conventional high-flux HD through convective transport, enhancing the clearance of solutes above 15\u0026ndash;25 kDa. Large multicenter trials, including the CONVINCE trial (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), the ESHOL study (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and the recent individual-patient review and meta-analysis of randomized controlled trials (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), demonstrated consistent survival benefits for high-volume OL-HDF compared with high-flux HD, following a dose\u0026ndash;response relationship with convective volume. A 2021 consensus by the ERA Dialysis Working Group concluded that HDF is associated with improved overall and cardiovascular survival, provided that convection volumes are sufficiently high (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Despite its proven efficacy, routine implementation of OL-HDF is restricted in many low- and middle-income countries (LMICs) because of the need for ultrapure water, online substitution monitoring, and rigorous fluid-quality control (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, SHF dialyzers have emerged as a pragmatic dialysis method to extend the removal of middle-large molecules besides OL-HDF, or serve as an alternative option where OL-HDF cannot be universally implemented. These membranes widen pore-size distribution and optimize fiber geometry to enhance middle-molecule permeability with acceptable albumin loss. Randomized trials in Thailand have shown that SHF-HD can achieve short-term removal of protein-bound and middle-molecule toxins comparable to post-dilution high-volume OL-HDF (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Observational data from Japan indicate that SHF-HD yields survival outcomes equivalent to OL-HDF when albumin leakage is matched (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and the 2024 registry analyses from the Japanese Society for Dialysis Therapy provided robust epidemiological evidence that use of type V dialyzer \u0026ndash; or super high-flux dialyzer \u0026ndash; correlates with better survival (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Similar trends are observed with newer medium-cutoff (MCO) membranes, which extend permeability to larger middle molecules while maintaining albumin safety (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Together, these findings suggest that optimized diffusive clearance may narrow the performance gap with convective therapy. The consensus so far is that if SHF-HD can remove middle molecules to the same degree as HDF, it should in theory confer similar benefits, but this has not been definitively proven, especially in low-resource countries. In Vietnam, where dialysis resources are stretched and OL-HDF is not yet widespread, nephrologists have innovated within HD programs. Nguyen Huu Dung and colleagues adopted a practical strategy by incorporating hemoperfusion into routine HD, aiming to mimic the toxin removal benefit of OL-HDF (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Their pilot study reported a noticeable reduction in cardiovascular mortality with the HD plus hemoperfusion approach, suggesting that better removal of middle molecules may translate into meaningful clinical benefit even when resources are limited. Removing solutes is only part of what makes a dialysis technique clinically meaningful. Any modality that claims to be \u0026ldquo;advanced\u0026rdquo; must also be judged on safety, tolerability, and overall biocompatibility, since intradialytic complications remain a practical concern for both clinicians and patients. SHF dialyzers, for instance, have not been shown to have higher rates of hypotension compared with other membranes. Albumin handling is another crucial issue. These super-permeable membranes still need to retain albumin effectively; otherwise, they risk exacerbating malnutrition and worsening long-term outcomes. High-volume HDF inevitably loses a few grams of albumin per session, which is generally acceptable but still worth monitoring. In a crossover randomized trial from Thailand, Tiranathanagul and colleagues found that patients tolerated both HDF and SHF-HD used alongside hemoperfusion, without differences in intradialytic events, reinforcing the idea that these modalities can be used safely when properly implemented (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Serum albumin level remained unchanged after an 8-week study period, despite the observation of greater albumin in dialysate during combination of SHF and hemoperfusion dialysis than during HDF.\u003c/p\u003e \u003cp\u003eVietnam\u0026rsquo;s dialysis system reflects these global contrasts. Maintenance hemodialysis has expanded quickly across the country, yet the use of OL-HDF remains modest. Cost constraints, machine limitations, and the demanding requirements for water quality control all contribute to this slow uptake, leaving many centers reliant on conventional high-flux HD despite interest in more advanced modalities (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Although SHF-HD has been used abroad for more than a decade, its introduction into Vietnam is recent, and it is quickly becoming a practical bridge toward more modern dialysis care. When looking across the international literature, a fairly consistent pattern emerges: both OL-HDF and SHF-HD tend to outperform conventional high-flux HD in clearing middle-molecule toxins. Yet nearly all of these data come from non-Vietnamese cohorts, which leaves several questions unanswered for local practice. No published study has evaluated SHF-HD in Vietnamese patients or directly compared it with OL-HDF in this context. That gap matters. Differences in diet, body size, and center-level treatment protocols could influence how well SHF membranes perform, and we do not know whether safety profiles regarding blood pressure stability, electrolyte handling, or albumin loss hold true in Vietnamese settings. These gaps create the small but important space that our study steps into. In short, Vietnam needs evidence generated within its own dialysis units to determine whether adopting SHF-HD is both feasible and beneficial. Our work contributes to that effort by examining SHF-HD in real-world Vietnamese patients and comparing its performance with OL-HDF for the first time. We hypothesized that SHF-HD would provide comparable short-term solute removal and safety profile to OL-HDF, thereby establishing a basis for future multicenter studies and guiding modality selection in resource-limited dialysis settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted at the Dialysis Unit of People\u0026rsquo;s Hospital 115, Ho Chi Minh City, Vietnam, between July and September 2025. The study was carried out under real-world clinical conditions at one of the largest tertiary renal centers in southern Vietnam, which manages a high-volume population of patients with end-stage kidney disease (ESKD).\u003c/p\u003e \u003cp\u003e All participants received verbal and written explanations and provided written informed consent before enrollment. Ethical conduct followed the principles of the Declaration of Helsinki. The protocol was approved by the Institutional Review Board of People\u0026rsquo;s Hospital 115 (Approval No. 2497/QĐ-BVND115; registration CS/15/25/46). This study was not registered on ClinicalTrials.gov because it was not an interventional trial.\u003c/p\u003e \u003cp\u003eBecause this study was designed as a cross-sectional, exploratory analysis conducted within a fixed period and a defined dialysis population, no formal sample size calculation was performed. The number of participants was determined by the availability of eligible patients meeting inclusion criteria. Convenience sampling was applied among patients who met criteria and consented within the study timeframe.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eA total of thirty ESKD patients undergoing HD were included, of that fifteen were treated with SHF-HD, and fifteen were treated with OL-HDF.\u003c/p\u003e \u003cp\u003e \u003cem\u003eInclusion criteria\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAdults aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years with ESKD\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReceiving stable maintenance HD for at least three months with a thrice-weekly dialysis schedule.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrescription of either SHF-HD or post-dilution OL-HDF.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUse an arteriovenous fistula, arteriovenous graft or tunneled cuffed catheter as vascular access.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eExclusion criteria\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInadequate blood flow rate (\u0026lt;\u0026thinsp;250 mL/min for OL-HDF or \u0026lt;\u0026thinsp;200 mL/min for SHF-HD)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eResidual urine volume\u0026thinsp;\u0026gt;\u0026thinsp;100 mL/24 albumin\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePresence of severe acute illness\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eOutcome\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the short-term efficacy of SHF-HD, assessed by reduction ratio (RR) of middle molecules after dialysis, compared with OL-HDF. Secondary outcomes comprised intradialytic complications and post-dialysis changes in serum albumin and CRP, representing treatment safety and biocompatibility, and were likewise compared with OL-HDF.\u003c/p\u003e\n\u003ch3\u003eData collection and laboratory measurements\u003c/h3\u003e\n\u003cp\u003eIn Vietnam, the indication of OL-HDF and HD using SHF dialyzers follows the criteria established by the Ministry of Health (Official Decision No. 3365/QĐ-BYT) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Patients are eligible for OL-HDF when presenting with any of the following conditions: hyperphosphatemia-related disorders, malnutrition, anemia with poor response to erythropoietin, uremic pruritus, infection-related complications, amyloidosis, cardiovascular or neurological complications related to ESKD, refractory hypertension, or in acute emergencies requiring cytokine removal when conventional hemodialysis is insufficient. The indication of hemodialysis using SHF dialyzers is similar to those for conventional low-flux and high-flux dialyzers.\u003c/p\u003e \u003cp\u003eAt the Dialysis Unit of People\u0026rsquo;s Hospital 115, treatment modality assignment adheres to both national and institutional policies. Patients are prescribed OL-HDF if they meet the national criteria. The use of SHF dialyzer is indicated for patients who meet the criteria for OL-HDF but are unable to undergo the procedure due to specific limitations such as: patient\u0026rsquo;s refusal, financial constraints, poor vascular access, or failure to achieve the sufficient Qb required for HDF. The decision to use SHF dialyzer therefore represents a technical and pragmatic institution, aimed at enhancing the middle molecule clearance in patients who cannot access OL-HDF, while maintaining the same clinical indication framework defined by the Vietnam\u0026rsquo;s Ministry of Health.\u003c/p\u003e \u003cp\u003eDialysis was performed using Fresenius dialysis machines (Fresenius Medical Care, Germany) model 4008S for SHF-HD and 5008S for OL-HDF, both were connected to a two-stage reverse osmosis system with DIASAFEⓇ plus filters (Fresenius Medical Care, Germany) to ensure water purity. SHF sessions used Elisio-17HX or Elisio-19HX dialyzers (Nipro Corporation, Japan). OL-HDF was delivered in post-dilution mode. All treatments used dialysate flow rate of 500 mililiters per minute and a treatment duration of 240 minutes dialysis session. All participants received bicarbonate-based dialysate, and dialyzers were single-use during sampling to eliminate reuse bias.\u003c/p\u003e \u003cp\u003eFor each patient, venous blood sample was drawn immediately before and after a single 240-minute dialysis session using a slow-flow technique following the 2015 KDOQI guideline (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) to prevent access-related fluctuations. Main biochemical molecules included B2M, interleukin-6 (IL6), parathyroid hormone (PTH), leptin, albumin, and CRP.\u003c/p\u003e \u003cp\u003eThe corrected reduction ratio was calculated following the hematocrit-corrected formula according to Daniel Schneditz et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), applied for PTH, β2MG, IL6 and Leptin:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:RR\\:\\left(corrected,\\:\\%\\right)=\\left(1-\\frac{\\:{H}_{0}\\left(1\\:-\\:{H}_{1}\\right){C}_{1}}{{H}_{1}\\left(1-\\:{H}_{0}\\right){C}_{0}}\\right)*100\\%$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe reduction ratio of Urea and Phosphate using the following formula:\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:RR\\left(\\%\\right)=\\left(1-\\:\\frac{{C}_{1}}{{C}_{0}}\\right)*100\\%$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eH\u003csub\u003e0\u003c/sub\u003e and C\u003csub\u003e0\u003c/sub\u003e represent for the hematocrit and solute concentration from the blood line of pre-dialyzer at time 0 minute. H\u003csub\u003e1\u003c/sub\u003e and C\u003csub\u003e1\u003c/sub\u003e denote the hematocrit and solute concentration from the blood line of pre-dialyzer at time 240 minutes.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll data were analyzed using R Console v4.5.1, Microsoft Excel, and Word 2021 for data handling and reporting. Data normality was evaluated with the Shapiro-Wilk test. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD if normally distributed, or median [IQR] otherwise. Independent samples were compared using Welch\u0026rsquo;s t-test or Mann-Whitney U test, while paired data were analyzed with the paired t-test or Wilcoxon signed-rank test. We treated p values below 0.05 as statistically significant. To explore how the biochemical and clinical measures related to one another, we carried out a correlation analysis. Variables that followed a normal distribution were examined using Pearson coefficients, whereas those that did not were assessed with Spearman\u0026rsquo;s rank method. This approach allowed us to capture both linear relationships and those that were less strictly proportional. Correlation strength was interpreted as follows: very weak (|r| \u0026lt; 0.20), weak (0.20 \u0026le; |r| \u0026lt; 0.40), moderate (0.40 \u0026le; |r| \u0026lt; 0.60), strong (0.60 \u0026le; |r| \u0026lt; 0.80), and very strong (|r| \u0026ge; 0.80).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eA total of 30 ESKD patients undergoing maintenance HD who met the study criteria were enrolled. Of these, 15 patients were treated with SHF-HD (SHF group) and 15 patients received OL-HDF (HDF group). Across the study population, 46.8% were male, and the median age was 48.0 [39.0\u0026ndash;58.9] years. Blood pressure, BMI, and dialysis vintage have no statistically significant differences between the two groups. Hypertension and Diabetes Mellitus were the two most common comorbidities, accounting for 73.3% and 53.5% of all participants, respectively. Further details are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristic of study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHDF (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSHF (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years, \u003c/p\u003e \u003cp\u003emedian [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48.0 [39.0-58.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.0 [36.5\u0026ndash;51.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.0 [45.0\u0026ndash;61.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;, \u003c/p\u003e \u003cp\u003emedian [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.5 [19.3\u0026ndash;24.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.8 [21.7\u0026ndash;24.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.8 [18.1\u0026ndash;24.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic BP (mmHg, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125.0 [120.0-140.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120.0 [110.0-135.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e130.0 [120.0-140.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic BP (mmHg, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70.0 [62.5\u0026ndash;80.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.0 [60.0\u0026ndash;80.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.0 [70.0\u0026ndash;80.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis vintage (months, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.0 [29.8\u0026ndash;49.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.2 [30.5\u0026ndash;61.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.0 [30.5\u0026ndash;43.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVF as vascular access, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVD, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of kidney transplantation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDialysis parameters and baseline biochemical markers\u003c/h3\u003e\n\u003cp\u003eThe Qb in the HDF group was significantly higher than that in the SHF group (p\u0026thinsp;=\u0026thinsp;0.008). Other treatment session parameters were similar between the two groups. At the baseline, there were no statistically significant differences in any laboratory marker concentrations between the HDF group and the SHF group. Details of all biochemical marker concentrations and dialysis parameters are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasline dialysis and laboratory parameters of study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHDF (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSHF (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood flow rate (Qb, mL/min, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e270.00\u0026thinsp;\u0026plusmn;\u0026thinsp;22.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e240.00\u0026thinsp;\u0026plusmn;\u0026thinsp;23.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstitution flow rate (mL/min, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConvective volume (L/session, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUF volume (L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.00 [3.00\u0026ndash;4.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.00 [2.75\u0026ndash;4.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKt/V (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.43 [1.33\u0026ndash;1.60]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.37 [1.34\u0026ndash;1.48]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (Hb, g/dL, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.909\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea (mmol/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.82\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.11\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (\u0026micro;mol/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1123.11\u0026thinsp;\u0026plusmn;\u0026thinsp;264.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1209.02\u0026thinsp;\u0026plusmn;\u0026thinsp;308.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.420\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin (g/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.128\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium (Ca, mmol/L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 [2.2\u0026ndash;2.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 [2.2\u0026ndash;2.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhospho (P, mmol/L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.50 [2.2\u0026ndash;2.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.11 [1.9\u0026ndash;2.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH (pg/mL, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0 [0.6\u0026ndash;1.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1 [0.7\u0026ndash;1.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB2M (mg/L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2 [22.1\u0026ndash;25.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9 [21.8\u0026ndash;25.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL6 (pg/mL, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.3 [7.3\u0026ndash;11.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2 [6.3\u0026ndash;10.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeptin (ng/mL, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3 [3.8\u0026ndash;22.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9 [3.2\u0026ndash;16.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe heatmap illustrates the correlations among pre-dialysis biochemical markers. B2M showed a positive correlation with both IL6 and leptin, with moderate correlation strength (r\u0026thinsp;=\u0026thinsp;0.51, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.004; and r\u0026thinsp;=\u0026thinsp;0.41, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.025, respectively). IL6 also demonstrated a positive, moderate correlation with CRP (r\u0026thinsp;=\u0026thinsp;0.5, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.005), and leptin also showed the a moderate correlation with calcium (r\u0026thinsp;=\u0026thinsp;0.43, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.017). Other marker pairs showed only weak and non-significant correlation. Further information on correlation matrix is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDialysis Efficacy\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-dialysis laboratory parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarker\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHDF (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSHF (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (Hb, g/dL, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea (mmol/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (\u0026micro;mol/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e465.17\u0026thinsp;\u0026plusmn;\u0026thinsp;131.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e465.59\u0026thinsp;\u0026plusmn;\u0026thinsp;157.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin (g/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/L, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.02\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium (Ca, mmol/L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.84 [2.59\u0026ndash;3.17]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.89 [2.74\u0026ndash;2.98]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhospho (P, mmol/L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.61 [0.94\u0026ndash;1.79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.12 [0.85\u0026ndash;1.41]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH (pg/mL, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44 [0.15\u0026ndash;0.62]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.35 [0.13\u0026ndash;1.11]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.678\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB2M (mg/L, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.72 [6.89\u0026ndash;9.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.82 [6.77\u0026ndash;9.31]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL6 (pg/mL, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.72 [6.51\u0026ndash;9.41]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.11 [4.72\u0026ndash;7.87]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeptin (ng/mL, median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.04 [1.88\u0026ndash;10.73]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.07 [1.62\u0026ndash;10.11]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the clearance of middle-molecular-weight uremic toxins and cytokines after a single dialysis session, both modalities demonstrated equivalent performance. The median RRs of all evaluated middle molecules were not significantly different in the SHF group compared with the HDF group, including phospho (51.71% [31.91\u0026ndash;53.75] vs. 39.52% [30.02\u0026ndash;58.86]; p\u0026thinsp;=\u0026thinsp;0.901), PTH (66.32% [34.87\u0026ndash;82.56] vs. 63.57% [49.41\u0026ndash;79.22]; p\u0026thinsp;=\u0026thinsp;0.803), B2M (65.05% [61.61\u0026ndash;68.39] vs. 68.20% [63.86\u0026ndash;67.68]; p\u0026thinsp;=\u0026thinsp;0.561), leptin (41.08% [34.25\u0026ndash;49.39] vs. 36.36% [34.25\u0026ndash;49.39]; p\u0026thinsp;=\u0026thinsp;0.678), and IL6 (23.62% [20.26\u0026ndash;30.72] vs. 21.20% [14.76\u0026ndash;24.90]; p\u0026thinsp;=\u0026thinsp;0.213), as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSafety profile\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the SHF group, the mean change in serum albumin and CRP after treatment was \u0026minus;\u0026thinsp;0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 g/L and \u0026minus;\u0026thinsp;0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63 mg/L, respectively. In comparison to the HDF group, there were no significant differences in either albumin (-0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32 g/L, p\u0026thinsp;=\u0026thinsp;0.911) or CRP (0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32 mg/L, p\u0026thinsp;=\u0026thinsp;0.356), as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThroughout all thirty treatment sessions, there were no intradialytic complications in either patient group, including intradialytic hemodynamic instability, cardiac arrhythmias, dialyzer allergic reactions, dialysis disequilibrium syndrome, gastrointestinal syndromes, muscle cramps, and dialyzer rupture.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eExisting evidence on SHF or expanded HD largely originates from high-income countries (Japan, Europe) or upper-middle-income settings such as Thailand. To our knowledge, this study is the first to investigate the use of SHF dialyzers in Vietnam, and one of the first from any LMICs, to evaluate the efficacy and safety profile compared with OL-HDF. In this light, it is noteworthy that the SHF dialyzer in our study achieved middle molecules reduction comparable to OL-HDF. The primary endpoint, B2M, cytokines, and peptide hormones reduction did not differ significantly between modalities, as expected in four-hour treatment with both groups. Albumin declined insignificantly following SHF-HD and nonsignificantly to OL-HDF, and CRP did not alter in either group. None of the acute safety events were observed. Our findings are in line with prior controlled studies in which SHF-HD achieved comparable clearance of solutes and middle molecules to high-volume OL-HDF, without acute safety concerns (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eB2M is a surrogate for middle molecules and is the basis for dialyzer flux classification in Japan. Over 90% of Japanese HD patients have been treated with type IV/V high-performance membranes for over a decade, which has been associated with lower B2M levels and a decline in amyloidosis complications. Notably, a 2024 Japanese Society for Dialysis Therapy registry study found that the use of type V dialyzers with B2M clearance\u0026thinsp;\u0026ge;\u0026thinsp;70 mL/min was independently associated with improved 2-year survival, with adjusted HR 0.86 (95% CI, 0.80\u0026ndash;0.92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) vs. standard HF membranes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). For instance, recent studies in Thailand demonstrated that thrice-weekly SHF-HD eliminates middle molecules and protein-bound toxins as effectively as post-dilution OL-HDF. In one such trial, RRs for indoxyl sulfate and B2M in the SHF-HD group were statistically indistinguishable from those on high-volume OL-HDF with the convective volume achieved 24\u0026ndash;26 liters per session (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). We also measured IL6 and leptin as markers of larger uremic toxins. Both showed a 20%-40% reduction per session with no differences between modalities. These larger cytokines and adipokines are poorly removed by diffusion alone, but HDF can remove some through convection. The efficacy is probably supported by the membrane properties of SHF dialyzers. Larger and more uniformly distributed pores increase the sieving coefficient for middle molecules while maintaining a cutoff below albumin\u0026rsquo;s molecular size. In the dialyzer, the secondary flows and Taylor dispersion have contributed to the amplification of the mass transfer beyond pure diffusion at higher rates of blood flow, which is sometimes called internal convection. All these phenomena, along with the long fibres and the optimised packing of fibres, can increase the transport of larger solutes, which can be transported without the presence of a substitution fluid supplied externally. Some studies even suggest that \u0026ldquo;expanded HD\u0026rdquo; with novel membranes might exceed OL-HDF in removing the largest solutes: for example, certain SHF or MCO dialyzers have shown higher clearance of cytokines than OL-HDF (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother important dimension is biocompatibility and inflammation. Persistent low-grade inflammation in dialysis patients has long been tied to their high burden of cardiovascular disease. OL-HDF might attenuate this inflammation over time by two mechanisms: the requirement for ultrapure dialysate reduces exposure to endotoxins, and convective transport can remove some cytokines. In the short term, however, we observed no significant difference in inflammatory markers between SHF-HD and OL-HDF. This suggests that both modalities were similarly biocompatible in our setting with real-world dialysis fluid quality in both arms and modern synthetic membranes. Panichi et al. observed that switching from standard HD to HDF led to significant reductions in CRP and IL6 levels over 4 months, whereas reverting to conventional HD caused these markers to rise again (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In our comparison, we did not detect any short-term difference in inflammatory markers between SHF-HD and OL-HDF, which is reasonable given that acute inflammatory shifts rarely emerge within a single session. Even so, membrane design may matter more than the modality alone. Recent work with vitamin E\u0026ndash;coated SHF dialyzers is a good example. In a randomized study, the vitamin E-coated membrane achieved middle-molecule clearance similar as an MCO dialyzer, yet it also lowered oxidative and inflammatory biomarkers (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Findings like these hint that incremental refinements in membrane biocompatibility might influence the inflammatory response, although whether these effects persist or translate into clinical benefit remains uncertain. Across the 30 sessions we followed, no intradialytic complications occurred, not even the small issues that sometimes surface when membranes are changed. This pattern is similar to the experience reported by Tiranathanagul and colleagues in Thailand, where patients tolerated SHF-HD just as well as OL-HDF and showed no rise in hypotension or other symptoms over their eight-week crossover periods (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Taken together, these findings support the view that well-designed high-flux membranes can offer HDF-like clearance while remaining safe and comfortable for patients in the short term, although longer-term effects still need clearer evidence.\u003c/p\u003e \u003cp\u003eOur study has several limitations. The most obvious is the small sample. With only fifteen patients in each group, our ability to detect very small differences was inevitably limited. Even so, the overlap in almost every measured parameter was striking, and that consistency gives at least some confidence that the patterns we observed were not simply noise. Another limitation involves the blood-flow rates. Both groups operated at lower Qb than what is typically reported in larger trials (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), sometimes because of protocol constraints and sometimes because of patient factors that restricted achievable flow. This makes comparison with other studies a little tricky, and it raises the possibility that some performance differences could be masked by lower baseline flow. Lower blood-flow rates often limit the convective volume that HDF can generate, and this can blunt the clinical advantages it would otherwise offer. That concern was relevant in our setting. Although the HDF group in our study operated at a higher Qb than the SHF group, about 270 compared with 240 mL per minute, the SHF treatments still matched HDF in terms of toxin removal. This outcome is striking because, at least in theory, the lower Qb should have placed SHF-HD at a disadvantage. Yet we did not see any meaningful reduction in clearance. It raises the possibility that membrane performance in SHF-HD may compensate for modest flow limitations, although we cannot say how far this effect extends beyond the short-term observations we captured. Third, our study did not measure albumin concentration in the dialysate or ultrafiltrate, so we could not directly quantify albumin loss through the dialyzer. We did observe that serum albumin levels after treatment were unchanged in both groups, which is an encouraging indirect indicator that albumin loss was minimal. Furthermore, the mean albumin decreases during SHF-HD (\u0026minus;0.40 g/L) was virtually identical to that during OL-HDF (\u0026minus;0.44 g/L). In OL-HDF, a small amount of albumin, typically 1\u0026ndash;3 g per session, is known to be lost into the discarded ultrafiltration fluid. It stands to reason that SHF dialyzers might allow a similar scale of loss. Evidence from other studies supports this: a crossover trial by Tiranathanagul et al. noted slightly higher albumin leakage into dialysate with SHF-HD compared to HDF, but importantly no significant drop in patients\u0026rsquo; serum albumin over 8 weeks of treatment (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Likewise, long-term observational work from Thailand found that 15 months on SHF-HD did not lead to hypoalbuminemia; mean serum albumin remained approximately 4.0 g/dL, unchanged from baseline (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Still, we acknowledge that without direct measurement, we cannot definitively state the grams of albumin lost in SHF-HD. And finally, because our work was limited to a short observational window, we were not able to examine outcomes that unfold slowly, such as survival, cardiovascular events, or changes in quality of life. That is a real constraint, and it leaves open questions that a longer study would be better suited to answer. Even so, it does not undermine the central pattern we observed: over the short term, SHF-HD performed on par with OL-HDF in both solute clearance and safety. If anything, these limitations simply point toward the next steps, inviting larger and longer studies to determine whether the short-term equivalence we found holds up when patients are followed over months or years.\u003c/p\u003e \u003cp\u003eThese results are best interpreted within the context of routine dialysis practice in settings where OL-HDF is not yet widely available, as is still the case in many centers in Vietnam. Conventional high-flux HD remains highly effective for the removal of small solutes, yet its limited capacity for middle-molecule clearance continues to be a concern given the established links between these toxins and complications such as dialysis-related amyloidosis, chronic inflammation, and cardiovascular disease. OL-HDF offers a more efficient solution for this problem, but its broader implementation is constrained by the need for ultrapure water systems, compatible machines, and higher operational costs. Against this background, SHF membranes represent a technically simpler approach that can be readily applied on standard HD platforms and may enhance middle-molecule removal under everyday clinical conditions. From a physiological standpoint, our findings are consistent with the growing body of work supporting the concept of \u0026ldquo;expanded HD,\u0026rdquo; in which enhanced diffusive transport and internal convection achieved by SHF or MCO membranes can approach the biochemical clearance profile of post-dilution OL-HDF. Nevertheless, the present study was designed to capture only short-term biochemical and safety outcomes, and any inference beyond acute solute removal would go beyond what our data can reliably support. While SHF-HD may therefore be considered a pragmatic option in centers where OL-HDF cannot be routinely implemented, its influence on longer-term outcomes such as survival, cardiovascular events, or hospitalization cannot be addressed by this study. Importantly, we observed no acute safety concerns, including hemodynamic instability or meaningful albumin loss, which supports the short-term tolerability of SHF-HD in a real-world clinical setting. Whether this favorable short-term biochemical and safety profile translates into sustained clinical benefit will require confirmation in larger studies with longitudinal follow-up.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this cross-sectional study conducted under routine clinical conditions in Vietnam, SHF-HD achieved short-term removal of small and middle-molecule solutes comparable to OL-HDF, with minimal changes in serum albumin, stable inflammatory markers, and no intradialytic adverse events. These findings indicate that, in the short term, SHF-HD can provide a biochemical performance similar to OL-HDF in everyday practice. However, given the limited sample size and single-session design, no conclusions can be drawn regarding long-term clinical outcomes. Larger, prospective studies with extended follow-up are needed to clarify the sustained efficacy and safety of SHF-HD in comparison with OL-HDF.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArteriovenous fistula\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eB2M\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eβ₂-microglobulin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlood pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiovascular diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESKD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd-stage kidney disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHemodiafiltration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIL6\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterleukin-6\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKDOQI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKidney Disease Outcomes Quality Initiative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKt/V\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDialysis clearance normalized to volume distribution of urea\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedium cut-off (membrane)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOL-HDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOnline hemodiafiltration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParathyroid hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQb\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlood flow rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReduction ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSuper high-flux\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHF-HD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHemodialysis using super high-flux dialyzer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrafiltration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eAll participants received verbal and written explanations and provided written informed consent before enrollment.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEthical conduct followed the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe protocol was approved by the Institutional Review Board of People\u0026rsquo;s Hospital 115 (Approval No. 2497/QĐ-BVND115; registration CS/15/25/46).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis study was not registered on ClinicalTrials.gov because it was not an interventional trial.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAll authors have reviewed and approved the final manuscript and consent to its publication.\u003c/li\u003e\n \u003cli\u003eThis manuscript does not contain any individual person\u0026rsquo;s identifiable data.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDue to institutional policies and patient confidentiality regulations at People\u0026rsquo;s Hospital 115, the datasets generated and/or analyzed during the current study are not publicly available.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eData may be made available upon reasonable request and with approval from the hospital\u0026rsquo;s Institutional Review Board and corresponding author.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThanh Cong Nguyen received financial support from Nipro Corporation (Japan) as speaker honoraria to present the findings of this study at the 5th National Dialysis Conference (2025) of the Vietnam Dialysis Association.\u003c/li\u003e\n \u003cli\u003eAll other authors declare no competing interests.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThis study was partially supported by Nipro Corporation (Japan), including provision of dialyzers for patients and partial financial support for laboratory testing and research materials.\u003c/li\u003e\n \u003cli\u003eThe funder had no role in study design, patient recruitment, dialysis procedures, laboratory measurements, data analysis, interpretation of findings, manuscript writing, or the decision to submit the article for publication.\u003c/li\u003e\n \u003cli\u003eThe authors are fully responsible for the content and editorial decisions. The funder had no influence on scientific conclusions or publication decisions.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThanh Cong Nguyen conceived and designed the study, supervised dialysis procedures, coordinated data and laboratory work, performed the analyses, interpreted the results, \u0026nbsp;prepared and reviewed the manuscript for scientific accuracy as corresponding author. Van Song Tran and Hong Vu Le Thi provided clinical supervision, project management, and contributed to manuscript review. Hoai Vy Nguyen Thi assisted with patient recruitment, data collection, sample handling, monitoring of dialysis sessions, and manuscript editing.\u0026nbsp;Phu Quoc Nguyen supported data collection, helped with statistical analysis, and reviewed the manuscript for technical accuracy. Ngoc Tran Le Nguyen assisted with patient recruitment, data collection, laboratory coordination.\u0026nbsp;All authors read and approved the final manuscript and meet the ICMJE authorship criteria.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe are deeply grateful to Assoc. Prof. Le Viet Thang, MD, PhD (Division of Nephrology and Dialysis, Vietnam Military Medical University), whose insightful comments and critical suggestions strengthened the scientific quality of this manuscript. We also thank Phung Huy Hoang, MD (Department of Cardiac Arrhythmias, People\u0026rsquo;s Hospital 115) and Phan Ngoc Phuong Thao, MD (Division of Infectious Diseases, Pham Ngoc Thach University of Medicine), for their technical support during data analysis. We acknowledge Pham Hoang Lam, along with Nguyen Ba Hai, Nguyen Truc, Nguyen Manh Hung, Nguyen Van Thao, Phan Thanh Nam, and all staff from the Nephrology and Transplant Immunology Department, the hospital laboratory teams, and collaborating units for their continued assistance during the project. Finally, we thank Nipro Corporation (Japan) for providing partial financial and material support for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRosner MH, Reis T, Husain-Syed F, Vanholder R, Hutchison C, Stenvinkel P, et al. Classification of Uremic Toxins and Their Role in Kidney Failure. Clin J Am Soc Nephrol CJASN. 2021;16(12):1918\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Suri RS, et al. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis. 2015;66(5):884\u0026ndash;930.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlankestijn PJ, Vernooij RWM, Hockham C, Strippoli GFM, Canaud B, Hegbrant J, et al. Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure. N Engl J Med. 2023;389(8):700\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaduell F, Moreso F, Pons M, Ramos R, Mora-Maci\u0026agrave; J, Carreras J, et al. High-Efficiency Postdilution Online Hemodiafiltration Reduces All-Cause Mortality in Hemodialysis Patients. J Am Soc Nephrol. 2013;24(3):487.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVernooij RWM, Hockham C, Strippoli G, Green S, Hegbrant J, Davenport A, et al. Haemodiafiltration versus haemodialysis for kidney failure: an individual patient data meta-analysis of randomised controlled trials. The Lancet. 2024;404(10464):1742\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanaud B, Strippoli G, Davenport A. High-Volume Hemodiafiltration Versus High-Flux Hemodialysis: A Narrative Review for the Clinician. J Clin Med. 2025;14(8):2614.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBattaglia Y, Shroff R, Meijers B, Nistor I, Alfano G, Franssen C, et al. Haemodiafiltration versus high-flux haemodialysis\u0026mdash;a Consensus Statement from the EuDial Working Group of the ERA. Nephrol Dial Transplant. 2025;40(8):1590\u0026ndash;614.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBello AK, Okpechi IG, Levin A, Ye F, Saad S, Zaidi D. ISN\u0026ndash;Global Kidney Health Atlas: A report by the International Society of Nephrology: An Assessment of Global Kidney Health Care Status focussing on Capacity, Availability, Accessibility, Affordability and Outcomes of Kidney Disease. [Internet]. International Society of Nephrology; 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.theisn.org/global-atlas\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThammathiwat T, Tiranathanagul K, Limjariyakul M, Chariyavilaskul P, Takkavatakarn K, Susantitaphong P, et al. Super high-flux hemodialysis provides comparable effectiveness with high‐volume postdilution online hemodiafiltration in removing protein‐bound and middle‐molecule uremic toxins: A prospective cross‐over randomized controlled trial. Ther Apher Dial. 2021;25(1):73\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiranathanagul K, Khemnark N, Takkavatakarn K, Limjariyakul M, Mahatanan N, Chariyavilaskul P, et al. Comparative efficacy between hemodialysis using super high-flux dialyzer with hemoperfusion and high-volume postdilution online hemodiafiltration in removing protein bound and middle molecule uremic toxins: A cross-over randomized controlled trial. Artif Organs. 2022;46(5):775\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukkanalikitkul E, Kidkaem H, Phonrat M, Prathompong P, Anutrakulchai S. A randomized trial comparing medium cut-off membrane dialyzers with online hemodiafiltration for uremic toxins clearance in hemodialysis patients. Sci Rep. 2025;15(1):5467.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkada K, Tashiro M, Michiwaki H, Inoue T, Shima H, Minakuchi J, et al. Comparison of survival for super high-flux hemodialysis (SHF-HD) with high albumin leakage versus online hemodiafiltration or SHF-HD with low albumin leakage: the SUPERB study. Ren Replace Ther. 2023 July 6;9(1):32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbe M, Kikuchi K, Kanda E, Wada A, Nakai S, Hanafusa N. Super high-flux dialyzers improve survival in patients on hemodialysis: a cohort study of the Japanese Society for Dialysis Therapy (JSDT) Renal Data Registry. Ren Replace Ther. 2024;10(1):50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner DE, Falzon L, Skoufos L, Bernardo A, Beck W, Xiao M, et al. Efficacy and Safety of Expanded Hemodialysis with the Theranova 400 Dialyzer: A Randomized Controlled Trial. Clin J Am Soc Nephrol. 2020 Sept;15(9):1310.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim JH, Park Y, Yook JM, Choi SY, Jung HY, Choi JY, et al. Randomized controlled trial of medium cut-off versus high-flux dialyzers on quality of life outcomes in maintenance hemodialysis patients. Sci Rep. 2020;10(1):7780.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelmouaz M, Goussard G, Joly F, Sibille A, Martin C, Betous T, et al. Comparison of High-Flux, Super High-Flux, Medium Cut-Off Hemodialysis and Online Hemodiafiltration on the Removal of Uremic Toxins. Blood Purif. 2023;52(3):309\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen Huu D, Dao Bui Quy Q, Nguyen Thi Thu H, Phan The C, Nguyen Thi Hong Q, Nguyen Duc L, et al. A Combination of Hemodialysis with Hemoperfusion Helped to Reduce the Cardiovascular-Related Mortality Rate after a 3-Year Follow-Up: A Pilot Study in Vietnam. Blood Purif. 2020 July 2;50(1):65\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHyodo T, Fukagawa M, Hirawa N, Isaka Y, Nakamoto H, Van Bui P, et al. Present status of renal replacement therapy in Asian countries as of 2017: Vietnam, Myanmar, and Cambodia. Ren Replace Ther. 2020;6(1):65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePham Van B, Vo Duc C. Global Dialysis Perspective: Vietnam. Kidney360. 2020 July 21;1(9):974\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTran PQ, Nguyen NTY, Nguyen B, Bui QTH. Quality of life assessment in patients on chronic dialysis: Comparison between haemodialysis and peritoneal dialysis at a national hospital in Vietnam. Trop Med Int Health. 2022;27(2):199\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVăn Thuấn Trần, Anh Đức H\u0026agrave;, Gia Tuyển Đỗ, Tam V\u0026otilde;, Việt Thắng L\u0026ecirc;, et al. Guideline on Technical Procedures in Nephrology and Urology - Volume 1.1. Vietnam\u0026rsquo;s Ministry of Health; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneditz D, Putz-Bankuti C, Ribitsch W, Schilcher G. Correction of plasma concentrations for effects of hemoconcentration or hemodilution. ASAIO J Am Soc Artif Intern Organs 1992. 2012;58(2):160\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanichi V, Manca-Rizza G, Paoletti S, Taccola D, Consani C, Filippi C, et al. Effects on inflammatory and nutritional markers of haemodiafiltration with online regeneration of ultrafiltrate (HFR) vs online haemodiafiltration: a cross-over randomized multicentre trial. Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc - Eur Ren Assoc. 2006;21(3):756\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelmouaz M, Cogne E, Joly F, Duthe F, Desport E, Martin C, et al. Effects of super high-flux vitamin E\u0026ndash;coated and medium cut-off dialyzers on uremic toxins removal and biocompatibility: the E-FLUX randomized controlled study. Clin Kidney J. 2025;18(5): sfaf106.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Super high-flux dialyzer, online hemodiafiltration, middle molecules, β₂-microglobulin, interleukin-6, hemodialysis, Vietnam","lastPublishedDoi":"10.21203/rs.3.rs-8307919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8307919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOnline hemodiafiltration (OL-HDF) enhances removal of middle-molecule uremic toxins but requires ultrapure water systems and specialized equipment, limiting uptake in many low- and middle-income countries. Super high-flux (SHF) dialyzers have been proposed as a pragmatic alternative to improve permeability and remove larger solutes using standard hemodialysis machines, yet no evaluation has been conducted in Vietnam. Our study aimed to compare the short-term efficacy and safety of HD using SHF dialyzers (SHF-HD) with post-dilution OL-HDF in a real-world Vietnamese tertiary center.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis cross-sectional study enrolled 30 patients receiving maintenance dialysis at People\u0026rsquo;s Hospital 115 (Ho Chi Minh City, Vietnam). Among those, fifteen patients received SHF-HD and fifteen received OL-HDF. A single 240-minute session was examined per patient. Blood samples were drawn pre- and post-dialysis to measure urea, β₂-microglobulin, parathyroid hormone, interleukin-6, leptin, albumin, and C-reactive protein concentration. Reduction ratios for middle molecules were hematocrit-corrected.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBaseline demographics, comorbidities, and biochemical parameters were comparable between groups. Both pre- and post-dialysis concentrations of solutes showed no significant differences between modalities. Reduction ratios of middle-molecule toxins showed no significant differences between SHF-HD and OL-HDF, including β₂-microglobulin (65.05% vs. 68.20%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.561), parathyroid hormone (66.32% vs. 63.57%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.803), interleukin-6 (23.62% vs. 21.20%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.213), and leptin (41.08% vs. 36.36%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.678). Albumin changes were minimal in both groups (\u0026minus;\u0026thinsp;0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 vs. \u0026minus;0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32 g/L, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.911), and C-reactive protein remained stable. Across all 30 treatment sessions, no intradialytic complications were observed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e \u003cp\u003e In this first Vietnamese evaluation, SHF-HD provided short-term removal of middle-molecule solutes comparable to OL-HDF, with minimal albumin loss, stable inflammatory markers, and no adverse events. Larger longitudinal studies are warranted to determine whether the observed biochemical equivalence translates into long-term clinical benefits.\u003c/p\u003e","manuscriptTitle":"Short-term efficacy and safety of hemodialysis using super high-flux dialyzers compared with online hemodiafiltration: a cross-sectional study in Vietnam","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 07:12:51","doi":"10.21203/rs.3.rs-8307919/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26e234e8-d5e0-42d5-8470-78f76edd4f3d","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T10:53:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 07:12:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8307919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8307919","identity":"rs-8307919","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}