To date, there are no known or documented contraindications for HDF. Therefore, in principle, all dialysis patients could benefit from the advantages of HVHDF. To implement HVHDF effectively in a clinic where all patients are currently receiving high-flux HD, the following prioritization rules are recommended:

9.1  | Eligibility Criteria

Before considering the switch from high-flux dialysis to post-dilution HVHDF, it is suggested to evaluate if patients meet the following baseline requirements:

• Blood flow rate ≥ 330 ml/min. A well-functioning AVF is preferred. Patients with CVCs or AVGs may be considered if they can achieve Qb > 330 ml/min.
• Treatment time ≥ 210 minutes/session.
• Anticoagulants: Preventing clotting within the extracorporeal circuit is mandatory to optimize HDF efficacy and ensure patient safety.
• Normal blood viscosity: Patients with high blood viscosity (e.g., polycythemia, high blood concentration of fibrinogen and lipids) are at higher risk of fiber clogging.

9.2  | Prioritization Based on Clinical Benefit

Once eligibility is confirmed, prioritize patients based on the potential benefits of HVHDF:

1. High Priority
   1. Patients capable of achieving high convection volumes ≥ 23 L/session.
   2. Patients on active kidney transplantation list.
   3. Patients with hemodynamic instability.
   4. Patients with heart failure, coronary artery disease.
   5. Patients with high ultrafiltration needs requiring substantial fluid removal.
   6. Patients with large body size.
2. Moderate Priority
   1. Patients with residual kidney function. Those maintaining urine output >1000 mL/24 hours may experience improved toxin clearance with HVHDF.
   2. Patients with elevated serum phosphorus levels.
   3. Patients with dialysis-related amyloidosis.
   4. Patients with worsening nutritional status.
   5. Patients with polyneuropathy.
   6. Patients with itching.
3. Lower Priority
   1. Patients with limited vascular access. Individuals with CVCs or AVGs that cannot achieve high Qbs may not realize the full benefits of HVHDF.
   2. Patients with shorter session durations. Those unable to undergo 4-hour sessions may not achieve the necessary convection volumes for optimal HVHDF efficacy.
   3. Patients who are not compliant with the dialysis procedure and accompanying prescriptions, mainly the frequency and duration of dialysis treatment, should have lower priority.
   4. Patients with life expectancy of less than 3 months.
   5. Patients intolerant of heparin or anticoagulants.

9.3  | Implementation Considerations

• Gradual transition: Begin with high-priority patients, monitoring their response closely before expanding to other groups.
• Monitor convection volumes: To maximize HVHDF benefits, aim for a target convection volume of > 23 liters per session.
• Patient education: Inform patients about the potential advantages and any risks associated with HVHDF to ensure informed decision-making.
• Resource assessment: Ensure the availability of necessary equipment and trained staff to support HVHDF therapy.
• By adhering to these criteria, clinics can effectively identify and prioritize patients who are most likely to benefit from transitioning to HVHDF, thereby optimizing clinical outcomes and resource utilization.