{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T17:01:20Z","timestamp":1790096480369,"version":"4.0.1"},"reference-count":0,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["JASN"],"abstract":"<jats:p>Hemodialysis remains the predominant form of kidney replacement therapy worldwide, yet mortality, hospitalization, symptom burden, and impaired health-related quality of life remain substantial. Historically, dialysis innovation has emphasized surrogate measures such as solute clearance and biochemical targets. Although these advances have improved treatment delivery, gains in patient-important outcomes\u2014including survival, hospitalization, symptoms, and functional status\u2014have been limited, suggesting diminishing returns from further optimization of traditional adequacy targets. Dialysis therapies should therefore be evaluated by their effects on clinical outcomes, patient-reported outcomes, safety, equity, sustainability, and value. This review assesses contemporary extracorporeal modalities and emerging technologies using an outcome-based framework incorporating implementation, health-system implications, and patient priorities. High-flux hemodialysis is the current standard of care but has not consistently been associated with lower all-cause mortality despite achievement of modern adequacy targets. Medium cut-off membranes, adsorption-based approaches, personalized schedules, and portable, wearable, or implantable technologies offer compelling physiologic rationales and may improve selected surrogate measures; however, evidence of meaningful clinical benefit remains limited. Among extracorporeal therapies, online hemodiafiltration has the strongest evidence base. Randomized trials and individual-participant-data meta-analyses indicate better survival with high-volume online hemodiafiltration versus high-flux hemodialysis, with supportive patient-reported and cost-effectiveness evidence. However, CONVINCE patients achieved high convection volumes; benefit is uncertain for those unable to reach these targets, and implementation depends on infrastructure, reimbursement, regulation, and quality assurance. Current evidence supports shifting dialysis innovation from surrogate endpoints toward outcomes that matter to patients. Physiologic plausibility and surrogate improvements alone should not justify widespread adoption. Future progress requires rigorous comparative-effectiveness research, implementation science, real-world evidence, routine integration of standardized patient-reported outcomes, and attention to environmental sustainability and equitable access. Aligning reimbursement, quality metrics, implementation, and policy with patient-level outcomes will be essential to translate technological advances into better care for people with kidney failure.<\/jats:p>","DOI":"10.1681\/asn.0000001286","type":"journal-article","created":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T16:00:39Z","timestamp":1790092839000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Hemodialysis Care"],"prefix":"10.1681","author":[{"given":"Allen R.","family":"Nissenson","sequence":"first","affiliation":[{"name":"David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, United States of America"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2695-1838","authenticated-orcid":false,"given":"J\u00f6rgen","family":"Hegbrant","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank W.","family":"Maddux","sequence":"additional","affiliation":[{"name":"Henscratch Studios, Danville, VA, United States of America"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni F.M.","family":"Strippoli","sequence":"additional","affiliation":[{"name":"Sydney School of Public Health, The University of Sydney, NSW Australia"},{"name":"Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,9,22]]},"container-title":["Journal of the American Society of Nephrology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.1681\/ASN.0000001286","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T16:00:39Z","timestamp":1790092839000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.1681\/ASN.0000001286"}},"subtitle":["Evolving to Enhance Patient-Level Outcomes"],"short-title":[],"issued":{"date-parts":[[2026,9,22]]},"references-count":0,"URL":"https:\/\/doi.org\/10.1681\/asn.0000001286","relation":{},"ISSN":["1046-6673","1533-3450"],"issn-type":[{"value":"1046-6673","type":"print"},{"value":"1533-3450","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,22]]},"assertion":[{"value":"2026-06-19","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-09-17","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}