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The main aims of dialysis treatment are to prolong patient survival, reduce morbidity and improve quality of life. However, despite many technical advances made over the last few years, morbidity and mortality of dialysis patients remain unacceptably high [1] and their quality of life is often poor. The delivered dose of dialysis can affect morbidity and mortality of dialysis patients [2]. Moreover, in the last decade, several epidemiological studies, based mainly on longitudinal database registries, have suggested a possible superiority of convective dialysis treatments in improving patient outcome [3–7]. Thus, in addition to the dose of dialysis delivered, the size of molecules removed can also be of importance. In a randomized controlled study of 380 patients, Locatelli et al. [8] compared four dialysis modalities (cuprophan dialysis, lowand high-flux polysulfone dialysis, and high-flux polysulfone haemodiafiltration). While there was no difference in treatment tolerance and nutritional status, a statistically significant difference in pre-dialysis plasma b-microglobulin levels between convective and diffusive treatments (high vs low flux) was found. No difference in morbidity and mortality was found; however, this study was not designed to detect such a difference. Given the importance of these issues, it is not surprising that the primary aim of the HEMO study, the largest clinical trial on outcome of chronic haemodialysis (HD) patients reported to date, was to evaluate the effect of dialysis dose and convection on patient survival [9]. The HEMO study was thus designed to answer two basic questions: (i) should we increase dialysis dose above the currently recommended minimum dose [a single-pool (sp) KtuV of 1.3], and (ii) should the concept of dialysis adequacy be widened to include, in addition to urea removal, medium and large-size molecule clearance in order to improve the outcome of dialysis patients?

Dose of dialysis, convection and haemodialysis patients outcome--what the HEMO study doesn't tell us: the European viewpoint