Risk of vascular access complications with frequent hemodialysis

Frequent hemodialysis requires using the vascular access more often than with conventional hemodialysis, but whether this increases the risk for access-related complications is unknown. In two separate trials, we randomly assigned 245 patients to receive in-center daily hemodialysis (6 days per week) or conventional hemodialysis (3 days per week) and 87 patients to receive home nocturnal hemodialysis (6 nights per week) or conventional hemodialysis, for 12 months. The primary vascular access outcome was time to first access event (repair, loss, or access-related hospitalization). Secondary outcomes were time to all repairs and time to all losses. In the Daily Trial, 77 (31%) of 245 patients had a primary outcome event: 33 repairs and 15 losses in the daily group and 17 repairs, 11 losses, and 1 hospitalization in the conventional group. Overall, the risk for a first access event was 76% higher with daily hemodialysis than with conventional hemodialysis (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.11-2.79; P=0.017); among the 198 patients with an arteriovenous (AV) access at randomization, the risk was 90% higher with daily hemodialysis (HR, 1.90; 95% CI, 1.11-3.25; P=0.02). Daily hemodialysis patients had significantly more total AV access repairs than conventional hemodialysis patients (P=0.011), with 55% of all repairs involving thrombectomy or surgical revision. Losses of AV access did not differ between groups (P=0.58). We observed similar trends in the Nocturnal Trial, although the results were not statistically significant. In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.

ENHANCING LIFESTYLE THROUGH HOME HAEMODIALYSIS

The Sydney Dialysis Centre (SDC) supports 150 patients who dialyze in the home environment. Since its inception SDC has been assisting patients to modify their dialysis regime according to individual needs. In 2003-2004 a postal survey was sent to SDC patients who had changed their dialysis regime to ascertain the effect of this change on lifestyle. This article will present the results of the survey with regard to patients who dialyze nocturnally (LND) and for longer hours (LH). The patients experience will be presented in relation to their reason for modifying treatment, resultant changes in diet and medication prescription and their subjective experience of wellbeing. Findings indicate that patients who dialyse nocturnally and for longer hours experience improved sense of wellbeing, diet control and increased energy levels. While nocturnal dialysis does not suit all patients, the respondents in this survey reported benefits such as: increased opportunity for employment; less restrictions on free time; improved blood results and better lifestyle.

Effects of six versus three times per week hemodialysis on physical performance, health, and functioning: Frequent Hemodialysis Network (FHN) randomized trials

BACKGROUND AND OBJECTIVES

Relatively little is known about the effects of hemodialysis frequency on the disability of patients with ESRD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study examined changes in physical performance and self-reported physical health and functioning among subjects randomized to frequent (six times per week) compared with conventional (three times per week) hemodialysis in both the Frequent Hemodialysis Network daily (n=245) and nocturnal (n=87) trials. The main outcome measures were adjusted change in scores over 12 months on the short physical performance battery (SPPB), RAND 36-item health survey physical health composite (PHC), and physical functioning subscale (PF) based on the intention to treat principle.

RESULTS

Overall scores for SPPB, PHC, and PF were poor relative to population norms and in line with other studies in ESRD. In the Daily Trial, subjects randomized to frequent compared with conventional in-center hemodialysis experienced no significant change in SPPB (adjusted mean change of -0.20±0.19 versus -0.41±0.21, P=0.45) but experienced significant improvement in PHC (3.4±0.8 versus 0.4±0.8, P=0.009) and a relatively large change in PF that did not reach statistical significance. In the Nocturnal Trial, there were no significant differences among subjects randomized to frequent compared with conventional hemodialysis in SPPB (adjusted mean change of -0.92±0.44 versus -0.41±0.43, P=0.41), PHC (2.7±1.4 versus 2.1±1.5, P=0.75), or PF (-3.1±3.5 versus 1.1±3.6, P=0.40).

CONCLUSIONS

Frequent in-center hemodialysis compared with conventional in-center hemodialysis improved self-reported physical health and functioning but had no significant effect on objective physical performance. There were no significant effects of frequent nocturnal hemodialysis on the same physical metrics.

Cardiac and vascular structure and function parameters do not improve with alternate nightly home hemodialysis: an interventional cohort study

BACKGROUND

Nightly extended hours hemodialysis may improve left ventricular hypertrophy and function and endothelial function but presents problems of sustainability and increased cost. The effect of alternate nightly home hemodialysis (NHD) on cardiovascular structure and function is not known.

METHODS

Sixty-three patients on standard hemodialysis (SHD: 3.5-6 hours/session, 3-5 sessions weekly) converted to NHD (6-10 hours/session overnight for 3-5 sessions weekly). 2Dimensional transthoracic echocardiography and ultrasound measures of brachial artery reactivity (BAR), carotid intima-media thickness (CIMT), total arterial compliance (TAC) and augmentation index (AIX) were performed post dialysis at baseline and 18-24 months following conversion to NHD. In 37 patients, indices of oxidative stress: plasma malonyldialdehyde (MDA) and anti-oxidant enzymes: catalase (CAT), glutathione peroxidase (GPX) and superoxide dismutase (SOD) activity and total antioxidant status (TAS) were measured at baseline, 3 and 6 months.

RESULTS

Left ventricular mass index (LVMI) remained stable. Despite significant derangement at baseline, there were no changes in diastolic function measures, CIMT, BAR and TAC. AIX increased. Conversion to NHD improved bone mineral metabolism parameters and blood pressure control. Interdialytic weight gains increased. No definite improvements in measures of oxidative stress were demonstrated.

CONCLUSIONS

Despite improvement in uremic toxin levels and some cardiovascular risk factors, conversion to an alternate nightly NHD regimen did not improve cardiovascular structure and function. Continuing suboptimal control of uremic toxins and interdialytic weight gains may be a possible explanation. This study adds to the increasing uncertainty about the nature of improvement in cardiovascular parameters with conversion to intensive hemodialysis regimens. Future randomized controlled trials will be important to determine whether increases in dialysis session duration, frequency or both are most beneficial for improving cardiovascular disease whilst minimizing costs and the impact of dialysis on quality of life.

[Home peritoneal ultrafiltration in the treatment of chronic heart failure]

Due to its epidemiological characteristics, chronic heart failure refractory to conventional medical treatment is a significant problem involving an increasing number of cardiac patients. Chronic heart failure currently represents one of the most remarkable clinical manifestations of cardiovascular disease because of its frequency, morbidity, impact on quality of life, and costs. The use of new therapeutic approaches is particularly important for patients who become refractory to conventional therapies or are not eligible for heart transplant or other surgical treatment. The benefits of continuous extracorporeal ultrafiltration therapies are well known, but these treatments may be associated with complications and can be used only during hospitalization. Peritoneal ultrafiltration seems to be useful as chronic therapy to improve the quality of life and physical and social rehabilitation of patients with refractory chronic heart failure. The aim of this paper is to evaluate peritoneal ultrafiltration as an integrative treatment in chronic heart failure. Data from the literature suggest that peritoneal ultrafiltration is useful for the preservation of residual renal function, continuous ultrafiltration, hemodynamic stability, better middle-molecule clearance, sodium sieving with maintenance of normonatremia, and reduction of hospital admissions.

Home Hemodialysis and Remote Monitoring: Current Technology, Requirements and Capabilities

The changing patterns of utilization of home hemodialysis (HHD) are reviewed with special reference to the factors responsible for its decline and recent revival. Equipment and monitoring systems dedicated to HHD have been recently introduced in response to the demand for more frequent therapies at home. The advantages and disadvantages of novel technology versus time-tested, reliable and versatile platforms are discussed. Despite the significant technological progress achieved, much remains to be done in our quest to make HHD a simple, cost-effective and very safe renal replacement therapy.

Managing patients on dialysis in the community

In an average GP practice there will be one or two patients currently on renal replacement therapy (RRT) and a larger number with progressive chronic kidney disease who will reach end stage renal disease (ESRD). The options for RRT are kidney transplantation, haemodialysis (HD) or peritoneal dialysis (PD). For many patients with ESRD, treatment at home allows greater flexibility and independence than can be facilitated by inpatient HD. PD can be broadly categorised into two types: continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. Each PD patient has a personalised prescription depending on their body mass, residual renal function and the physical properties of their peritoneal membrane. On average patients can have four years of successful PD before needing to switch to an altemative mode of RRT. In home haemodialysis (HHD), the entire process is initiated and managed by the patient at home. HHD is an option for any motivated patient who can learn the necessary skills to manage their own HD and deal with the potential complications. The strongest clinical argument for choosing HHD is the ability to provide longer and more regular HD sessions. Daily HD results in an improvement in BP control, solute clearance and anaemia management, and thus confers a significant survival benefit to patients.

Nocturnal home hemodialysis: implementation, quality assurance and future challenges

Nocturnal home hemodialysis (NHHD) has been associated with several clinical benefits compared to conventional thrice-weekly in-center hemodialysis. However, the prevalence of NHHD remains low. To date, few studies have focused on the importance of training and education of a complex medical procedure such as NHHD. In the present review, we will describe guidelines for implementation of a NHHD program by focusing on 1) patients' selection, assessment and training; 2) challenges of adult education; 3) prescription and 4) barriers to adoption of home hemodialysis. Future challenges in research, the importance of quality assurance and innovations in clinical care delivery in NHHD will also be discussed.

Intensifying renal replacement therapy during pregnancy: the role for nocturnal home hemodialysis

Fertility among women receiving conventional hemodialysis or peritoneal dialysis is very low. For those able to conceive it appears that infant survival is poor, and prematurity and its related complications are still commonplace. Nocturnal hemodialysis (NHD) is a form of intensive, self-administered hemodialysis whereby patients receive 3-4 times the duration of conventional hemodialysis resulting in superior removal of uremic toxins compared to traditional dialysis modalities. NHD has been associated with increased fertility, infants with higher birth weights born at more advanced gestational ages, and fewer maternal and fetal complications. These encouraging results suggest a greater role for much more intensive dialysis in pregnancy.

The evaluation of a successful home hemodialysis program: establishing a prospective framework for quality

A mounting body of clinical data and purported quality of life benefits has been primarily responsible for a renewed interest in programs providing longer more frequent home hemodialysis. As novel forms of home hemodialysis (HHD) like nocturnal (nightly) home hemodialysis (NHD) move from strictly the academic "experimental" arenas to potentially the preferred renal replacement modality for patients, it will be necessary for programs to plan and evaluate standardized metrics for program quality. This will be essential for smaller, less experienced centers to gauge their outcomes against larger, more established programs. Driven by market forces primarily in the United States, conventional hemodialysis programs have begun to explore optimal strategies for reporting quality of care in their respective dialysis centers. Extrapolating this to home hemodialysis modalities the question remains which criteria do we use as measures of quality? The evidence is limited to small, observational studies and one small randomized controlled trial. Extrapolating existing quality indices from conventional hemodialysis seems reasonable however may miss many of the true clinically significant advantages of HHD as a modality. Although definitive evidence does not yet exist for intensive home hemodialysis strategies, clearly clinicians, payers and patients are convinced enough of this approach for programs to justify the expansion of these modalities. We have laid the groundwork for the CANadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP), a multicenter cohort aimed to investigate the clinical and programmatic outcomes of NHD. This will allow for the assessment of numerous outcomes on a global scale for this state-of-the art dialysis modality in the form of a multidimensional programmatic evaluation.

Short daily and nocturnal hemodialysis: new therapies for a new century?

The National Institutes of Health (NIH) sponsored HEMO Study did not demonstrate that an increase in dialysis dose was associated with an improvement in patient mortality rates. Despite this negative result, there is ongoing interest in determining if still higher doses of dialysis may be of benefit to patients receiving chronic hemodialysis therapy. Testing this hypothesis requires the use of more fre-quent hemodialysis and/or a much longer duration for each dialysis session. "Short daily hemodialysis", actually six times per week hemodialysis for 1.5 to 3 hours per session, provides a significant increase in small molecule clearance as measured by urea kinetics. "Long nocturnal daily hemodialysis", actually six times per week hemodialysis for 6-8 hours per session, provides a significant increase in both small and large molecular weight clearance and often alleviates the need to take phosphate binders. Both forms of more frequent dialysis have been shown to improve control of blood pressure. One small randomized trial of nocturnal versus conventional home dialysis showed a decrease in left ventricular (LV) mass at 6 months in the nocturnal arm only. Most clinical trials conducted in these dialysis modalities have been observational trials and have enrolled small numbers of patients. The National Institutes of Health is sponsoring two clinical trials via the Frequent Hemodialysis Network to determine the effect of these two more frequent dialysis modalities on intermediate outcomes. In the short daily study, 250 patients will be randomized to receive either six times per week HD, with a session length of 1.5 to 2.75 hours, or conventional in-center hemodialysis. In the nocturnal study, 150 patients will be randomized to receive either six times per week overnight dialysis, with a session length of at least 6 hours, or conventional home hemodialysis.

[Nocturnal hemodialysis: an alternative treatment for a better quality of life]

The interest of investigators in intensified dialysis regimens has been growing in recent years, especially since the HEMO Study Group showed that a higher dose of thrice-weekly hemodialysis fails to reduce mortality and morbidity but improves clinical outcomes. Alternative hemodialysis strategies including short daily hemodialysis (SDHD), long hemodialysis (LHD) and nocturnal daily hemodialysis (NDHD) have been developed in the hope to improve patients' outcomes. A growing number of investigators are studying patients on alternative dialysis regimens and most publications in this field have reported significant improvements in clinical outcomes including left ventricular hypertrophy, blood pressure control, anemia, calcium-phosphate metabolism, and fluid and electrolyte balance; all of these parameters can be considered as indirect signs of improvement in quality of life. However, the strength of these results is often limited by shortcomings in study design. Indeed, in most of these studies an adequate control group is missing, the patient groups are not properly matched, and the number of patients enrolled is small. Similarly, most studies have evaluated the effects of NDHD and/or nocturnal LHD on health-related quality of life (HRQoL) by questionnaire administration. Even though better results might be achieved with nocturnal hemodialysis, no conclusive data exist to prove statistically significant differences in HRQoL between conventional and intensive hemodialysis. In conclusion, all of these novel dialysis strategies offer reliable opportunities for uremic patients, but further trials are needed to determine whether alternative hemodialysis can reduce morbidity and mortality in this high-risk population of patients.

The use of alternative anti-coagulation strategies for a nocturnal home hemodialysis patient with heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a potentially catastrophic hyercoagulable state. The prevalence of HIT in individuals doing nocturnal home hemodialysis (NHD) is unknown and the appropriate treatment protocol has yet to be determined. The objective is to describe the clinical course and treatment plan ofa patient who developed HIT while undergoing NHD. A 49-year-old man with a past history of end stage renal disease (ESRD) of unknown etiology was initiated on NHD in February 2005. His clinical and biochemical parameters improved after conversion to NHD. However, excessive bleeding at the vascular access sites complicated his treatments. Clinical investigations revealed development of HIT Alternative therapeutic strategies were attempted to enable our patient to continue NHD: unfractionated heparin, citrated regional anticoagulation, Danaparoid, and Argatroban. In conclusion, NHD patients with HIT pose a specific clinical challenge. We speculate that the augmented exposure of heparin coupled with a primed autoimmune response may be responsible for the development of HIT in our patient. Further research is required to elucidate the appropriate clinical monitoring and treatment strategy for this patient.

The first nocturnal home haemodialysis patient in Hong Kong

We report our experience of the first use of nocturnal home haemodialysis in Hong Kong. The patient, a 40-year-old man with end-stage renal failure, was recruited into the Nocturnal Home Haemodialysis Programme at Princess Margaret Hospital in 2006. He received haemodialysis at home on alternate nights (3.5 sessions per week) for 5.5 to 6 hours per session. After 1 year of nocturnal home haemodialysis, his recombinant human erythropoietin requirement had been reduced by more than 50%. His serum phosphate level decreased by 35% and calcium phosphate product by 34%. After nocturnal home haemodialysis, his blood pressure control has been excellent and he was able to cease taking anti-hypertensive medications soon after commencing nocturnal home haemodialysis. Regression of his left ventricular hypertrophy has also been noted, with a 39% decrease in his left ventricular mass index. The haemodialysis adequacy index, weekly single-pool Kt/V, increased by 59% after switching to nocturnal home haemodialysis and his quality-of-life indices also showed significant improvement. Nocturnal home haemodialysis holds promise as an alternative dialytic therapy for patients on chronic haemodialysis in Hong Kong.

Portable home hemodialysis for kidney failure

(1) Home hemodialysis has been in limited use in Canada for some time. Newer, portable hemodialysis machines that are easier for patients to operate may encourage the uptake of this technology. (2) One portable system is already available in the US. The NxStage System One hemodialysis machine operates on standard electric current, does not require plumbing or specialized disinfection, and is small enough for patients to travel with. (3) It is not yet clear whether the use of the NxStage system improves long-term survival and quality of life. (4) Home hemodialysis is less costly than conventional in-centre programs, but it is unknown whether these savings extend to portable devices.