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Perl J, Dember LM, Bargman JM, Browne T, Charytan DM, Flythe JE, Hickson LJ, Hung AM, Jadoul M, Lee TC, Meyer KB, Moradi H, Shafi T, Teitelbaum I, Wong LP, Chan CT. The Use of a Multidimensional Measure of Dialysis Adequacy-Moving beyond Small Solute Kinetics. Clin J Am Soc Nephrol 2017; 12:839-847. [PMID: 28314806 PMCID: PMC5477210 DOI: 10.2215/cjn.08460816] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures.
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Affiliation(s)
- Jeffrey Perl
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Miller AJ, Perl J, Tennankore KK. Survival comparisons of intensive vs. conventional hemodialysis: Pitfalls and lessons. Hemodial Int 2017; 22:9-22. [DOI: 10.1111/hdi.12559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Amanda J. Miller
- Department of Medicine, Division of Nephrology; Nova Scotia Health Authority; Halifax Nova Scotia Canada
| | - Jeff Perl
- Department of Medicine, Division of Nephrology; University of Toronto; Toronto Ontario Canada
| | - Karthik K. Tennankore
- Department of Medicine, Division of Nephrology; Nova Scotia Health Authority; Halifax Nova Scotia Canada
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53
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Obi Y, Chou J, Kalantar-Zadeh K. Introduction to the Critical Balance - Residual Kidney Function and Incremental Transition to Dialysis. Semin Dial 2017; 30:232-234. [PMID: 28335077 PMCID: PMC5418087 DOI: 10.1111/sdi.12600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Jason Chou
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
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54
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Brown EA, Finkelstein FO, Iyasere OU, Kliger AS. Peritoneal or hemodialysis for the frail elderly patient, the choice of 2 evils? Kidney Int 2017; 91:294-303. [DOI: 10.1016/j.kint.2016.08.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 02/02/2023]
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Smith JR, Zimmer N, Bell E, Francq BG, McConnachie A, Mactier R. A Randomized, Single-Blind, Crossover Trial of Recovery Time in High-Flux Hemodialysis and Hemodiafiltration. Am J Kidney Dis 2016; 69:762-770. [PMID: 28024931 PMCID: PMC5438239 DOI: 10.1053/j.ajkd.2016.10.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 10/15/2016] [Indexed: 12/12/2022]
Abstract
Background The choice between hemodiafiltration (HDF) or high-flux hemodialysis (HD) to treat end-stage kidney disease remains a matter of debate. The duration of recovery time after treatment has been associated with mortality, affects quality of life, and may therefore be important in informing patient choice. We aimed to establish whether recovery time is influenced by treatment with HDF or HD. Study Design Randomized patient-blinded crossover trial. Settings & Participants 100 patients with end-stage kidney disease were enrolled from 2 satellite dialysis units in Glasgow, United Kingdom. Intervention 8 weeks of HD followed by 8 weeks of online postdilution HDF or vice versa. Outcomes Posttreatment recovery time, symptomatic hypotension events, dialysis circuit clotting events, and biochemical parameters. Measurements Patient-reported recovery time in minutes, incidence of adverse events during treatments, hematology and biochemistry results, quality-of-life questionnaire. Results There was no overall difference in recovery time between treatments (medians for HDF vs HD of 47.5 [IQR, 0-240] vs 30 [IQR, 0-210] minutes, respectively; P = 0.9). During HDF treatment, there were significant increases in rates of symptomatic hypotension (8.0% in HDF vs 5.3% in HD; relative risk [RR], 1.52; 95% CI, 1.2-1.9; P < 0.001) and intradialytic tendency to clotting (1.8% in HDF vs 0.7% in HD; RR, 2.7; 95% CI, 1.5-5.0; P = 0.002). Serum albumin level was significantly lower during HDF (3.2 vs 3.3 g/dL; P < 0.001). Health-related quality-of-life scores were equivalent. Limitations Single center; mean achieved HDF convection volume, 20.6 L. Conclusions Patients blinded to whether they were receiving HD or HDF in a randomized controlled crossover study reported similar posttreatment recovery times and health-related quality-of-life scores.
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Affiliation(s)
- James R Smith
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom; Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland, United Kingdom.
| | - Norica Zimmer
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Elizabeth Bell
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Bernard G Francq
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Robert Mactier
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
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56
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Rivara MB, Adams SV, Kuttykrishnan S, Kalantar-Zadeh K, Arah OA, Cheung AK, Katz R, Molnar MZ, Ravel V, Soohoo M, Streja E, Himmelfarb J, Mehrotra R. Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal disease. Kidney Int 2016; 90:1312-1320. [PMID: 27555118 PMCID: PMC5123950 DOI: 10.1016/j.kint.2016.06.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/19/2016] [Accepted: 06/23/2016] [Indexed: 01/16/2023]
Abstract
Extended-hours hemodialysis offers substantially longer treatment time compared to conventional hemodialysis schedules and is associated with improved fluid and electrolyte control and favorable cardiac remodeling. However, whether extended-hours hemodialysis improves survival remains unclear. Therefore, we determined the association between extended-hours compared to conventional hemodialysis and the risk of all-cause mortality in a nationally representative cohort of patients initiating maintenance dialysis in the United States from 2007 to 2011. Survival analyses using causal inference modeling with marginal structural models were performed to compare mortality risk among 1206 individuals undergoing thrice weekly extended-hours hemodialysis or 111,707 patients receiving conventional hemodialysis treatments. The average treatment time per session for extended-hours hemodialysis was 399 minutes compared to 211 minutes for conventional therapy. The crude mortality rate with extended-hours hemodialysis was 6.4 deaths per 100 patient-years compared with 14.7 deaths per 100 patient-years for conventional hemodialysis. In the primary analysis, patients treated with extended-hours hemodialysis had a 33% lower adjusted risk of death compared to those who were treated with a conventional regimen (95% confidence interval: 7% to 51%). Additional analyses accounting for analytical assumptions regarding exposure and outcome, facility-level confounders, and prior modality history were similar. Thus, in this large nationally representative cohort, treatment with extended-hours hemodialysis was associated with a lower risk for mortality compared to treatment with conventional in-center therapy. Adequately powered randomized clinical trials comparing extended-hours to conventional hemodialysis are required to confirm these findings.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.
| | - Scott V Adams
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sooraj Kuttykrishnan
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Onyebuchi A Arah
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA; UCLA Center for Health Policy Research, Los Angeles, California, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Ronit Katz
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Irvine, California, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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57
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Collins AJ, Chan CT. Intensive Hemodialysis: Time to Give the Therapy Greater Consideration. Am J Kidney Dis 2016; 68:S1-S4. [DOI: 10.1053/j.ajkd.2016.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/11/2016] [Indexed: 12/26/2022]
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58
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Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA, Komenda P. Intensive Hemodialysis and Treatment Complications and Tolerability. Am J Kidney Dis 2016; 68:S43-S50. [DOI: 10.1053/j.ajkd.2016.05.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 11/11/2022]
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59
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Poon CK, Chan CT. Home hemodialysis associated infection-The “Achilles' Heel” of intensive hemodialysis. Hemodial Int 2016; 21:155-160. [PMID: 27781373 DOI: 10.1111/hdi.12508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Clara K. Poon
- Division of Nephrology; University Health Network; Toronto Ontario Canada
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60
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O'Brien FJ, Fong KD, Sirich TL, Meyer TW. More Dialysis Has Not Proven Much Better. Semin Dial 2016; 29:481-490. [PMID: 27556575 DOI: 10.1111/sdi.12533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients maintained on standard three times weekly hemodialysis have a high mortality rate and a limited quality of life. Some of this illness is due to systemic diseases that have caused kidney failure, and thus may be irreversible. But we presume that imperfect replacement of normal kidney function by dialysis contributes importantly. Patients on hemodialysis are subject to fluctuations in extracellular fluid volume and inorganic ion concentrations and their plasma levels of many organic waste solutes remain very high. It is thus natural to suppose that their health could be improved by increasing the intensity of dialysis treatment. But despite a great deal of work over the past 20 years, evidence that such improvement can be obtained is generally lacking. Specific benefits can indeed be achieved. Patients who cannot control their intradialytic weight gains or plasma phosphate levels with standard therapy can benefit from extending treatment time. But we cannot promise the average patient that longer or more frequent treatment will reduce mortality or improve the quality of life.
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Affiliation(s)
- Frank J O'Brien
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California.
| | - Kara D Fong
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
| | - Tammy L Sirich
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
| | - Timothy W Meyer
- The Departments of Medicine, VA Palo Alto HCS and Stanford University, Palo Alto, California
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61
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Ananthakrishnan S, Depner TA. Dose Targeting Metrics in Conventional and Intensive Maintenance Dialysis. Semin Dial 2016; 29:471-475. [PMID: 27592623 DOI: 10.1111/sdi.12526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hemodialysis has come a long way since its early days and is a life sustaining therapy for millions of people with end-stage kidney disease throughout the world. Although thrice weekly hemodialysis remains the most common form of renal replacement therapy, other therapies such as more frequent, prolonged dialysis modalities have seen a rise recently. In this review, we compare and contrast methods for measuring the dialysis dose, with a focus on small molecule clearance (Kt/Vurea ) among various dialysis modalities. We also describe newer on-line methods to measure dialysis and limitations to current adequacy measurement. Distinguishing dialysis adequacy from adequate treatment of the patient is also emphasized.
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Affiliation(s)
- Shubha Ananthakrishnan
- Division of Nephrology, Davis School of Medicine, University of California, Sacramento, California.
| | - Thomas A Depner
- Division of Nephrology, Davis School of Medicine, University of California, Sacramento, California
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62
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Treatment frequency and mortality among incident hemodialysis patients in the United States comparing incremental with standard and more frequent dialysis. Kidney Int 2016; 90:1071-1079. [PMID: 27528548 DOI: 10.1016/j.kint.2016.05.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 05/16/2016] [Accepted: 05/26/2016] [Indexed: 12/11/2022]
Abstract
Most patients with end-stage renal disease in the United States are initiated on thrice-weekly hemodialysis (HD) regimens. However, an incremental approach to HD may provide several patient benefits. We tested whether initiation of incremental HD does or does not compromise survival compared with a conventional HD regimen. The survival of 434 incremental, 50,162 conventional, and 160 frequent HD patients were compared using Cox regression analysis after matching for demographic and comorbid factors in a longitudinal national cohort of adult incident HD patients enrolled between January 2007 and December 2011. Sensitivity analysis included adjustment for residual kidney function. After adjustment for residual kidney function, all-cause mortality was not significantly different in the incremental compared with conventional HD group (hazard ratio 0.88, 95% confidence interval 0.72-1.08), but was higher in the frequent compared with the conventional HD group (hazard ratio, 1.56, 95% confidence interval 1.21-2.03). The comorbidity burden modified the association of treatment frequency and mortality, with higher comorbidity associated with higher mortality in the incremental HD group (hazard ratio, 1.77, 95% confidence interval 1.20-2.62) for a Charlson Comorbidity Index of ≥5. Thus, among incident HD patients with low or moderate comorbid disease, survival was similar for patients initiated on an incremental or conventional HD regimen. Clinical trials are needed to examine the safety and effectiveness of incremental HD and the selected patient populations who may benefit from an incremental approach to HDs initiation.
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63
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Mathew AT, Fishbane S, Obi Y, Kalantar-Zadeh K. Preservation of residual kidney function in hemodialysis patients: reviving an old concept. Kidney Int 2016; 90:262-271. [PMID: 27182000 PMCID: PMC5798008 DOI: 10.1016/j.kint.2016.02.037] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/18/2016] [Accepted: 02/24/2016] [Indexed: 12/30/2022]
Abstract
Residual kidney function (RKF) may confer a variety of benefits to patients on maintenance dialysis. RKF provides continuous clearance of middle molecules and protein-bound solutes. Whereas the definition of RKF varies across studies, interdialytic urine volume may emerge as a pragmatic alternative to more cumbersome calculations. RKF preservation is associated with better patient outcomes including survival and quality of life and is a clinical parameter and research focus in peritoneal dialysis. We propose the following practical considerations to preserve RKF, especially in newly transitioned (incident) hemodialysis patients: (1) periodic monitoring of RKF in hemodialysis patients through urine volume and including residual urea clearance with dialysis adequacy and outcome markers such as anemia, fluid gains, minerals and electrolytes, nutritional, status and quality of life; (2) avoidance of nephrotoxic agents such as radiocontrast dye, nonsteroidal anti-inflammatory drugs, and aminoglycosides; (3) more rigorous hypertension control and minimizing intradialytic hypotensive episodes; (4) individualizing the initial dialysis prescription with consideration of an incremental/infrequent approach to hemodialysis initiation (e.g., twice weekly) or peritoneal dialysis; and (5) considering a lower protein diet, especially on nondialysis days. Because RKF appears to be associated with better patient outcomes, it requires more clinical and research focus in the care of hemodialysis and peritoneal dialysis patients.
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Affiliation(s)
- Anna T Mathew
- Hofstra Northwell School of Medicine, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, New York, USA
| | - Steven Fishbane
- Hofstra Northwell School of Medicine, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, New York, USA.
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA; Fielding School of Public Health at UCLA, Los Angeles, California, USA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA
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64
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Obi Y, Streja E, Rhee CM, Ravel V, Amin AN, Cupisti A, Chen J, Mathew AT, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Incremental Hemodialysis, Residual Kidney Function, and Mortality Risk in Incident Dialysis Patients: A Cohort Study. Am J Kidney Dis 2016; 68:256-265. [PMID: 26867814 PMCID: PMC4969165 DOI: 10.1053/j.ajkd.2016.01.008] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/04/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Maintenance hemodialysis is typically prescribed thrice weekly irrespective of a patient's residual kidney function (RKF). We hypothesized that a less frequent schedule at hemodialysis therapy initiation is associated with greater preservation of RKF without compromising survival among patients with substantial RKF. STUDY DESIGN A longitudinal cohort. SETTING & PARTICIPANTS 23,645 patients who initiated maintenance hemodialysis therapy in a large dialysis organization in the United States (January 2007 to December 2010), had available RKF data during the first 91 days (or quarter) of dialysis, and survived the first year. PREDICTOR Incremental (routine twice weekly for >6 continuous weeks during the first 91 days upon transition to dialysis) versus conventional (thrice weekly) hemodialysis regimens during the same time. OUTCOMES Changes in renal urea clearance and urine volume during 1 year after the first quarter and survival after the first year. RESULTS Among 23,645 included patients, 51% had substantial renal urea clearance (≥3.0mL/min/1.73m(2)) at baseline. Compared with 8,068 patients with conventional hemodialysis regimens matched based on baseline renal urea clearance, urine volume, age, sex, diabetes, and central venous catheter use, 351 patients with incremental regimens exhibited 16% (95% CI, 5%-28%) and 15% (95% CI, 2%-30%) more preserved renal urea clearance and urine volume at the second quarter, respectively, which persisted across the following quarters. Incremental regimens showed higher mortality risk in patients with inadequate baseline renal urea clearance (≤3.0mL/min/1.73m(2); HR, 1.61; 95% CI, 1.07-2.44), but not in those with higher baseline renal urea clearance (HR, 0.99; 95% CI, 0.76-1.28). Results were similar in a subgroup defined by baseline urine volume of 600mL/d. LIMITATIONS Potential selection bias and wide CIs. CONCLUSIONS Among incident hemodialysis patients with substantial RKF, incremental hemodialysis may be a safe treatment regimen and is associated with greater preservation of RKF, whereas higher mortality is observed after the first year of dialysis in those with the lowest RKF. Clinical trials are needed to examine the safety and effectiveness of twice-weekly hemodialysis.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine, Orange, CA
| | - Adamasco Cupisti
- Division of Nephrology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Yangpu, Shanghai, China
| | - Anna T Mathew
- Hofstra North Shore-LIJ School of Medicine, Division of Kidney Diseases and Hypertension, North Shore-LIJ Health System, Great Neck, NY
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA; Fielding School of Public Health at UCLA, Los Angeles, CA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA.
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65
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Robinson BM, Akizawa T, Jager KJ, Kerr PG, Saran R, Pisoni RL. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices. Lancet 2016; 388:294-306. [PMID: 27226132 PMCID: PMC6563337 DOI: 10.1016/s0140-6736(16)30448-2] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than 2 million people worldwide are being treated for end-stage kidney disease (ESKD). This Series paper provides an overview of incidence, modality use (in-centre haemodialysis, home dialysis, or transplantation), and mortality for patients with ESKD based on national registry data. We also present data from an international cohort study to highlight differences in haemodialysis practices that affect survival and the experience of patients who rely on this therapy, which is both life-sustaining and profoundly disruptive to their quality of life. Data illustrate disparities in access to renal replacement therapy of any kind and in the use of transplantation or home dialysis, both of which are widely considered preferable to in-centre haemodialysis for many patients with ESKD in settings where infrastructure permits. For most patients with ESKD worldwide who are treated with in-centre haemodialysis, overall survival is poor, but longer in some Asian countries than elsewhere in the world, and longer in Europe than in the USA, although this gap has reduced. Commendable haemodialysis practice includes exceptionally high use of surgical vascular access in Japan and in some European countries, and the use of longer or more frequent dialysis sessions in some countries, allowing for more effective volume management. Mortality is especially high soon after ESKD onset, and improved preparation for ESKD is needed including alignment of decision making with the wishes of patients and families.
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Affiliation(s)
- Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA.
| | - Tadao Akizawa
- Showa University School of Medicine, Shinagawa, Tokyo, Japan
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam-Zuidoost, Netherlands
| | - Peter G Kerr
- Monash Medical Centre and Monash University Clayton, Clayton, VIC, Australia
| | - Rajiv Saran
- Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA
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66
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Sahutoglu T, Kara E, Ahbap E, Sakaci T, Koc Y, Basturk T, Sevinc M, Akgol C, Ucar ZA, Ozdemir Kayalar A, Caglayan FB, Unsal A. Test of the recommended dialysis dose on one-year mortality of nondiabetic maintenance hemodialysis patients; observations from a single dialysis unit. Ren Fail 2016; 38:1174-9. [PMID: 27418390 DOI: 10.1080/0886022x.2016.1208515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The optimal delivered dialysis dose has been of a great interest for the last three decades, though a clear cut point has not been reached yet. We aimed to evaluate the relationship between one-year mortality and the delivered dialysis dose, which was recommended by Kidney Disease Outcomes Quality Initiative (KDOQI), in our maintenance hemodialysis (MHD) patients. METHODS This was a single center, prospective observational study with one year of follow-up. Patients with extremes of age, BMI, residual renal function, diabetes mellitus, severe infection malignancy, and recent hospitalization within the last three months were excluded. Demographic, anthropometric, laboratory, and outcome data (mortality as the primary) were prospectively collected. Patients were classified into two groups according to baseline spKt/V levels; group 1 (n = 20): spKt/V ≤ 1.4, group 2 (n = 60): spKt/V > 1.4. RESULTS Median (IQR) age and hemodialysis vintage of all patients (M/F: 41/39) were 49.5 (29) years and 60 (94) months, respectively. Both groups had similar characteristics, with the exception of significantly higher BMI (24 vs. 21.7, p = 0.012), serum creatinine and uric acids, and lower spKt/V (1.30 vs. 1.71, p < 0.001) in group 1. Overall death occurred in seven (8.75%) patients (5 from group 1 and 2 from group 2). Patients in group 1 had significantly higher one-year mortality rate and shorter survival time (25% vs. 3.3%, p = 0.003 and 43.9 vs. 47.3 weeks, p = 0.003, respectively). CONCLUSIONS Higher spKt/V (>1.4) was associated with a lower one-year mortality in this small cohort of patients.
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Affiliation(s)
- Tuncay Sahutoglu
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Ekrem Kara
- b Department of Internal Medicine, Faculty of Medicine , Recep Tayyip Erdogan University , Rize , Turkey
| | - Elbis Ahbap
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Tamer Sakaci
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Yener Koc
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Taner Basturk
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Mustafa Sevinc
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Cuneyt Akgol
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Zuhal Atan Ucar
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Arzu Ozdemir Kayalar
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Feyza Bayraktar Caglayan
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
| | - Abdulkadir Unsal
- a Department of Nephrology , Sisli Hamidiye Etfal Educational and Research Hospital , Istanbul , Turkey
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Jayanti A, Foden P, Wearden A, Mitra S. Illness Beliefs in End Stage Renal Disease and Associations with Self-Care Modality Choice. PLoS One 2016; 11:e0154299. [PMID: 27368055 PMCID: PMC4930164 DOI: 10.1371/journal.pone.0154299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/12/2016] [Indexed: 12/02/2022] Open
Abstract
Background Interest in self-care haemodialysis (HD) has increased because it improves patients’clinical and quality-of-life outcomes. Patients who undertake self-management for haemodialysis may hold illness beliefs differently to those choosing institutional care at the time of making the modality choice or moulded by their illness and dialysis treatment experience. Illness perceptions amongst predialysis patients and in those undertaking fully-assisted and self-care haemodialysis are being investigated in a combined cross-sectional and longitudinal study. Study Design The study data are derived from the BASIC-HHD study, a multicentre observational study on factors influencing home haemodialysis uptake. 535 patients were enrolled into three groups: Predialysis CKD-5 group, prevalent ‘in-centre’ HD and self-care HD groups (93% at home). We explore illness perceptions in the cross-sectional analyses of the three study groups, using the revised Illness Perception Questionnaire (IPQ-R). Predialysis patients’ illness beliefs were reassessed prospectively, typically between 4 and 12 months after dialysis commencement. Results Illness belief subscales are significantly different between in-centre and self-care HD groups. In a step-wise hierarchical regression analysis, after adjustment for age, education, marital status, diabetes, dialysis vintage, depression, anxiety scores, and IPQ-R subscales, personal control (p = 0.01) and illness coherence (p = 0.04) are significantly higher in the self-care HD group. In the predialysis group, no significant associations were found between illness representations and modality choices. In prospectively observed predialysis group, scores for personal control, treatment control, timeline cyclical and emotional representations reduced significantly after commencing dialysis and increased significantly for illness coherence. Conclusions Illness beliefs differ between hospital and self-care haemodialysis patients. Patient’s affect and neurocognitive ability may have an important role in determining illness beliefs. The impact of modality upon illness representations may also be significant and remains to be explored.
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Affiliation(s)
- Anuradha Jayanti
- Department of Nephrology, Central Manchester Hospitals NHS Trust, Manchester, United Kingdom
- * E-mail:
| | - Philip Foden
- Department of Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Alison Wearden
- School of Psychological Sciences, University of Manchester, Manchester, United Kingdom
| | - Sandip Mitra
- Department of Nephrology, Central Manchester Hospitals NHS Trust, Manchester, United Kingdom
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Chan CT, Mok MM. In Search of the True Effect of Home Intensive Hemodialysis. Am J Kidney Dis 2016; 67:539-41. [DOI: 10.1053/j.ajkd.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 11/11/2022]
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Marshall MR, Polkinghorne KR, Kerr PG, Hawley CM, Agar JW, McDonald SP. Intensive Hemodialysis and Mortality Risk in Australian and New Zealand Populations. Am J Kidney Dis 2016; 67:617-28. [DOI: 10.1053/j.ajkd.2015.09.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/21/2015] [Indexed: 11/11/2022]
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Kerr PG, Agar JW. Keeping Home Dialysis Patients at Home. Am J Kidney Dis 2016; 67:542-4. [DOI: 10.1053/j.ajkd.2016.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/08/2016] [Indexed: 11/11/2022]
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Sherman RA. Briefly Noted. Semin Dial 2016. [DOI: 10.1111/sdi.12460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Marcello Tonelli
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
| | - S. Ananth Karumanchi
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
| | - Ravi Thadhani
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
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Rocco MV. Chronic Hemodialysis Therapy in the West. KIDNEY DISEASES (BASEL, SWITZERLAND) 2015; 1:178-86. [PMID: 27536678 PMCID: PMC4934827 DOI: 10.1159/000441809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/18/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic hemodialysis (HD) in the 1960s encompassed a wide variety of prescriptions from twice weekly to five times per week HD. Over time, HD prescriptions in the West became standardized at three times per week, 2.5-4 h per session, with occasional additional treatments for volume overload. SUMMARY When clinical trials of dialysis dose failed to show significant benefit of extending time compared with the traditional dialysis prescription, interest in more frequent HD was renewed. Consequently, there has been growth in home HD therapies as well as alternative dialysis prescriptions. Data from recent randomized clinical trials have demonstrated the benefits and risks of these more frequent therapies, with surprising differences in outcomes between short daily HD and long nocturnal HD. More frequent therapies improve control of both hypertension and hyperphosphatemia, but at the expense of increased vascular access complications and, at least for nocturnal HD, a faster loss of residual renal function. KEY MESSAGES In the West, the standard HD prescription is three treatments per week with a minimal time of 3.0 h and dialysis is performed in an outpatient dialysis center. A minority of patients will have a fourth treatment per week for volume issues. Alternative HD prescriptions, although rare, are more available compared to the recent past. FACTS FROM EAST AND WEST (1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.
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Affiliation(s)
- Michael V. Rocco
- Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, N.C., USA
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Obi Y, Eriguchi R, Ou SM, Rhee CM, Kalantar-Zadeh K. What Is Known and Unknown About Twice-Weekly Hemodialysis. Blood Purif 2015; 40:298-305. [PMID: 26656764 DOI: 10.1159/000441577] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The 2006 Kidney Disease Outcomes Quality Initiative guidelines suggest twice-weekly or incremental hemodialysis for patients with substantial residual kidney function (RKF). However, in most affluent nations de novo and abrupt transition to thrice-weekly hemodialysis is routinely prescribed for all dialysis-naïve patients regardless of their RKF. We review historical developments in hemodialysis therapy initiation and revisit twice-weekly hemodialysis as an individualized, incremental treatment especially upon first transitioning to hemodialysis therapy. SUMMARY In the 1960's, hemodialysis treatment was first offered as a life-sustaining treatment in the form of long sessions (≥10 hours) administered every 5 to 7 days. Twice- and then thrice-weekly treatment regimens were subsequently developed to prevent uremic symptoms on a long-term basis. The thrice-weekly regimen has since become the 'standard of care' despite a lack of comparative studies. Some clinical studies have shown benefits of high hemodialysis dose by more frequent or longer treatment times mainly among patients with limited or no RKF. Conversely, in selected patients with higher levels of RKF and particularly higher urine volume, incremental or twice-weekly hemodialysis may preserve RKF and vascular access longer without compromising clinical outcomes. Proposed criteria for twice-weekly hemodialysis include urine output >500 ml/day, limited interdialytic weight gain, smaller body size relative to RKF, and favorable nutritional status, quality of life, and comorbidity profile. KEY MESSAGES Incremental hemodialysis including twice-weekly regimens may be safe and cost-effective treatment regimens that provide better quality of life for incident dialysis patients who have substantial RKF. These proposed criteria may guide incremental hemodialysis frequency and warrant future randomized controlled trials.
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Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
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Daugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Suri RS, Weiner DE, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Slinin Y, Wilt TJ, Rocco M, Kramer H, Choi MJ, Samaniego-Picota M, Scheel PJ, Willis K, Joseph J, Brereton L. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis 2015; 66:884-930. [DOI: 10.1053/j.ajkd.2015.07.015] [Citation(s) in RCA: 603] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/31/2015] [Indexed: 12/13/2022]
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Jardine M, Perkovic V. First Light After the Long Night: A Follow-up Report of the Randomized FHN Nocturnal Trial. Am J Kidney Dis 2015; 66:379-82. [DOI: 10.1053/j.ajkd.2015.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 05/26/2015] [Indexed: 11/11/2022]
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