In-Center Nocturnal Hemodialysis Versus Conventional Hemodialysis: A Systematic Review of the Evidence

Association of Sleep Problems With Dialysis Shifts in Patients Undergoing Hemodialysis in Tbilisi, Georgia

Introduction According to a 2023 poll by the International Society of Nephrology, 850 million individuals worldwide suffer from chronic kidney disease (CKD) and hemodialysis (HD) is the primary treatment for 69% of the patients with CKD. While HD effectively regulates fluid balance and electrolyte levels, patients often face challenges such as weakness, exhaustion, and cognitive changes, which impact their quality of life. Sleep-related issues, including poor quality, excessive morning sleepiness, insomnia, and restless leg syndrome (RLS), are particularly common among HD patients. These disturbances stem from various factors, including psychological discomfort and biochemical imbalances. Dialysis shifts, despite their importance, remain poorly studied regarding their impact on sleep and biochemical parameters. Our study aims to address these gaps, exploring how different dialysis shifts affect sleep quality and biochemical parameters. Our hypothesis suggests that the particular dialysis shift that hemodialysis patients undergo has an impact on the quality of sleep, with various groups exhibiting varying degrees of sleep disturbance. Simultaneously, we believe that the time of dialysis shifts could influence biochemical parameter variations, which in turn could affect the quality of sleep in hemodialysis patients. Methodology This cross-sectional study focuses on assessing sleep problems and analyzing biochemical variables among hemodialysis (HD) patients in Georgia. A total of 150 participants were selected from morning, afternoon, and evening dialysis shifts, with strict inclusion criteria and exclusion criteria. Assessment procedures involved questionnaires on sleep quality, restless leg syndrome (RLS), daytime sleepiness, and severity of insomnia. Biochemical variables were obtained from the hospital records. Statistical analyses were performed using Graph Pad Prism software (GraphPad, San Diego, USA), including ANOVA and Chi-square tests for association between biochemical variables and dialysis shifts, as well as logistic regression for assessing the influence of biochemical variables on insomnia and poor sleep quality. The significance level was set at 95%. Results Results showed that patients in the afternoon shift undergo longer sessions of hemodialysis compared to other shifts. Notably, a larger proportion of morning shift patients reported poor sleep quality, while a smaller fraction of evening shift patients experienced insomnia. There were no significant associations between dialysis shift and excessive morning sleepiness or restless leg syndrome. Potassium emerged as the sole biochemical variable exhibiting an association with all three dialysis shifts. Biochemical parameters showed no discernible impact on insomnia or poor sleep quality. Conclusion Our findings suggest an association between poor sleep quality and insomnia with dialysis shifts. Hemodialysis does influence potassium levels. However, biochemical variables like sodium, potassium, calcium, phosphorus, vitamin D3, parathyroid gland hormone (PTH), and hemoglobin do not seem to affect poor sleep quality and insomnia. Further research is needed to explore potential sleep issues with nocturnal shifts and to assess if creatinine and chloride have any influence on poor sleep quality. It is important to acknowledge dialysis shift as a contributor to sleep problems, emphasizing the need for targeted interventions to enhance the quality of life for these patients.

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Hypertension and cardiomyopathy associated with chronic kidney disease: epidemiology, pathogenesis and treatment considerations

Chronic kidney disease (CKD) is a complex condition with a prevalence of 10-15% worldwide. An inverse-graded relationship exists between cardiovascular events and mortality with kidney function which is independent of age, sex, and other risk factors. The proportion of deaths due to heart failure and sudden cardiac death increase with progression of chronic kidney disease with relatively fewer deaths from atheromatous, vasculo-occlusive processes. This phenomenon can largely be explained by the increased prevalence of CKD-associated cardiomyopathy with worsening kidney function. The key features of CKD-associated cardiomyopathy are increased left ventricular mass and left ventricular hypertrophy, diastolic and systolic left ventricular dysfunction, and profound cardiac fibrosis on histology. While these features have predominantly been described in patients with advanced kidney disease on dialysis treatment, patients with only mild to moderate renal impairment already exhibit structural and functional changes consistent with CKD-associated cardiomyopathy. In this review we discuss the key drivers of CKD-associated cardiomyopathy and the key role of hypertension in its pathogenesis. We also evaluate existing, as well as developing therapies in the treatment of CKD-associated cardiomyopathy.

Long-Term In-Center Nocturnal Hemodialysis Improves Renal Anemia and Malnutrition and Life Quality of Older Patients with Chronic Renal Failure

Background

Older patients with chronic renal failure (CRF) which currently is referred to as end-stage renal disease (ESRD) are associated with higher mortality. In-center nocturnal dialysis (INHD) is a new blood purification model, which is characterized by longer sessions and nighttime administration. However, no data for the efficacy of INHD in older patients with ESRD are available. This study is to analyze the effect of INHD in the treatment of older patients with ESRD.

Methods

A retrospective, observational study was conducted in a university teaching hospital. Seventy-two patients with ESRD receiving INHD were enrolled. They were divided into the older ESRD patients (age ≥60) group (n = 22) and the non-older ESRD patients (age <60) group (n = 50). The causes of older ESRD patients and non-older ESRD patients receiving INHD were analyzed. Differences of laboratory test indicators of older patients with ESRD before INHD and after INHD were compared. Quality of life for older ESRD patients receiving INHD was assessed by using the Kidney Disease Quality of Life-36 Instrument (KDQOL-36).

Results

Serum concentration of hemoglobin and serum concentration of albumin of older patients with ESRD increased significantly after INHD (p < 0.05). There were similar results in the non-older cohort (p ≤ 0.05). Scores of five KDQOL-36 subscales increased significantly after INHD (p ≤ 0.001) indicated that the quality of life for old patients with ESRD was significantly improved after INHD.

Conclusion

INHD is an effective blood purification therapy that can improve the condition of renal anemia, and it may provide a potential positive impact in the malnutrition of older and non-older patients with ESRD. INHD can improve the quality of life of older patients with ESRD. The results will provide a basis for formulating new policies of blood purification therapy for older patients.

Evaluating the clinical experience of a regional in-center nocturnal hemodialysis program: The patient and staff perspective

INTRODUCTION

End-stage kidney disease causes significant morbidity, mortality, and reduced quality of life. Despite improvements in conventional hemodialysis, these problems persist. In-center nocturnal hemodialysis (INHD) has been shown to be beneficial in observational studies. This report outlines a 4-year renal network experience of INHD from the patient and frontline staff perspective.

METHODS

Staff and patients' experiences of INHD were evaluated through two work streams. Work stream one: 12 patients who chose to stop INHD and 24 patients who chose to continue with INHD completed an anonymous survey. Work stream two: one-to-one interviews with 20 patients receiving INHD and seven staff working INHD shifts were conducted. Clinical incident reporting for conventional hemodialysis and INHD from April 2014 to December 2018 was reviewed.

FINDINGS

Work stream one: Five themes were identified; facilities, time, health and well-being, sleep, and transport. A patient "starter pack" was developed and improvements to the dialysis unit were completed. Work stream two: Patient interviews demonstrated starter packs to aid sleep were well received; sleep itself was not a single reason to discontinue INHD. Staff indicated that their greatest concern was staffing levels; although staff-to-patient ratio remains unchanged, total numbers on INHD shifts were fewer, causing concern around less colleague availability for support during an emergency.

SAFETY

363 clinical incidents were reported across all dialysis shifts; for conventional hemodialysis, a larger proportion were due to medical interventions, infection control, and transport; for INHD, most incidents centered around communication with patients and relatives, delays in patient transfer, and issues with medical equipment or facilities.

DISCUSSION

Patients continue with INHD due to increased social time and perceived health benefits. Patient starter packs and adjustments to the dialysis unit may enhance sleep. This experience has optimized the design of the NightLife study; a randomized controlled trial evaluated the effect of INHD on quality of life.

In-center nocturnal hemodialysis improves health-related quality of life for patients with end-stage renal disease

BACKGROUND

Conventional in-center hemodialysis (HD) is associated with significant symptom burden and reduced health-related quality of life (HRQOL). The HRQOL effects of conversion to in-center nocturnal hemodialysis (INHD) remain unclear, especially amongst those with poor HRQOL.

METHODS

Prospective cohort study of HD patients converting to INHD. Linear regression models summarized the mean score at baseline and at 12 months for the cohort. To assess whether patients with low baseline HRQOL derive greater benefit, we compared values before and after by levels of baseline score for each domain (below vs equal to or above the median) using a formal interaction test (t test).

RESULTS

36 patients started INHD, 7 withdrew (5 transplanted, 1 death, 1 moved) and 5 declined follow-up. After 12 months the mental component score (MCS) increased by 7.1 points to a value of 51.0 (95% CI + 1.5 to 10.9, p = 0.01). Amongst patients with baseline scores below the median, improvements were seen in: Symptoms/Problems of Kidney Disease (+ 15.2, 95% CI + 5.5 to + 24.9, p = 0.003), Effects of Kidney Disease (+ 16.9, 95% CI + 2.2 to + 31.7, p = 0.026), Physical Component Score (+ 9.4, 95% CI + 1.69 to + 17.2, p = 0.018), MCS (+ 10.7, 95% CI + 2.4 to + 19.1, p = 0.013). Burden of Kidney Disease domain change was not significant (+ 15.1, 95% CI - 2.1 to + 32.3, p = 0.083).

DISCUSSION

INHD is a potential intervention for HD patients who struggle with reduced HRQOL, especially for those who struggle with poor mental health. Medical benefits of reduced pill burden and improved phosphate control occur with transition to INHD.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Western Europe

Populations in the high-income countries of Western Europe are aging due to increased life expectancy. As the prevalence of diabetes and obesity has increased, so has the burden of kidney failure. To determine the global capacity for kidney replacement therapy and conservative kidney management, the International Society of Nephrology conducted multinational, cross-sectional surveys and published the findings in the International Society of Nephrology Global Kidney Health Atlas. In the second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to describe the availability, accessibility, quality, and affordability of kidney failure care in Western Europe. Among the 29 countries in Western Europe, 21 (72.4%) responded, representing 99% of the region's population. The burden of kidney failure prevalence varied widely, ranging from 760 per million population (pmp) in Iceland to 1612 pmp in Portugal. Coverage of kidney replacement therapy from public funding was nearly universal, with the exceptions of Germany and Liechtenstein where part of the costs was covered by mandatory insurance. Fourteen (67%) of 21 countries charged no fees at the point of care delivery, but in 5 countries (24%), patients do pay some out-of-pocket costs. Long-term dialysis services (both hemodialysis and peritoneal dialysis) were available in all countries in the region, and kidney transplantation services were available in 19 (90%) countries. The incidence of kidney transplantation varied widely between countries from 12 pmp in Luxembourg to 70.45 pmp in Spain. Conservative kidney care was available in 18 (90%) of 21 countries. The median number of nephrologists was 22.9 pmp (range: 9.47-55.75 pmp). These data highlight the uniform capacity of Western Europe to provide kidney failure care, but also the scope for improvement in disease prevention and management, as exemplified by the variability in disease burden and transplantation rates.

[Prolonged hemodialysis: Rationale, practical organization, results]

In France, long nocturnal dialyses, eight hours three-times a week, are sparsely proposed. However, numerous studies reported that this specific type of dialysis is associated to better blood pressure control, better cardiac remodeling, better mineral and nutritional balance as well as better life quality and survival rate. MATERIAL AND METHODS: In this study, we aimed at quantifying the benefits, risks and obstacles of developing night dialysis and at describing the results of a program that took place in Rennes from 2002 to 2019. Data were collected between 2008 and 2014 for eighteen case-patients and were compared to thirty-six controls that underwent conventional dialysis. Patients were paired according sex, age and year of dialysis start. RESULTS: The median age for dialysis start was 47.5 years [27-60] with a male prevalence (5/1). After six months, a significant difference was reported for postdialytic, systolic and diastolic pressure (respectively 126±15 vs 139±21 [P=0.04] and 72±9 vs 81±14 [P=0.02]) despite an antihypertensive reduction ranging from 2.4±1.4 to 1.3±0.9 per day at six months and 0.7±0.9 at one year (P=0.02). An increase of nPCR was evidenced at 6 and 9 months (P=0.02). At the end of the study, the phosphate level was maintained for both cohorts at the expense of an increased consumption of phosphate binder for the long nocturnal dialysis group (P=0.025). As a whole, 61% of the patients that pursued long night dialysis maintained a professional activity compared to only 30% for the controls (P=0.04). This highlights the advantages of night dialysis for maintaining employment but also the bias that represents the employment status in observational study on this specific topic.

Nocturnal Hemodialysis: Why Aren't More People Doing It?

Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.

Technique Survival and Determinants of Technique Failure in In-Center Nocturnal Hemodialysis: A Retrospective Observational Study

Background

Long-duration (7-8 hours) hemodialysis provides benefits compared with conventional thrice-weekly, 4-hour sessions. Nurse-administered, in-center nocturnal hemodialysis (INHD) may expand the population to whom an intensive dialysis schedule can be offered.

Objective

The primary objective of this study was to determine predictors of INHD technique failure, disruptions, and technique survival.

Design

This study used retrospective chart and database review methodology.

Setting

This study was conducted at a single Canadian INHD program operating in Victoria, British Columbia, within a tertiary care hospital. Our program serves a catchment population of approximately 450 000 people.

Patients/Sample/Participants

Forty-three consecutive incident INHD patients took part in the INHD program of whom 42 provided informed consent to participate in this study.

Methods

We conducted a retrospective observational study including incident INHD patients from 2015 to 2017. The primary outcome was technique failure ≤6 months (TF ≤6). Secondary outcomes included technique survival and reasons for/predictors of INHD discontinuation or temporary disruption. Predictors of each outcome included demographics, comorbidities, and Clinical Frailty Scale (CFS) scoring.

Results

Among 42 patients, mean (SD) age, dialysis vintage, CFS score, and follow-up were 63 (16) years, 46 (55) months, 4 (1), and 11 (9) months, respectively. 52% were aged ≥65 years. TF ≤6 occurred in 12 (29%) patients. One-year technique survival censored for transplants and home dialysis transitions was 60%. Discontinuation related to insomnia (32%), medical status change (27%), and vascular access (23%). In unadjusted Cox survival analysis, 1-point increases in CFS score associated with a higher risk of technique failure (hazard ratio: 2.04, 95% confidence interval [CI]: 1.26-3.31). In an adjusted analysis, higher frailty severity also associated with temporary INHD disruptions (incidence rate ratio: 2.64, 95% CI: 1.55-4.50, comparing CFS of ≥4 to 1-3).

Limitations

The retrospective, observational design of this study resulted in limited ability to control for confounding factors. In addition, the relatively small number of events observed owing to a small sample size diminished statistical power to inform study conclusions. Use of a single physician to determine the clinical frailty score is another limitation. Finally, the use of a single center for this study limits generalizability to other programs and clinic settings.

Conclusions

INHD is a sustainable modality, even among older patients. Higher frailty associates with INHD technique failure and greater missed treatments. Inclusion of a CFS threshold of ≤4 into INHD inclusion criteria may help to identify individuals most likely to realize the long-term benefits of INHD.

Trial Registration

Due to the retrospective and observational design of this study, trial registration was not necessary.

Survival of patients treated with extended-hours haemodialysis in Europe: an analysis of the ERA-EDTA Registry

Background

Previous US studies have indicated that haemodialysis with ≥6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients.

Methods

We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association–European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5–4 h/treatment), EHD (three times weekly, ≥6 h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders.

Results

From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.1 ± 0.8 h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 ± 0.2 h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62–0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71–0.90)].

Conclusions

EHD is associated with better survival in European patients treated with haemodialysis three times weekly.

Impact of old age on the association between in-center extended-hours hemodialysis and mortality in patients on incident hemodialysis

With the global problem of aging, it has become more difficult to improve the prognosis of older dialysis patients. Extended-hours hemodialysis offers longer treatment time compared to conventional hemodialysis regimen and provides favorable metabolic status, hemodynamic stability, and increased dietary intake. Despite prior studies reporting that in-center extended-hours hemodialysis can reduce the mortality rate, the treatment impact on elderly patients remains unclear. Therefore, we examined the association between extended-hours hemodialysis compared to conventional hemodialysis and all-cause mortality. Survival analyses using Cox proportional hazard model with multivariable adjustments and propensity-score based method were performed to compare mortality risk between 198 consecutive patients who started in-center extended-hours hemodialysis (Extended-HD) and 1407 consecutive patients who initiated conventional hemodialysis. The median age was 67.1 years in the Extended-HD group and 70.7 years in the conventional hemodialysis group. Extended-HD was associated with lower all-cause mortality in overall patients and the subgroup >70 years (adjusted hazard ratios of 0.60 [95% CI, 0.39–0.91] and 0.35 [95% CI, 0.18–0.69], respectively). There was a significant interaction between age >70 years and Extended-HD. In conclusion, extended-hours hemodialysis was associated with a lower mortality rate, especially in elderly patients.

Nocturnal haemodialysis is associated with a reduced occurrence of low triiodothyronine serum levels in haemodialysed patients

Background

End-stage renal disease (ESRD) is associated with a broad spectrum of morphological and functional thyroid disorders. Recent studies have shown that low free triiodothyronine (fT3) levels are related to inflammatory status and endothelial activation in ESRD patients on haemodialysis (HD). Limited data exist about a possible relationship between dialysis regimen, namely long nocturnal haemodialysis (LNHD), and thyroid function parameters. The aim of this study was to evaluate the relationship between dialysis regimen and thyroid function, and consequently with the main patient outcomes.

Methods

To this purpose, we performed a retrospective, single-centre cohort study including 220 incident chronic HD patients treated during an 8-year period (from January 2010 to December 2017). The main clinical and haematochemical parameters, including thyroid function, were evaluated and related to the main patient outcomes.

Results

Patients with low fT3 levels (<3.05 ng/mL) showed significantly lower survival rates than patients with normal fT3 levels (>3.05 ng/mL) (P < 0.001), although there were no substantial differences in the demographic and clinical characteristics between the two groups. After propensity score 1:3 matching of 25 patients treated with nocturnal HD to 75 patients treated with diurnal HD, LNHD patients showed significantly higher survival rates (88.0% versus 61.3%, P = 0.001) and lower incidence of cardiovascular events than patients on diurnal dialysis (8.0% versus 40.0%, P = 0.001). Moreover, an 8-year time-dependent analysis showed that at any time, except for baseline, the rate of patients with fT3 levels >3.05 ng/mL was significantly higher in LNHD patients than in patients treated with diurnal dialysis.

Conclusions

Our data suggest that the application of alternative dialysis regimens, also reducing the frequency of low T3, could ameliorate outcomes and therefore reduce the incidence of cardiovascular events in HD patients.

Effect of nocturnal hemodialysis on sleep parameters in patients with end-stage renal disease: a systematic review and meta-analysis

Introduction

Recently, a small but growing literature has depicted the beneficial effects of nocturnal hemodialysis (NHD) over conventional hemodialysis (CHD) in the fields of sleep disorders such as sleep apnea. The impact of various dialysis models on sleep disorders, however, has not been determined. The objective of our meta-analysis is to examine the potential effects of NHD, compared with CHD, on sleep disorders in HD patients.

Methods

Several electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and CNKI were searched, using the search terms “nocturnal” (or “nightly”) and “dialysis” (or “hemodialysis” or “renal dialysis”) from the earliest available date of indexing to March 2018. Two authors independently extracted data, evaluated the study quality, and conducted random-effects meta-analyses using STATA 12.0.

Results

Of 1789 potentially relevant citations, 9 fulfilled eligibility criteria, consisting of 6 single-arm studies (comparing pre- and post-intervention outcomes), 1 observational study, and 2 randomized controlled trials (a total of 286 participants). Regarding objective sleep assessments, conversion from CHD to NHD resulted in a significant reduction in the AHI (Mean difference was -14.90; 95% CI, -20.12 to -9.68), a significant increase of SaO2 (Mean difference was 1.38%; 95% CI, 0.35% to 2.42%), and a significant decrease of TST (Mean difference was -0.31; 95% CI, -0.47 to -0.15). The trends were even stronger in the HD patients with sleep disorders. However, regarding subjective sleep assessments, improved sleep quality was found in the prospective pre-post intervention studies and cohort studies, while no significant improvements were found in the randomized controlled trials.

Conclusion

Although a significant improvement of sleep apnea was observed by switching from CHD to NHD, it may not yield a net benefit in overall subjective sleep quality.

Nutritional status in short daily hemodialysis versus conventional hemodialysis patients in China

PURPOSE

Malnutrition is the main determinant of mortality and morbidity in maintenance hemodialysis patients. In many countries except for China, it has been reported that short daily hemodialysis (SDHD) could improve nutritional status. We will report here the nutritional results obtained in the SDHD therapy period compared with conventional hemodialysis (cHD) therapy period in Chinese patients.

METHODS

This study compared 29 SDHD patients (SDHD group), each patient served as his own control, with 30 cHD patients (cHD group) serving as the parallel controls. The hematologic parameters, anthropometric measurements, modified quantitative subjective global assessment (MQSGA) score, weekly standard Kt/V (std Kt/V) and average daily intake of protein were measured at baseline (SDHD₀ or cHD₀ period), at 3 months (SDHD₁ or cHD₁ period) and at 6 months (SDHD₂ or cHD₂ period).

RESULTS

The average daily intake of protein, dry weight, body mass index, mid-arm circumference, mid-arm muscle circumference, serum albumin, prealbumin, cholesterol, hemoglobin, weekly std Kt/V values at SDHD₂ were higher than the corresponding values at SDHD₀ (p < 0.05, p < 0.05, p < 0.001, p < 0.05, p < 0.05, p < 0.05, p < 0.001, p < 0.05, p < 0.05, p < 0.001 and p < 0.001, respectively). Meanwhile, the average daily intake of protein, serum albumin, prealbumin, cholesterol, hemoglobin, weekly std Kt/V values at SDHD₂ were higher than the corresponding values at cHD₂ (p < 0.05, p < 0.001, p < 0.05, p < 0.05, p < 0.001 and p < 0.001, respectively), whereas the MQSGA score at SDHD₂ was lower than the score at SDHD₀ and cHD₀ (p < 0.05, respectively).

CONCLUSIONS

SDHD may improve the nutritional status compared with cHD in Chinese patients undergoing maintenance hemodialysis.

Home Hemodialysis (HHD) Treatment as Effective yet Underutilized Treatment Modality in the United States

End-stage renal disease (ESRD) is a major health burden and its incidence has been increasing yearly reaching 120,000 cases in 2014. Home hemodialysis (HHD) is a treatment modality option that has been shown to contribute to numerous clinical benefits but is largely underutilized due to many contributing factors. The purpose of this review paper is to analyze the advantages and disadvantages of HHD and the reasons for its low utilization with a special focus on its socioeconomic impact as compared to facility hemodialysis. Key factors contributing to HHD underutilization are related to the reimbursement system of the facility and nephrologists as well as the underutilization of the pre-dialysis educational benefit. Based on this comprehensive review of the literature, we propose several suggestions which may contribute to the expansion of HHD treatment modality.